Healthcare Compliance Updates: June 2021




Environment of Care Survey Process Modified

Beginning in 2021, organizations receiving a Joint Commission (TJC) accreditation survey (primarily hospitals and critical access hospitals) will undergo a different survey of the Environment of Care (EC) standards. This modified survey process includes:

Life Safety Code (LSC) Surveyor will review EC documents as part of building tours

  • Previously held, hour-long EC Committee meeting is scrubbed
  • Clinical surveyors may review EC compliance issues as part of their normal survey process, which may include “obvious” life safety observations
  • LSC Surveyor will use the TJC’s, “Life Safety and Environment of Care Document List and Review Tool” for direction and survey focus points

Accreditation surveys, which have occurred following the COVID -19 “pause” appear to have a greater focus on the presentation of documentation than in the past. Well-presented policies, and, more importantly, inspection, testing and maintenance (ITM) documents, are key elements in the preparation for any survey. Failure to have concise ITM documentation can jeopardize a survey.


Fire Damper Testing: Ambulatory & Business Occupancy Portions of the Hospital

Existing fire and smoke dampers are to be “operated” and inspected every six years in healthcare facilities as required by the Joint Commission (TJC) to verify they fully close (HAP -EC.02.03.05 EP18). For those separate “ambulatory” locations, the requirement is testing every four years (AHC – EC.02.03.05, EP18). However, determining the inspection frequency becomes blurry for dampers located in spaces designated as “ambulatory” occupancies when intermixed within a healthcare facility! Should it be four or six years?

The National Fire Protection Association (NFPA) reference identified in both TJC requirements states the following:

  • NFPA 80-2010 The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years.

The keyword is “hospital” which pertains to the location of the dampers within the building. As defined in NFPA 1 20121, Definitions;

  • Hospital – A building, or portion thereof, used on a 24-hour basis for the medical, psychiatric, obstetrical, or surgical care of four or more inpatients. [101, 2012]

Therefore, those spaces in the “portion” of the building defined as “ambulatory” occupancy, based on patient care services identified in NFPA 1 –, should have dampers inspected and tested every four years rather than six as may be the custom is now. A damper inventory should “clearly” identify those dampers as totally in the “ambulatory” occupancy portions of the hospital to document the required four-year testing.


FGI Document: Guidance for Responding to Emergency Conditions

In response to the COVID-19 Pandemic, the Facility Guidelines Institute (FGI) developed a white paper: “Guidance for Designing Health and Residential Care Facilities that Respond and Adapt to Emergency Conditions”. The paper provides practical guidance for establishing accommodations for healthcare patients as well as for adapting existing facilities to meet the particular needs of a pandemic or other emergency events.

Topics of key importance are provided in specific sections to allow a focused approach. These sections include:

  • Risk Assessments – assessment for disaster, emergency, and vulnerability assessment (DEVA), which incorporates the safety risk assessment (SRA) and the CMS mandated Hazard Vulnerability Analysis (HVA)
  • Surge Capacity Considerations – conversion of existing exterior areas into support spaces, and repurposing spaces to meet current patient care needs
  • Alternate Care Sites – utilization of other structures for patient care needs such as tents, modular units, and nearby buildings
  • Resiliency- response to various weather and man-made events, such as hurricanes, floods, and utility outage
  • Renovation and Future Facility Design – approach to planning renovated and new facilities to meet the potential emergency condition with three types of recommendations: “basic” “enhanced,” and “advanced”
  • Small and/or Rural Health Care Facilities – approach for rural and smaller facilities to prepare for potential emergencies with economic challenges
  • Emergency Preparedness in Residential Settings – information on preparedness for nursing homes, hospice facilities, and assisted living settings

FGI CEO, Douglas S. Erickson states that the overarching goal of the white paper is “to help health and residential care organizations respond to emergency events and plan mitigation strategies in anticipation of future emergency events”. The press release states that the draft also provides updates to the FGI document, “Guidelines for Emergency Conditions in Health and Residential Care Facilities.” A three-month public comment period opens concurrent with the release of the white paper on April 1, 2021 and closes on June 30, 2021.



Spare Electric Breakers: Labeled and Placed in “Off” Position – EC.02.05.01

As of January 1, 2021, finding a “spare” breaker in the “on” position in an electrical panel will result in a Requirement for Improvement (RFI) during a TJC survey (EC.02.05.01 EP9). To mitigate an RFI:

  • Review current procedures for inspecting, managing, and labeling breaker
  • Update the inventory of the panels and identify spares correctly
  • Document inspections for each panel in inventory per policy frequency
  • Check panels during environmental tours to demonstrate an on-going process


Water Management Becomes a New TJC Standard EC.02.05.02

After residing in the Utility System Management Standard (EC.02.05.01 EP14) for many years, the requirements to minimize waterborne pathogens will become a new Joint Commission (TJC) Standard, EC.02.05.02, in January 2022. The Standard provides specific Elements of Performance (EP1-4) for compliance guidance which were not available before, and should be used during a survey to determine compliance.

The new Standard combines both facility management and infection control activities into a Program to minimize the risk of exposure to patients, staff, and visitor from Legionella and other waterborne pathogens. A major focus is the assessment of the exposure risks from water sources and equipment on patient care activities. The new Elements of Performance are:

Management (EP1)

  • Identify the team responsible for the oversight and implementation of the Program
  • Recognize development, management, and maintenance activities

 Water Systems Information and Risk Assessments (EP2)

  • Develop water flow diagrams for water supply sources, control treatment measures, and point of use components
  • Conduct risk assessments of water sources, equipment, and medical equipment to identify potentially hazardous conditions (ASHRAE – 188)
  • Conduct risk assessments of patient care and services activities spaces for the risks of exposure to waterborne pathogens from water sources and equipment. (CDC – WICRA)
  • Identify and implement control measures to minimize risks, including temperature, chemicals and water flow

Monitoring, Implementing Corrective Actions and Documenting Results (EP3)

  • Document monitoring activities, including treatment levels and pathogen testing results
  • Implement corrective actions and procedures to address “out of range” conditions
  • Document results of corrective actions when control limits are not maintained

Program Review (EP4)

  • Review annually prior to the end of the calendar year
  • Evaluate water systems after changes which could potentially add risks
  • Examine additions of new equipment which could generate aerosols or be a potential source for Legionella
  • Review water sources and systems prior to commissioning a new wing or building

Though the Standard was approved by Centers for Medicare & Medicaid Services (CMS) in January 2021, it will not be officially published until July 2021, though surveys began in January 2020. The organization’s Water Management Plan should be updated to include the new Elements of Performance requirements.


Clarification of Eyewash Station Requirements when Handling Chemicals

A recent article in the Joint Commission’s (TJC) publication, Joint Commission Perspectives®, (March 2021, Volume 41, Issue 3), clarified the requirements for providing eyewash stations when handling hazardous chemicals (EC.02.02.01 EP5). The TJC “Consistent Interpretation” article referenced standards from the American National Standards Institute’s (ANSI) Eyewash Standard (Z358.1) and Occupational Safety and Health Administration (OSHA). Of interest are these listings:

  • Strict compliance with the ANSI Standard Eyewash Standard (Z358.1) is not required
  • An organization is required to self-determine the frequency of the eyewash station “checks” as well as define and comply with its identified time frame
  • An organization can be cited, “only if a caustic or corrosive chemical is identified and documented in the observation, and an approved eyewash station is not present
  • A corrosive or caustic is defined as any chemical having a pH less than 2.0 or greater than 11.5 (OSHA (29 CFR 1910.151[c])
  • High-level disinfectants typically do not require an eyewash station, but it does vary from manufacturer to manufacturer
  • Eyewash stations are not required where noncorrosive chemicals or irritants are used, mixed, and dispensed
  • An eyewash station is not required for “simple” storage of corrosive chemicals

To be compliant and provide proper eyewash stations, organizations must develop a policy which defines its requirements based on hazards identified in the chemical Safety Data Sheet (SDS) and manufacturers’ recommendations. The policy should identify a process to conduct the following:

  • Review the SDS for hazards and precautions for chemicals listed in its inventory (EC.02.02.01 EP1)
  • Conduct a risk assessment based on the SDS to determine the appropriate need, correct placement, and required “checking” and maintenance activities
  • Define clearly, follow, and document the maintenance and installation processes
  • Specify, follow, and document eyewash “checks” by the “defined” time frame frequency based on the risk assessment
  • Install hot and cold water mixing valves to maintain water temperature between 60 and 100 degrees (documented temperatures are within range if a valve is not installed)

The placement of the eyewash station is important for minimizing the risk of injury. At a minimum, the placement should be:

  • Accessible where the corrosive or caustic chemicals are used, mixed, and dispensed
  • Without obstruction or being blocked; i.e., behind a linen cart, locked door, or other structure
  • Within 10 seconds of hazard by way of normal pathways, roughly 55 feet

An eyewash station is important for minimizing the risk from corrosive and caustic chemicals, but it should not replace the use of the proper Personal Protective Equipment (PPE). The appropriate PPE must be available and used in accordance with SDS criteria (EC.02.02.01 EP3). The organization should establish a clear policy which identifies the “checking” frequency and process and should obtain a copy of the Perspectives article to reference for compliance during a survey.








Talk to an expert about your compliance needs.