In the first quarter of 2017, we have seen a number of changes to the Joint Commission standards. It can be difficult to keep track of all the changes, so we have compiled the changes in the following list, separated by category:

SURVEY PROCESS:

  • Surveys have been very difficult in Environment of Care and Life Safety.
  • Elimination of “C” standards and the “see it – cite it” philosophy have resulted in a dramatic increase in findings. Each observation of a problem is written. 
  • Pressure differential problems may be scored in box 9 on the SAFER Matrix, or sometimes Immediate Threat to Life.
  • There is a significant increase in the number of surveys with condition level deficiencies. Sometimes this is due to the number of findings rather than severity.

DOCUMENT REVIEW:

  • All documents are expected to be available at the time they are requested or very shortly thereafter. Missing documents will not be accepted later.
  • Any questions about document review must be asked on site. There are no document-related clarifications permitted post-survey.

STATEMENT OF CONDITIONS:

  • Anything previously documented on an SOC will not be reviewed.
  • All deficiencies will be cited, regardless of previous identification by organization.
  • If there were inaccessible dampers on the SOC, access must be created.
  • There is still a requirement to do a building assessment for Life Safety Code (LSC) compliance at frequency to be determined by organization.  (LS.01.01.01 EP2)
  • Highly recommend still proactively managing LSC compliance in the building with an SOC-like tool. Joint Commission SOC is still available online, use your own, or even a spreadsheet.
  • The goal is to have no deficiencies at survey.
  • Equivalencies may no longer be proactively requested. They will only be considered if the organization has first been cited by Joint Commission and/or CMS.

CATEGORICAL WAIVERS:

  • With the adoption of the 2012 editions of the LSC and NFPA 99, most categorical waivers are no longer necessary.
  • The only potential waiver still needed is to use an OR humidity range of 20-60%. This must also include a risk assessment for supplies and equipment stored in the OR under lower humidity, as well as consideration of the HVAC manufacturer’s recommendations. Note that this waiver ONLY applies to ORs, and not to Sterile Processing or sterile storage.

POST SURVEY:

  • A Survey-Related PFI (S-PFI) will be generated. There must be someone in the organization designated to manage this.
  • The default is a 60-day correction period for all items on the S-PFI, and all findings in general.
  • If LSC deficiencies cannot be corrected within 60 days, a Time-Limited Waiver (TLW) must be requested within 30 days post-survey. This can be done on line through Joint Commission. When requesting a TLW, choose your anticipated completion date carefully. There will be no extensions granted.

STANDARDS DELETIONS:

  • Many elements of performance (EPs) have been deleted in the EC chapter. Some of the deletions are fairly irrelevant.
  • Some deletions are made because the process should be part of regular operations or are implicit in another EP. These are still recommended by MSL for compliance and include:
    • Safety Officer intervention authority
    • Annual performance improvement recommendation to leadership
    • Evaluation of changes made by the EC Committee to determine resolution
    • Protective measures for patients when a generator test fails
    • Retest after generator repairs following failure
  •  Some deletions are left to the organization's discretion. At MSL, we strongly believe that these are integral to your EC program and highly recommend they remain part of the organization’s Environment of Care management process and are best practices. These include:
    • Environmental Tours
    • Scheduling and use of data from Environmental Tours
    • EC Committee membership composition

2017 STANDARDS:

  • CMS generated additional K-tags with the adoption of the 2012 editions of NFPA 101 and NFPA 99.
    • Some of the new K-tags are reflected in the 2017 Joint Commission standards.
    • Since all JC standards must now be vetted by CMS, other K-tags did not make it into the standards due to timing issues. These K-tags are STILL BEING SCORED at various “wild card” elements of performance throughout the EC and LS chapters of the accreditation manual.
  • Wild card standards include:
    • EC.02.04.03 EP 14:  All other Healthcare Facilities Code requirements, NFPA 99 (2012) chapter 10
    • EC.02.05.05 EP 7:  All other Healthcare Facilities Code requirements, NFPA 99 (2012) chapters 6 and 9
    • EC.02.05.09 EP 8:  All other Healthcare Facilities Code requirements, NFPA 99 (2012) chapters 5 and 11
    • LS.02.01.XX, The last EP of each standard: All other Life Safety Code requirements, NFPA 101 (2012),  chapter XX
  • All EPs that are related to any of the NFPA codes have new code references, and some have changed testing frequencies.
  • Many EPs were relocated within the standards.

NEW 2017 REQUIREMENTS:

  • EC.02.03.05 EP 25:  Annual fire door inspection.
  • EC.02.04.03 EP 3:  Non-high risk medical equipment in an AEM program. Requires a 100% preventive maintenance completion rate.
  • EC.02.05.03:  Emergency power within 10 seconds.
  • EC.02.05.05 EP 1:  Infection control during general maintenance.  (Also appears in EC.02.06.05 EP 2)
  • EC.02.05.07 EP 4:  Weekly generator inspection.
  • EC.02.05.07 EP 8:  Annual generator fuel test.
  • EC.02.05.09 EP 2:  Bulk oxygen systems location and signage.
  • EC.02.05.09 EP 6:  Gas cylinder policy.
  • LS.01.01.01:  New requirements related to SOC discussion, above.
  • LS.02.01.01 EP 2:  Fire department notification and fire watch requirements.
  • LS.02.01.01 EP 15:  Other ILSMs.
  • LS.02.01.10 EP 2:  Reference NFPA 101 (2012) chapter 43 for building rehabilitation.
  • LS.02.01.10 EP 4:  Building and occupancy separations.
  • LS.02.01.10 EP 5:  Rating of opening protectives in fire barriers.
  • LS.02.01.10 EP 6:  Rating of exit stairs.
  • LS.02.01.10 EP 9:  Rating of dampers.
  • LS.02.01.20 EP 10:  Nothing unrelated in exit enclosure.
  • LS.02.01.20 EPs 14 & 15:  Corridor width in new and existing construction.
  • LS.02.01.20 EPs 23 & 24:  Suite separation and subdivision.
  • LS.02.01.20 EPs 27-29:  Suite size.
  • LS.02.01.30 EPs 2 & 3:  New and existing hazardous areas.
  • LS.02.01.30 EP 4:  Cooking areas open to corridor.
  • LS.02.01.30 EP 5:  Installation of alcohol-based hand sanitizer.
  • LS. 02.01.30 EPs 8 & 10:  Corridor partitions.
  • LS.02.01.30 EP 19:  Doors in smoke barriers.
  • LS.02.01.30 EPs 20-22:  Openings in smoke barriers.
  • LS.02.01.30 EP 23:  Patient rooms have outside window or door.
  • LS.02.01.30 EP 24:  Window sill height in new patient sleeping rooms.
  • LS.02.01.34 EP 3:  Ceiling membrane permits activation of smoke alarm.
  • LS.02.01.35 EP 5:  Adds missing escutcheons.
  • LS.02.01.35 EP 7:  At least 6 spare sprinkler heads of each type.
  • LS.02.0135 EP 8:  No sprinklers required in clothing closets.
  • LS.02.01.35 EP 9:  Quick response sprinklers in new patient sleeping compartments.
  • LS.03.05.35 EP 12:  Grease producing cooking devices have hood, ducts, and grease removal devices.
  • LS.02.01.50 EP 1:  Fireplaces meet requirements.
  • LS.02.01.70 EP 1:  No smoking in any compartment with flammable liquids, combustible gases, or oxygen, and appropriate signage.
  • LS.02.01 70 EP 2:  Ashtrays where smoking is permitted.

This is quite a list of changes to digest! Please feel free to contact us with your consulting needs. At MSL, we truly believe we have developed the powerful tools and have built the experienced team necessary to navigate these changes.

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