FY2024 NWI - Joint Commission Requirments- Document Requirements for EC and LS.xlsx

Intro

The Joint Commission

Life Safety & Environment of Care Document List and Review Tool

The following pages present documentation required by the Hospital Accreditation Program Life Safety (LS), and selected Environment of Care (EC) standards. The Life Safety surveyor will begin review of these documents soon after arrival for the onsite survey.

Surveyors may request other EC and LS documents, as needed, throughout the survey.

This list also includes some elements of performance that do not require documentation but appear as reminders to both organizations and surveyors of these expectations.

Organizations may want to consider using this tool in their continuous compliance and survey readiness efforts.

EC.02.03.05

Annual

EC.02.05.07

For new construction, renovation, or modernization battery-powered lighting in locations where deep sedation and general anesthesia are administered is tested annually for 30 minutes with test results and completion

Quarterly Annually

months using supplemental loads of 50% of nameplate rating for 30 minutes, followed by 75% of nameplate rating for 60 minutes for

EC.02.05.09

components of piped medical gas and vacuum systems, waste anesthetic gas disposal (WAGD), and support gas systems on the inventory.

Inventory of critical components includes at least all source subsystems, control valves, alarms, manufactured assemblies containing patient gases, and inlets and outlets with activities, dates and results documented

No prescribed frequency; recommend risk

LS.01.01.01

a. Areas of building fully sprinklered (if building only partially sprinklered)

b. Locations of all hazardous storage areas

c. Locations of all fire-rated barriers

d. Locations of all smoke-rated barriers

e. Sleeping and non-sleeping suite boundaries, including size of identified suites

f. Locations of designated smoke compartments g. Locations of chutes and shafts

h. Any approved equivalencies or waivers

LS.01.02.01

EC.02.03.01

of staff and LIPs at and away from fire including

• When and how to sound and report fire alarms

• How to contain smoke and fire

• How to use a fire extinguisher

• How to assist and relocate patients

• How to evacuate to areas of refuge Staff and LIPs periodically instructed on/kept informed of duties under plan Copy of plan readily available with telephone operator or security

COMMENTS:

EC.02.03.03

Annual

EP 5 Critiques include fire safety equipment and building features, and staff response YES NO

COMMENTS:

EC.02.04.01

Evaluates new types of equipment before initial use to determine whether they should be included in the inventory.

OR Deemed status requirement: Maintains a written inventory of all medical equipment.

Activities and associated frequencies are in accordance with manufacturers’ recommendations or with strategies of an alternative equipment maintenance (AEM) program.

COMMENTS:

EC.02.04.03

Medical Equipment Inspection, Testing, and Maintenance

EP 2 All high-risk equipment.

Note 1: High-risk equipment includes medical equipment for which there is a risk of serious injury or even death to a patient or staff member should it fail, which includes life-support equipment.

Note 2: Required activities and associated frequencies for maintaining, inspecting, and testing of medical equipment completed in accordance with manufacturers’ recommendations must have a 100% completion rate.

Note 3: Scheduled maintenance activities for high-risk medical equipment in an alternative equipment maintenance (AEM) program inventory must have a 100% completion rate. AEM frequency is determined by the hospital's AEM program.

EP 3 Non-high-risk equipment identified on the medical equipment inventory Note: Scheduled maintenance activities for non-high-risk medical equipment in an alternative equipment maintenance (AEM) program inventory must have a 100% completion rate. AEM frequency is determined by the hospital’s AEM program.

EC.02.05.01

EP 3 Non-deemed status requirement: Maintains written inventory of all operating components of utility systems or maintains a written inventory of selected operating components of utility systems based on risks for infection, occupant needs, and systems critical to patient care (including all life-support systems).

Evaluates new types of utility components before initial use to determine whether they should be included in the inventory.

Deemed status requirement: Maintains written inventory of all operating components of utility systems.

EP 4 Identifies high-risk operating components of utility systems on the inventory for which there is a risk of serious harm or death to a patient or staff member should the component fail.

Note: High-risk utility system components include life-support equipment.

EP 5 Identifies activities and associated frequencies, in writing, for inspecting, testing, and maintaining all operating components of utility systems on the inventory. These activities and associated frequencies are in accordance with manufacturers’ recommendations or with strategies of an alternative equipment maintenance (AEM) program.

Note 1: The strategies of an AEM program must not reduce the safety of equipment and must be based on accepted standards of practice. * Note 2: For guidance on maintenance and testing activities for Essential Electric Systems (Type I), see NFPA 99-2012: 6.4.4. Footnote *: An example of guidelines for physical plant equipment maintenance is the American Society for Healthcare Engineering (ASHE) book Maintenance Management for Health Care Facilities.

EP 14 Minimizes pathogenic biological agents in cooling towers, domestic hot- and cold-water systems, and other aerosolizing water systems Deemed status requirement: Review the following policies, procedures and reports:

• Facility risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility water system

• Water management program that considers the ASHRAE industry standard and the CDC toolkit

• Testing protocols and acceptable ranges for control measures o Documented results of testing o Corrective actions taken when control limits are not maintained EP 15 In critical care areas designed to control airborne contaminants (such as biological agents, gases, fumes, dust), the ventilation system provides appropriate pressure relationships, air-exchange rates, filtration efficiencies, temperature and humidity. (form of and frequency of assessment per hospital policy)

Note: For more information about areas designed for control of airborne contaminants, the basis for design compliance is the Guidelines for Design and Construction of Health Care Facilities, based on the edition used at the time of design (if available).

EC.02.05.05

EP 4 High-risk utility system components on the inventory with completion date and results of activities documented

Note 1: A high-risk utility system includes components for which there is a risk of serious injury or even death to a patient or staff member should it fail, which includes life-support equipment.

Note 2: Required activities and associated frequencies for maintaining, inspecting, and testing of utility systems components completed in accordance with manufacturers’ recommendations must have a 100% completion rate.

Note 3: Scheduled maintenance activities for high-risk utility systems components in an alternative equipment maintenance (AEM) program inventory must have a 100% completion rate.

EP 5 Infection control utility system components on the inventory with completion date and results of activities documented

Note 1: Required activities and associated frequencies for maintaining, inspecting, and testing of utility systems components completed in accordance with manufacturers’ recommendations must have a 100% completion rate.

Note 2: Scheduled maintenance activities for infection control utility systems components in an alternative equipment maintenance (AEM) program inventory must have a 100% completion rate.

EP 6 Non-high-risk utility system components on the inventory with completion date and results of activities documented

Note: Scheduled maintenance activities for non-high-risk utility systems components in an alternative equipment maintenance (AEM) program inventory must have a 100% completion rate. AEM frequency is determined by the hospital AEM program.

COMMENTS: