Healthcare Compliance Updates – September 2021

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Healthcare Compliance Updates – September 2021



Selecting the Correct Portable Fire Extinguisher

Selecting the proper portable fire extinguisher for protecting patients, staff, and visitors is extremely important. The National Fire Protection Association (NFPA) Standard for Portable Fire Extinguishers, found in NFPA 10-2010 Chapter 5, provides this information which is a part of The Joint Commission (TJC) accreditation survey process. Providing the appropriate portable fire extinguisher can minimize, or even eliminate the impact of a fire in the healthcare setting.

The TJC explains that an organization should determine the type of portable extinguisher used based on a risk assessment conducted for the space requiring an extinguisher (NFPA 10-2-2010 5.1). When the hazard exceeds the capability of a portable extinguisher, a wheeled unit may be required, such as for a heliport or transportation garage. This risk assessment includes:

  • Type of fire most likely to occur
  • Possible size of the fire based on the environment
  • Types of fuels, such as combustibles and flammables in the space
  • Sources of potential ignition when using flammable germicides or antiseptics during surgeries or other activities
  • Potential for chemical reactions with the extinguishing agent
  • Presence of electrical equipment which could cause an electric shock from the extinguishment
  • Physical ability of the staff to use the extinguisher

Fires are classified in accordance to the fuel available and the surrounding equipment which include:

  • Class A Fires (5.2.1) – ordinary combustible materials, such as wood, cloth, paper, rubber, and many plastics
  • Class B Fires (5.2.2) – flammable and combustible liquids, petroleum greases, tars, oils, oil-based paints, solvents, lacquers, alcohols, and flammable gases
  • Class C Fires (5.2.3) – potential for energized electrical equipment
  • Class D Fires (5.2.4) – combustible metals, such as magnesium, titanium, zirconium, sodium, lithium, and potassium
  • Class K Fires (5.2.5) – cooking appliances which involve combustible cooking media, such as vegetable or animal oils and fats

The space requiring the portable fire extinguisher should also be assessed for associated hazards as follows:

  • Light (Low) Hazards ( – low quantity and combustibility of Class A combustibles and Class B flammables, including spaces normally containing quantities of Class A combustible furnishings, and/or the total quantity of Class B flammables less than 1 gal (3.8 L).
  • Ordinary (Moderate) Hazards ( – moderate quantity and combustibility of Class A combustibles and Class B flammables, including spaces occasionally containing Class A combustible materials beyond normal anticipated furnishings, or the total quantity of Class B flammables from 1 gal to 5 gal (3.8 L to 18.9 L).
  • Extra (High) Hazards ( – high quantity and combustibility of Class A combustibles or high amounts of Class B flammables, including material storage, packaging, and handling spaces, or the total quantity of Class B flammables expected to be more than 5 gal (18.9 L).

The selection of a fire extinguisher is determined by the class of the potential fire, the hazard in the space, and quantity of extinguishment required. Based on the risk assessment, the appropriate extinguisher should be installed, inspected, and maintained.

Remember, an extinguisher not exceeding 40 pounds shall be installed so that the top of the fire extinguisher is not more than 5 feet above the floor, and the bottom of the extinguisher is not less than 4 inches above the floor ( & The installation of an extinguisher outside these measurements are a common citation during the survey process.

New Survey Emphasis on Emergency Management

During the recent American Society for Health Care Engineering (ASHE) Annual Conference, The Joint Commission (TJC) addressed changes to the Emergency Management (EM) survey process for surveys beginning in July 2022. The TJC emphasized their goal to bolster the EM session, to make the EM chapter more robust, and to provide more direction for healthcare facilities. An increased involvement of leadership in the EM process appears to be a prime focus of the new EM process.

In the past, the EM session has not been as formal as other sessions of the survey process, such as Environment of Care and Life Safety.  This may have caused EM concerns not to get the attention of Leadership as TJC deems necessary. Most emergencies were of relative short duration, such as 96 hours. However, with the prolonged effects of the pandemic, it appears that this perspective will change to focus on preparing for long term effects of an emergency.


Some of the new focus of TJC for revising the EM survey process for healthcare organizations when dealing with long term emergencies include:

  • Assessing Leadership’s support in developing and implementing the Emergency Operations Plan
  • Developing new standards and elements of performance to focus on long term needs and the Center for Medicare and Medicaid Services (CMS) requirements
  • Providing a “glossary” of terms used to address various emergencies and activities
  • Increasing the benefit of the survey process to healthcare organizations in preparing for emergencies
  • Focusing on “long-term” issue of supplies and staffing shortages, financial means to support a prolonged event, and overall staff involvement


Changes in the survey process may increase the surveyto an hour or more, and involve more than just the EM Committee and EM Coordinator. The TJC expects to finish updating the new process by the end of 2021 for implementation in July 2022. This should be fun!



Managing “Crash” Carts for Emergencies (EC.02.04.01-.03)

The hospital’s emergency “crash” cart contains medical supplies and high-risk medical equipment which are available during an emergency. Failure to properly manage or test its contents, such as, medication, defibrillators, and medical gases, can promote a negative impact on patient safety (EC.02.04.01 & EC.02.04.03).

A recent EC News article noted that The Joint Commission’s (TJC) chapter, Provision of Care, Treatment, and Services, states, ”resuscitation equipment and supplies should be available based on the needs of the population served and should be available for rapid response to a life threating event for a patient”. Therefore, crash carts are considered always “in use” and can be positioned properly in a corridor and not be cited during an accreditation survey for blocking the path of egress (LS.02.01.20 EP 14).

The management of crash carts and their contents involves several concerns which should be addressed:

  • Frequency and task for inspecting, restocking, and testing the contents of the cart, including expiration dates for supplies and battery charge levels
  • Charging procedures for battery-powered emergency carts and defibrillators, which are not required to be plugged into emergency power receptacles (red outlets) to maintain charging of the batteries
  • Security measures, such as breakaway tags, to prevent tampering, theft, or alteration while not creating a barrier or delay in accessing emergency supplies
  • Locations of crash carts which are easily accessible with staff knowledgeable of their location when questioned
  • Crash cart inventory maintained and reviewed periodically
  • Inspection of crash carts included during routine Environmental Tours

In 2017, TJC issued a Quick Safety bulletin titled “Crash Cart Preparedness,” which lists some patient safety concerns, noted during the accreditation survey process:

  • Missing, expired, damaged, contaminated, and unavailable equipment or medications
  • Empty oxygen cylinders
  • Drained batteries on battery-powered equipment
  • Failed medical equipment when tested
  • Unsecured carts or carts which showed evidence of tampering
  • Carts not checked or inspected according to the organization’s policies and procedures
  • Carts not positioned in a designated location
  • Staff unfamiliar with the items commonly stored in the crash cart or procedures for using the cart during a life-threatening emergency

The medical equipment, supplies, and medications contained in the crash cart are used during emergencies to save lives and should be considered high-risk. The use of the crash cart should be included in medical emergency exercises to reinforce the location and use of the cart.


Importance of Posting “NO EXIT” Signage (LS.02.01.02 EP41)

In a recent publication of EC News, The Joint Commission (TJC) clarified the requirements and design of a “No Exit” sign (LS.02.01.02 EP41). A “No Exit” sign is needed to designate any door, passage, or stairway that is not an exit or is not an access to an exit which could be mistaken for an exit (NFPA 101-2012 .  This includes space with multiple doors which could confuse occupants regarding the proper door to use as an exit.

According to NFPA Life Safety Code 101-2012 (, the sign should state NO EXIT in the following manner:

The NO:

  • Capitalized
  • Letter 2 inches in height
  • Letters 3/8 inches wide


  • Capitalized
  • Letters 1 inch in height.

The NO is placed above the EXIT as below:



NFPA provides an exception to positioning of these words for approved existing signs but does not specify the exceptions. The TJC further emphasizes that the words “Not an Exit” were not permitted and would be scored as non-compliant during an accreditation survey.


Oxygen Cylinder Segregation and Storage (EC.02.05.09)

The proper segregation and storage of E-size, oxygen cylinders have always been an issue in healthcare facilities. The recent emphasis by The Joint Commission (TJC) on these storage and labeling procedures has caused much concern during the survey process. A recent update by TJC on March 19, 2021 provided some guidance.

Requirements for the proper cylinder segregation and storage, ensuring that full and empty cylinders are not comingled, are identified in National Fire Protection Association (NFPA), Health Care Facilities Code 99, and TJC EC.02.05.09 EP 6 & 12. The recent guidance stated:

  • Cylinders defined as “empty” by the organization’s policy shall be segregated from all other cylinders which are intended for “patient care use”.
  • Cylinders defined as “partially” full by the organization’s policy without an integral pressure gauge, and those equipped with gauges with depleted volume content as determined by the organization’s policy, are to be stored with empty cylinders.
  • Cylinders determined “full” and “partially” full by the organization’s policy are permitted to be stored together.
  • Cylinders determined “empty” by the integral gauge, as defined by the organization’s policy, are marked by individual tags or by group signage, as appropriate.

The guidance provided an example for the storage of oxygen cylinders per NFPA 99-2012, and stating:

  • A rack containing twelve cylinders are in an area.
  • Four of the cylinders are determined to be empty,
  • Empty cylinders must be segregated from the other cylinders.
  • Empty cylinders are labeled as “empty” by either individual tagging or by group signage.

However, the guidance goes further to state that If there is a separate rack designated for “empty” cylinders, the designation of this rack would accomplish the “marking” of the cylinders by the nature of the rack being labeled. This has been questioned often during the survey process.

It is important to have a written policy describing the level of gas in a cylinder, with an internal pressure gauge, to determine the “full” or “partially” full status of the cylinder. This is to determine the status of the cylinder’s gas contents, to place the cylinder in the appropriate rack, and to ensure the rack containing the cylinders is properly labeled.



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