Healthcare Compliance Updates: April 2021


OSHA’s Proposed Rule Update to Hazard Communication Standard

To align the Hazard Communication Standard (HCS) with the current edition of the Globally Harmonized System of Classification and Labelling of Chemicals (GHS), OSHA proposed a rule “update” for later this year. The 300-page document strives to improve labeling directions for hazardous chemical containers and to revise the associated Safety Data Sheets (SDS). The focuses of the update are to:

  • Increase worker protection
  • Reduce the incidence of chemical-related occupational illnesses and injuries
  • Address issues raised since implementation of the 2012 standard
  • Improve alignment with other federal agencies’ requirements

These updates will affect the TJC’s, Hazardous Materials and Waste standards (EC.02.02.01 EP5 &EP11). A comment period is open until April 19, 2021, and can be submitted on the “Federal e- Details” available in the Federal Register Rulemaking Portal (, Docket No. OSHA-2019-0001.


TJC Recommends “Ventilation” Management Plan

Similar to the requirement for a Water Management Plan, TJC is now suggesting that organizations establish a “Ventilation Management Plan.” This also was a recommendation from ASHRAE (ASHRAE 170 -2013). As we all know, ventilation has been a primary focus of the TJC survey process for some time (EC.02.05.01 EP15-16). Some specific items in the Plan are:

  • Appoint team with various expertise including infection control, facilities, clinical, and environmental services to mention a few!
  • Assess spaces to determine the risks to patient care and service activities from the failure of the HVAC system (EC.02.05.01 EP2)
  • Identify HVAC systems serving specific spaces (EC.02.05.01 EP3)
  • Identify space generating airborne hazards including hazardous gases and vapors, dust, pathogenic organisms, etc. (EC.02.03.03)
  • List “high-risk” patient spaces for ventilation, including surgical suites, airborne infectious isolation rooms, and protective environment spaces
  • Determine the HVAC systems connected to Emergency Power Supply Systems (EPSS) (EC.02.05.03 EP7)

The Plan should also include requirements for maintaining the proper ventilation to reduce odors, provide comfort, and minimize airborne hazards, including the following:

  • Air exchange rates
  • Pressure relationships
  • Directional airflow
  • Humidity and temperature
  • Air filtration

To minimize the risks to patients, staff, and visitors from airborne hazards, the Plan should establish procedures involving all aspects of the organization. The following procedures should be established:

  • Monitor and evaluate ventilation parameters in a space
  • React and notify staff of ventilation risks
  • Establish action levels for conducting indoor air and particulate monitoring
  • Develop response plans for disruption of ventilation in various spaces
  • Document corrective actions taken and interim patient safety measures implemented to minimize identified risks
  • Conduct annual review of the Plan to determine the effectiveness


  Environment of Care


Fire Drill Matrix: Revised Version

The Fire Drill Matrix has become an essential and mandatory “Required Written Documentation” (RWD) for presentation during an “on-site” or “virtual” TJC survey (EC.02.03.03 EP3). TJC has made some recent revisions to the beloved form, including:

  • Document drills in Surgical and Hyperbaric Suites
  • Include other space considered “high-risk” for impact of fire on patients
  • List previous and current dates to demonstrate compliance with “annual” drill frequency
  • Prepare to use new matrix version by the 2021 second quarter
  • Use previous version of the matrix throughout the first quarter 2021

A blank matrix is provided by the Life Safety Code (LSC) surveyor for completion on first day of a “normal” on-site survey or requested for submission during a “virtual” survey. Should the organization currently be using the TJC-Fire Drill Matrix to demonstrate their compliance with the mandatory schedule, it can be used. Obtain revised TJC-Fire Drill Matrix through a link in TJC EC News, January 2021.

TJC Clarifies Quarterly Fire Drill Frequency

In an attempt to clarify the requirement for conducting fire drills and other quarterly testing, inspection, and maintenance (ITM) activities (EC.02.03.03), TJC provided a sample in the TJC’s EC News, January 2021:

if a health care occupancy holds a quarterly fire drill in February, the latest date for the next fire drill could be June 10, per The Joint Commission’s interpretation of quarterly.”

An earlier EC News edition (November 2020) stated that a quarterly fire drill conducted in February would have to be conducted the following May, not allowing for +/- 10 days of the quarterly period of the last activity as stated in January (EC.02.03.03 EP1).

However, the frequency for Triennial, Annual, and Semi-Annual ITM activities appears to require still +/- a certain number of days “from the last event” (CAM-H Chapter: Environment of Care; Page 1, January 2021). Earlier TJC presentations stated that the ITM activity requirement was from the “month of the last event.” Therefore, be sure to describe clearly the frequency followed for ITM activities in the policy and procedure for compliance with a specific Element of Performance.


  Emergency Management


Documentation: Required for EP references in EOP

As of January 1, 2021, TJC is requiring documentation for a number of Elements of Performance (EP) that are described in the Emergency Operations Plan (EOP). Most organizations maintain a “Tab Book” which contains documentation for use during a TJC survey and emergency. The EPs requiring documentation now include:

  • EM.02.01.01. EOP; EP7 – Identifying Alternate Care Sites
  • EM.02.02.01. Communication; EP4 – Notifying external authorities, EP7 – Suppliers, & EP12 – Patient information for a Third Party
  • EM.02.02.03. Resources & Assets; EP9 – Transporting patients and essentials to alternate care site
  • EM.02.02.05. Security & Safety; EP4 – Managing hazardous materials & waste
  • EM.02.02.07. Staff Roles & Responsibilities; EP7 – Training staff, & EP11 – Tracking location of on-duty staff
  • EM.02.02.09. Utility Systems; EP2 – Alternative electricity & lighting, EP3 & EP4 – Water, & EP7 – Other essential utility services
  • EM.02.02.11. Patient Managements; EP3 – Evacuating the facility, & EP5 – Managing patient personal hygiene & sanitation needs

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