Healthcare Compliance Updates – January 2022


New, Revised, and Deleted 2022 Physical Environment

The New Year always brings the excitement of change to the Joint Commission (TJC) Standards for the Physical Environment Chapters of the accreditation manual. This year is no exception, with new, revised, and deleted requirements reflected in the Elements of Performance (EP) for the Environment of Care (EC) and Life Safety (LS). Currently, Center for Medicaid and Medicare Services is reviewing the new Emergency Management (EM) Standards which will be in place later in the year.

Of significance, healthcare facilities, which do not meet the more stringent Life Safety requirements for healthcare or ambulatory healthcare occupancy, are considered as business occupancy. A group of new standards have been developed, specifically their own requirements for Life Safety. These cover general business requirements, means of egress, and fire protection in Standards (LS.05.01.10 -.35). Many standards in EC and EM chapters are already applicable to spaces considered as business occupancy. One requirement is to have a Management Plan, which describes the process to manage and minimize risks in the environment of these locations.

Some of the changes identified in the new TJC’s Comprehensive Accreditation Manual for Hospitals (CAMH) – January, 2022, are changes which occurred earlier in July 2021 or will apply in July 2022. There were several changes in the “cross-standard” references denoted in the EPs and some EPs were renumbered. The significant changes include the following:

Environment of Care

New Standard

  • 02.05.02 EPs 1–4: Requirements for a water management program

Revised Element of Performance

  • 02.01.01 EP 17: Requirement to conduct an annual worksite analysis related to their workplace violence prevention program
  • 04.01.01 EPs 1 & 6: Requirement to monitor, report, and investigate safety incidents, including workplace violence incidents

Deleted Element of Performance

  • 02.05.01 EP 14: Requirement deleted for management of waterborne pathogens and restated in a new standard EC.02.05.02

Emergency Management

New and Revised Standards – July 2022

  • New focus of the EM Standards: “to become effective with the overarching goal of providing more comprehensive, robust, and useful guidance on EM to health care facilities at a time when natural and human-caused disasters and public health emergencies are on the increase”. Note: see our recent  COHAN Healthcare Compliance Updates – December 2021  for more details on the new standards.

Life Safety

New Definition: Business Occupancy

  • 05.01.10.-35: a business occupancy as an occupancy used for the transaction of business other than mercantile. Outpatient clinics, administrative offices, and other functions that do not meet the more stringent definitions of health care occupancy or ambulatory health care occupancy are considered business occupancies.

New Standards: Business Occupancy

  • 05.01.10 EPs 1–7: Requirements to minimize the effects of fire, smoke, and heat
  • 05.01.20 EPs 1–9: Requirements to maintain the integrity of the means of egress
  • 05.01.30 EPs 1–4: Requirements to protect individuals from fire and smoke hazards
  • 05.01.34 EPs 1–3: Requirements to provide and maintain fire alarm systems
  • 05.01.35 EPs 1–6: Requirements that hospitals provide and maintain fire extinguishing equipment

New Requirements: Ambulatory Healthcare Occupancy

  • 03.01.35 EP 7: Related to spare sprinkler heads

Renumbered Requirements: Ambulatory Healthcare Occupancy

  • 03.01.35 EP 7: Now LS.03.01.35, EP 10
  • 03.01.35 EP 8: Now LS.03.01.35, EP 11

Deleted Requirements

  • Building Maintenance Program: determining compliance with the standards for Life Safety Code, NFPA 101-2021 including maintaining current Life Safety drawings (LS.01.01.01), as well as assessing Interim Life Safety Measures (LS.01.02.01) needed for deficiencies in the fire protection features of the building are required for all occupancies.

Plans for Managing Risks in the Environment of Care

Now that the Holidays are over and the Joint Commission (TJC) has issued the 2022 Environment of Care (EC) Standards, it is time to evaluate and revise the EC Management Plans. These Plans describe activities used to minimize risks in the environment and should be evaluated and updated at least annually (EC.01.01.01 & EC.04.01.01). This process is usually accomplished through a committee function, such as the Environment of Care Committee. Additionally, the EC Management Plans and the Annual Evaluations are requested initially during an accreditation survey.

Managing risks in the environment are different from the risks associated with patient care and service activities. A healthcare organization faces these specific risks in the environment, regardless of size, location, or specialty. According to TJC, the environment of care is made up of three basic elements:

  • The building or space, including arrangement and special features that protect patients, visitors, and staff
  • Equipment used to support patient care or to safely operate the building or space
  • People working within the hospital, patients, and anyone else entering the environment, which have a role in minimizing risks

The TJC has identified specific risks requiring a Management Plan. These risks are addressed by Standards containing descriptive Elements of Performance (EP), which identify requirements to minimize risks.  These Management Plans and Standards are:

  • Safety (EC.02.01.01)
  • Security (EC.02.01.01)
  • Hazardous Material and Wastes (EC.02.02.01)
  • Fire Safety (EC.02.03.01 – .05)
  • Medical Equipment (EC.02.04.01 – .03)
  • Utility Services (EC.02.05.01 – .09)

If an organization has several sites, such as Out-patient Surgery, Infusion, and Imaging centers, the specific risks and unique conditions of each site should be addressed in a Management Plan. One Plan may cover all sites or a separate plan may be developed for each site. Additionally, all the Management Plans for each risk may be combined into an Overall Management Plans, but having a separate Plan for each risk is easier to demonstrate compliance with the requirements in a Standard.

Specific topics are required in a Management Plan in order to comply with the annual evaluation requirements (EC.04.01.01 EP15). These items include:

  • Scope – a statement describing the actions taken to minimize the risk in the environment
  • Objectives – current activities addressed for improving the environment
  • Performance – rate-based measures of activities used to manage a risk or to improve the environment

Also, the Management Plan should include topics that demonstrate the management of the risks, including:

  • Responsibility – Identifies individuals responsible for managing a specific plan, such as Safety Officer – Safety Plan, and Clinical Engineering Director – Medical Equipment Plan, etc.
  • Function – describes the ongoing activities used to minimize risks such as surveillance tours, education efforts, and maintenance activities
  • Program Management Elements – briefly describes activities contained in policies and procedures used to minimize risks identified in the EPs associated with the Standards

The Management Plan does not provide policy but serves as the “cliff-notes” to describe activities used to minimize the risks documented in a policy, procedures, testing tasks, etc. Referencing the associated documentation for each EP makes demonstrating compliance easier during a survey.

As mentioned, the evaluation of the Management Plans is required at least annually and includes specific topics of the Plan. Each topic should be evaluated based on the items in the current Plan. This includes:

  • Scope – does the Plan describe the current process used to minimize the risks?
  • Objectives – were the objectives “met” or “not met” and why?
  • Performance Measures – did the measures demonstrate an improvement to minimize a risk-based on data collected over the year?
  • Effectiveness – was the Plan effective as written for managing the identified risk?

Based on the Evaluation, the Management Plan for the following year is prepared with new Objectives and Performance Measures if needed. Identifying Objectives and Performance Measures for the next year in the Evaluation makes a nice carry over for the new Plan. Remember, this evaluation is conducted of the Management Plan, not the Program. Having comprehensive and concise Management Plans and Evaluations, which describe a process for managing specific risks identified in the EPs of the Standard, provide a good beginning to a survey.



Importance of a Fire Door and Assembly Inspection Program (EC.02.03.05)

A fire door and assembly are important components of the fire protection system of the healthcare environment used to control the spread of fire from one area of a building to another. Performing the appropriate inspection, testing and maintaining (ITM) activities of these components at the proper frequency is essential in the protection of patients, staff, and visitors. Maintenance should be an on-going process, but the documentation of inspection and testing activities is required at least annually for compliance with the Joint Commission (TJC) and National Fire Protection Association (NFPA) requirement (EC.02.03.05 EP 20 & NFPA 80: 5.2.1). The proper management of fire doors and assemblies requires a Fire Door and Assembly Inspection Program.

The key elements of a quality Program include the following:

  • Policy – describe inspection team’s qualifications, inspection procedures and frequencies, risk and Interim Life Safety Measure (ILSM) assessment processes, and correction and retesting actions
  • Door inventory – identify the location and the space protected (stairwell, building separation, etc.)
  • Documentation – provide the data of inspecting and testing, assessment, corrective actions, and retesting activities

The policy should provide key information about the Program, including:

  • Training and experience of the individuals conducting the inspecting and testing activities, especially contract services, for presentation during an accreditation survey
  • Inspection and testing frequency, especially for a staged schedule due to the vast number in some facilities
  • Maintenance program for nonrated doors, including corridor doors to patient care rooms and smoke barrier doors, not required annually but should be routinely inspected and maintained

A current inventory of the fire doors and assemblies is essential to document compliance with the testing and inspection requirements in the policy. Failure to have a current inventory could be problematic during the building tour for an accreditation survey. The documentation for an inventory should contain the following:

  • Location and protection provided (stairwell, building separation, etc.) based on the current life safety drawing and building tour information
  • Current status of the fire door and assembly
  • Measures implemented, if necessary, from an ILSM assessment based on the impact of the risk of the deficiency on the protection of patients, staff, and visitors
  • Non-rated doors listed separately from fire doors and assemblies

The old adage holds for the fire door and assembly program, “if it isn’t written down, it did not happen”. Maintaining the appropriate and meaningful documentation for testing and inspection activities is essential, especially in reports provided by a contracted service. At least the following documentation should be included:

  • Qualification of individual conducting the activities
  • Date of the activities
  • Status of each fire door and assembly on the inventory (Pass, Fail, Not Tested, etc.)
  • ILSM assessment, corrective actions, re-inspection, and retest date for each deficiency
  • Appropriate NFPA testing reference (i.e., NFPA 80 2010)

During the inspection and testing process, any deficiency should be reported to the responsible department at least at the end of the day’s activities. Those situations which demonstrate a high risk to the fire protection features of the area should be reported as soon as possible. Since all deficiencies may not be corrected immediately, a risk assessment for the impact of the deficiency on the fire protection features should be conducted and those deficiencies with the greatest risk should be addressed first. Remember, all deficiencies should be assessed for ILSM activities when identified, measures implemented when appropriate, and actions documented. Maintaining proper documentation is key to an effective Fire Door and Assembly Inspection Program.

Maintaining Necessary Documentation for Automatic Transfer Switches (EC.02.05.01)

The Automatic Transfer Switch (ATS) is a crucial component of the Emergency Power Supply System (EPSS) needed to maintain essential patient care and services during the loss of normal electrical power. Providing the proper documentation for each ATS is extremely important to demonstrate compliance with the requirements of the Joint Commission (TJC) standards. Requirement for documentation for each ATS appears in four Standards involving seven Elements of Performance (EP).

The starting point for documenting compliance with the TJC standards is the complete identification of each ATS on the Utility System Component inventory (EC.02.05.01 EP3). The inventory should identify the associated generator, circuit supplied, and the space served. Based on this information in the inventory, the following documentation should be maintained:

EC.02.05.01      Utility System Management               

  • EP2: Risk Assessment – assess the impact of failure for each ATS on patient care served by that ATS
  • EP4: High Risk – identify each ATS which could cause death or severe injury if failed as “high-risk” on the inventory
  • EP5: ITM Activity and Frequency – Identify, in a work order system, the ITM activities required for each ATS based on manufacturer’s recommendations or alternative equipment maintenance program assigned

EC.02.05.03      Emergency Electrical Power Sources            

  • EP1: Electrical Branches Served – identification of the branch served by the ATS, being life safety, critical, or equipment branch
  • EP2 – 16: Response Time – each ATS provides essential electrical services to a specific service including high-risk spaces and critical equipment within 10 secs of loss of normal power

EC.02.05.05       Utility System Testing            

  • EP5: ITM Activities Completion Rate – document that all ITM activities identified for each ATS are completed on time

EC.02.05.07      Emergency Power Systems Testing                          

  • EP4: Weekly Inspection – document that the weekly inspection of the generators includes the inspection for each ATS device and the status noted as “pass” or “fail”.
  • EP7: Monthly Test – document that each ATS serving a generator is tested for operation and function and the status noted as “pass” or “fail”. By rotating the ATS used to initiate the start each month, it helps ensure that all of the ATS’s are exercised and will function properly.

Often, the documentation for a generator’s weekly or monthly ITM activity does not list each ATS serving that generator or the status of the ITM activity (Pass or Fail). Additionally, the identification information for an ATS, listed on a generator ITM activities report, may not match the information on the inventory or in a work order system for that ATS. This can lead to confusion during the documentation review portion of an accreditation survey.


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