D.3 ATTACHMENT 3 - EXHIBIT A TJC LIFE SAFETY EC DOCUMENT LIST REVIEW TOOL.pdf

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Life Safety & Environment of Care Document List and Review Tool Effective: 1/1/2022

The following pages present documentation required by the Critical Access Hospital and Hospital Accreditation programs 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.

Revisions to this document are identified by underlined text.

Additional resources, including a Fire Drill Matrix, are available on The Joint Commission website, Physical Environment Portal which is accessible using the following link: https://www.jointcommission.org/resources/patient-safety-topics/the-physical-environment/.

https://www.jointcommission.org/resources/patient-safety-topics/the-physical-environment/

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Legend: C=Compliant; NC=Not compliant; NA=Not applicable; IOU=Surveyor awaiting documentation

STANDARD -

EPs

See Legend Document / Requirement Yes No

C NC NA IOU

LS.01.01.01 Buildings serving patients comply w/ NFPA 101 (2012)

EP 1 Individual assigned to assess Life Safety Code® compliance

EP 2 Building Assessment to determine compliance with Life Safety (LS) chapter (frequency of assessment is defined by the hospital)

EP 3

Current and accurate drawings w/ fire safety features & related square footage

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

EP 5 Deemed Hospitals: Documentation of inspections and approvals made by state or local AHJs

EP 7 The hospital maintains current Basic Building Information (BBI) within the Statement of Conditions (SOC).

COMMENTS:

STANDARD

- EPs

See Legend Document / Requirement Frequency Yes No / Missing Date C NC NA IOU EC.02.01.01 The hospital manages safety and security risks.

EP 17

The hospital conducts an annual worksite analysis related to its workplace violence prevention program. The hospital takes actions to mitigate or resolve the workplace violence safety and security risks based upon findings from the analysis.

Note: A worksite analysis includes a proactive analysis of the worksite, an investigation of the hospital’s workplace violence incidents, and an analysis of how the program’s policies and procedures, training, education, and environmental design reflect best practices and conform to applicable laws and regulations.

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- EPs See Legend Document / Requirement Yes No

C NC NA IOU

EC.02.03.01 Hospital Manages Fire Risk – Fire Response Plan

EP 9

The written fire response plan describes the specific roles 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

NFPA 101-2012: 18/19.7.1; 7.2

See Legend Document / Requirement Frequency Q1 Semi

Q2

Q3

Q4 Annual C NC NA IOU

EC.02.03.05

Fire Protection and

Suppression Testing and Inspection

EP 1

Supervisory Signals-including:

Control valves; pressure supervisory; pressure tank, pressure supervisory for a dry pipe (both high and low conditions), steam pressure;

water level supervisory signal initiating device; water temperature supervisory; and room temperature supervisory.

NFPA 72-2010: Table 14.4.5

Quarterly

EP 2

Water flow devices NFPA 72-2010: Table 14.4.5 NFPA 25-2011: Table 5.1.1.2

Semiannual

Tamper switches NFPA 72-2010: Table 14.4.5 Semiannual

EP 3

Duct, heat, smoke detectors, and manual fire alarm boxes NFPA 72-2010: Table 14.4.5;

17.14

Annually

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- EPs

See Legend Document / Requirement Frequency Q1

Q4 Annual C NC NA IOU

EC.02.03.05

Fire Protection and

EP 4

Notification devices (audible & visual), and door-releasing devices

EP 5

Emergency services notification transmission equipment

EP 6

Electric motor-driven fire pumps tested under no-flow conditions

NFPA 25-2011: 8.3.1; 8.3.2

Monthly

Diesel-engine-driven fire pumps tested under no-flow conditions

NFPA 25-2011: 8.3.1; 8.3.2

Weekly

EP 7

Water storage tank high and low level alarms NFPA 25-2011: 9.3; Table 9.1.1.2

EP 8

Water storage tank low water temp alarms (cold weather only) NFPA 25-2011: 9.2.4; Table 9.1.1.2

EP 9

Sprinkler systems main drain tests on all risers

NFPA 25-2011: 13.2.5;

13.3.3.4; Table 13.1.1.2; Table 13.8.1

EP 10

Fire department connections inspected (Fire hose connections N/A) NFPA 25-2011: 13.7; Table 13.1.1.2

EP 11

Fire pump(s) tested – under flow

NFPA 25-2011: 8.3.3

EP 12

Standpipe flow test every 5 years

NFPA 25-2011: 6.3.1; 6.3.2;

Table 6.1.1.2

5 years

EP 13

Kitchen suppression semi-annual testing

NFPA 96-2011: 11.2

EP 14

Gaseous extinguishing systems inspected (no discharge req.)

NFPA 12-2011: 4.8.3 and NFPA 12A-2009: Chapter 6

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- EPs

See Legend Document / Requirement Frequency Q1

Q4 Annual C NC NA IOU

EC.02.03.05

Fire Protection and

EP 15

Portable fire extinguishers inspected monthly

NFPA 10-2010: 7.2.2; 7.2.4

EP 16

Portable fire extinguishers maintained annually

NFPA 10-2010: 7.1.2; 7.2.2;

7.2.4; 7.3.1

EP 17

Fire hoses hydro tested 5 years after install; every 3 years thereafter NFPA 1962-2008: Chapter 7 and NFPA 25-2011: Chapter 6

5 years / 3 years

EP 18

Smoke and fire dampers tested to verify full closure

NFPA 90A-2012: 5.4.8; NFPA

80-2010: 19.4; NFPA 105-2010:

6.5

1 year after install

At least every 6 years thereafter

EP 19

Smoke detection shutdown devices for HVAC tested

NFPA 90A-2012: 6.4.1

EP 20

All horizontal and vertical roller and slider doors tested

NFPA 80-2010: 5.2.14.3; NFPA

105-2010: 5.2.1; 5.2.2

EP 25

Inspection and testing of door assemblies by qualified person.

Does not include nonrated doors, including corridor doors to patient care rooms and smoke barrier doors.

NFPA101-2012: 7.2.1.5.10.1;

7.2.1.5.11; 7.2.1.15; NFPA 80-

2010: 4.8.4; 5.2.1; 5.2.3; 5.2.4;

5.2.6; 5.2.7; 6.3.1.7; NFPA 105-

2010: 5.2.1

EP 27

Elevators with firefighters’ emergency operations

NFPA 101-2012: 9.4.3; 9.4.6

EP 28

Documentation of maintenance testing and inspection activities for EPs 1-20 and 25 includes:

activity name; date; inventory of devices, equipment or other items; frequency; contact info

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- EPs

See Legend Document / Requirement Frequency Q1

Q4 Annual C NC NA IOU

EC.02.03.05

Fire Protection and for person performing activity;

NFPA standard; activity results

NFPA 25-2011: 4.3; 4.4; NFPA

72-2010: 14.2.1; 14.2.2; 14.2.3;

14.2.4

STANDARD -

EPs See Legend Document / Requirement Frequency Yes No / Missing Date

C NC NA IOU

EC.02.05.07 Emergency Power Systems are Maintained and Tested

EP 1

At least monthly performs functional test of emergency lighting systems and exit signs required for egress and task lighting for a minimum duration of 30 seconds, along with a visual inspection of other exit signs

NFPA 101-2012: 7.9.3; 7.10.9; NFPA 99-2012:

6.3.2.2.11.5

Every 12 months performs functional test of battery powered lights on the inventory required for egress and exit signs for a duration of 1 ½ hours

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 dates documented

NFPA 101-2012: 7.9.3; 7.10.9; NFPA 99-2012:

6.3.2.2.11.5

Functional test of Level 1 SEPSS, monthly;

Level 2 SEPSS, quarterly, for 5 minutes or as specified for its class Annual test at full load for 60% of full duration of its class

NFPA 111-2010: 8.4

Monthly

Note 1: Non-SEPSS tested per manufacturer’s specifications Per Mfr.

Note 2: Level 1 SEPSS defined for critical areas and equipment

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STANDARD -

EPs See Legend Document / Requirement Frequency Yes No / Missing Date

C NC NA IOU

EC.02.05.07 Emergency Power Systems are Maintained and Tested

Note 3: Class defines minimum time which SEPSS is designed to operate at rated load without recharging

Emergency power supply system (EPSS) inspected weekly, including all associated components and batteries

NFPA 110-2010: 8.3.1; 8.3.3; 8.3.4; 8.4.1

Weekly

Emergency generators tested monthly for 30 continuous minutes under load (plus cool-down)

NFPA 99-2012: 6.4.4.1

Monthly load test for diesel-powered emergency generators conducted with dynamic load at least 30% of nameplate rating or meets mfr. recommended prime movers’ exhaust gas temperature; OR

Emergency generators tested once every 12 months using supplemental loads of 50% of nameplate rating for 30 minutes, followed by 75% of nameplate rating for 60 minutes for total of 1 ½ continuous hours

NFPA 99-2012: 6.4.4.1

Annually

EP 7

All automatic and manual transfer switches monthly/12 times per year with results and completion dates documented

NFPA 99-2012: 6.4.4.1

EP 8 Fuel quality test to ASTM standards NFPA 110-2010: 8.3.8 Annually

EP 9

Generator load test once every 36 months for

4 hours NFPA 110-2010, Chapter 8

36 Months

EP 10

Generator 4-hour test performed at, at least

30% nameplate NFPA 110-2010, Chapter 8

36 Months

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- EPs

See Legend Document / Requirement

THIS MAY BE SCORED AS

CONDITIONAL OR STANDARD

Testing Dates C NC NA IOU Yes No

EC.02.05.09 Medical Gas and Vacuum Systems are Inspected and Tested

EP 7

Test, inspect and maintain critical 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 assessment if < annual

NFPA 99-2012: 5.1.14.2; 5.1.15; 5.2.14;

5.3.13

Per policy

EP 8

Location of and signage for bulk oxygen systems

NFPA 99-2012: 5.1.3.5.12

On Bldg. Tour

EP 9 Emergency oxygen supply connection NFPA 99-2012: 5.1.3.5.13 On Bldg. Tour

EP 10

Review medical gas installation/modification/breech certification results for cross connection, purity, correct gas, and pressure

NFPA 99-2012: 5.1.2; 5.1.4; 5.1.14.4.1;

5.1.14.4.6; 5.2.13

As applicable

Medical gas supply and zone valves are accessible and clearly labeled NFPA 99-2012: Table 5.1.11

NFPA 99-2012: 5.1.4; 5.1.11.1; 5.1.11.2;

5.1.14.3; 5.2.11; 5.3.13.3; 5.3.11

On Bldg. Tour

EP 12

Handling, transfer, storage, labeling, transfilling of cylinders

NFPA 99-2012: 11.5.3.1; 11.6.1; 11.6.2;

11.6.5; 11.7.3

Per policy

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- EPs

See Legend Document / Requirement Frequency Q1 Q2 Q3 Q4 Annual C NC NA IOU

EC.02.03.03 Fire Drills

EP 1

Fire drills once per shift per quarter in health care occupancies; Quarterly in each building defined as ambulatory health care occupancy (If available, please provide five quarters of fire drill data)

EP 2 Fire drills every 12 months from date of last drill: Business Occupancies Annually

EP 3

When quarterly fire drills are required, ALL are unannounced

• Drills held at unexpected times and under varying conditions – greater than one hour apart

• Drills include transmission of fire alarm signal and simulation of emergency fire conditions

NFPA 101-2012: 18/19: 7.1.7; 7.1; 7.2;

7.3

Quarterly (See fire drill matrix)

Staff participate in the drills according to the hospital's fire response plan

YES NO

Critiques include fire safety equipment and building features, and staff response

YES NO

See Legend Document / Requirement Frequency Yes No / Missing Date C NC NA IOU EC.02.05.01 Manages risks associated with utility systems

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).

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See Legend Document / Requirement Yes No C NC NA IOU EC.02.05.02 Manages risks associated with utility systems

– Water Management Program

EP 1 Verify individual or team responsible for oversight and implementation of the water management program

Review water management program to verify the following components are included:

• Diagram of water supply sources, treatment systems, processing steps, control measures, and end-use points

• Water risk management plan identifies areas where potentially hazardous conditions may occur

• Plan for addressing the use of water in areas of buildings where water may have been stagnant for a period of time

• Evaluation of immunocompromised patients

• Monitoring protocols and acceptable ranges for control measures

Verify that the water management program includes documentation of the following:

• Results of all monitoring activities

• Corrective actions and procedures to follow if test results are outside of acceptable limits

• Corrective actions taken when control limits are not maintained

Verify water management program reviewed annually and when changes have been made to the water system that add risk, new equipment or at-risk systems have been added that could generate aerosols or be source for Legionella

See Legend Document / Requirement Yes No C NC NA IOU EC.02.04.01 Management of Medical Equipment Risks

EP 2

Non-deemed status requirement: Maintains either a written inventory of all medical equipment or a written inventory of selected equipment categorized by physical risk associated with use (including all life-support equipment) and equipment incident history.

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.

EP 3 High-risk medical equipment identified on the inventory

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- EPs

See Legend Document / Requirement Yes No C NC NA IOU EC.02.04.01 Management of Medical Equipment Risks

EP 4

Inventory includes activities and associated frequencies for maintaining, inspecting, and testing all medical equipment on the inventory.

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

See Legend Document / Requirement Frequency Yes No / Missing Date C NC NA IOU 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.

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.

Conducts performance testing of and maintains all sterilizers

EP 10

All occupancies containing hyperbaric facilities comply with construction, equipment, administration, and maintenance requirements of NFPA 99-2012:

Chapter 14.

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- EPs

See Legend Document / Requirement Frequency Yes No / Missing Date C NC NA IOU EC.02.05.05 Utility system Inspection, testing and maintenance

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.

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.

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.

EP 7

Line isolation monitors (LIM), if installed, are tested at least monthly by actuating the LIM test switch. For LIM circuits with automated self-testing, a manual test is performance at least annually.

NFPA 99-2012: 6.3.2; 6.3.3; 6.3.3.3.2; 6.3.4

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Legend: C=Compliant; NC=Not compliant; NA=Not applicable; IOU=Surveyor awaiting documentation

STANDARD

- EPs See Legend Document / Requirement Frequency Yes No / Missing Date C NC NA IOU

EC.02.01.01 The hospital manages safety and security risks.

EP 1

The hospital implements its process to identify safety and security risks associated with the environment of care that could affect patients, staff, and other people coming to the hospital’s facilities.

Note: Risks are identified from internal sources such as ongoing monitoring of the environment, results of root cause analyses, results of proactive risk assessments of high-risk processes, and from credible external sources such as Sentinel Event Alerts.

EP 3 The hospital takes action to minimize or eliminate identified safety and security risks in the physical environment.

– EPs

See Legend Document / Requirement Frequency Yes No / Missing Date C NC NA IOU EC.01.01.01 The hospital plans activities to minimize risks in the environment of care.

EPs 1-9

The hospital has a written plan for managing the following;

EP-4 Environmental Safety EP-5 Security EP-6 Haz Materials EP-7 Fire Safety EP-8 Medical Equipment EP-9 Utility Systems

Note 1: One or more persons can be assigned to manage risks associated with the management plans described in this standard.

Note 2: For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital complies with the 2012 edition of NFPA 99: Health Care Facilities Code. Chapters 7, 8, 12, and 13 of the Health Care Facilities Code do not apply.

Note 3: For further information on waiver and equivalency requests, see https://www.jointcommission.org/resources/patient-safety-topics/the-physical-environment/life-safety-code-information-and-resources/ and NFPA 99-2012: 1.4.

https://www.jointcommission.org/resources/patient-safety-topics/the-physical-environment/life-safety-code-information-and-resources/ https://www.jointcommission.org/resources/patient-safety-topics/the-physical-environment/life-safety-code-information-and-resources/

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See Legend Document / Requirement Frequency Yes No / Missing Date C NC NA IOU

EC.04.01.01 The hospital collects information to monitor conditions in the environment.

EP 15

Every 12 months, the hospital evaluates each environment of care management plan, including a review of the plan’s objectives, scope, performance, and effectiveness.

See Legend Document / Requirement Frequency Yes No / Missing Date C NC NA IOU EC.04.01.03 The hospital plans activities to minimize risks in the environment of care.

The hospital uses the results of data analysis to identify opportunities to resolve environmental safety issues.

See Legend Document / Requirement Frequency Yes No / Missing Date C NC NA IOU EC.04.01.05 The hospital improves its environment of care.

The hospital takes action on the identified opportunities to resolve environmental safety issues.

See Legend Document / Requirement Addressed in policy? Implemented as required?

C NC NA IOU Yes No Yes No

LS.01.02.01 Interim Life Safety Measures (ILSM)

EP 1 ILSM policy identifying when and to what extent ILSM implemented

Alarms out of service 4 or more hours in 24 hours or sprinklers out of service more than 10 hours in 24 hours in an occupied building - Fire watch / Fire Dept. notification

NFPA 101-2012: 9.6.1.6; 9.7.6; NFPA 25-2011:

15.5.2

EP 3 Signs for alternate exits posted

EP 4 Daily inspection of routes of egress (See also

19.7.9.2 RE: daily inspections)

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- EPs

See Legend Document / Requirement Addressed in policy? Implemented as required?

C NC NA IOU Yes No Yes No

LS.01.02.01 Interim Life Safety Measures (ILSM)

EP 5 Temporary but equivalent systems while system is impaired

EP 6 Additional firefighting equipment provided

EP 7 Smoke tight non-combustible temporary barriers

EP 8 Increased surveillance implemented

EP 9 Storage and debris removal

EP 10 Additional training on firefighting equipment

EP 11 Additional fire drill per shift per quarter

EP 12 Temporary systems tested and inspected monthly

EP 13 Additional training on building deficiencies, construction hazards, temp measures

EP 14 Training for impaired structural or impaired compartment fire safety features

EP 15 Other ILSM's

NOTE: The following evaluation will be completed during the building tour.

See Legend Document / Requirement Frequency Yes No / Missing Date C NC NA IOU

EC.02.02.01 The hospital manages risks related to hazardous materials and waste.

EP 1

The hospital maintains a written, current inventory of hazardous materials and waste that it uses, stores, or generates. The only materials that need to be included on the inventory are those whose handling, use, and storage are addressed by law and regulation. (See also IC.02.01.01, EP 6; MM.01.01.03, EPs 1 and 2)

The hospital has written procedures, including the use of precautions and personal protective equipment, to follow in response to hazardous material and waste spills or exposures.

For managing hazardous materials and waste, the hospital has the permits, licenses, manifests, and safety data sheets required by law and regulation.

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See Legend Document / Requirement Frequency Yes No / Missing Date C NC NA IOU

EC.02.01.01 The hospital manages safety and security risks.

The hospital implements its process to identify safety and security risks associated with the environment of care that could affect patients, staff, and other people coming to the hospital's facilities.

Note: Risks are identified from internal sources such as ongoing monitoring of the environment, results of root cause analyses, results of proactive risk assessments of high-risk processes, and from credible external sources such as Sentinel Event Alerts.

The hospital takes action to minimize or eliminate identified safety and security risks in the physical environment.

EP 9

The hospital has written procedures to follow in the event of a security incident, including an infant or pediatric abduction.

EP 10 When a security incident occurs, the hospital follows its identified procedures.

Life Safety & Environment of Care Document List and Review Tool