In late September 2017, The Joint Commission released 87 pages of standards changes in the Environment of Care and Life Safety chapters. That’s a lot of changes! To be fair, this included the LS standards for both healthcare occupancies (LS.02) and ambulatory healthcare occupancies (LS.03) …but it’s still a lot!
First of all, none of these changes should have been a complete surprise since they, essentially, reflect the CMS changes based on the adoption of the 2012 editions of NFPA 99 and NFPA 101 in July 2016. These 2018 changes are those that were not able to be incorporated in the 2017 Joint Commission Standards simply from a timing perspective. Since the beginning of 2017, though, all of these issues have technically been scorable under the Joint Commission “wild card” standards (“all other NFPA 101/NFPA 99 requirements in chapter X”). The difference is that now all of these are in writing and are more top-of-mind for the surveyor. Therefore, they must be top-of-mind for those responsible for compliance in healthcare organizations as well.
It is important to read the standards closely. While the new EPs meet the intent of the CMS K-tags written to correspond with the 2012 codes, the statement of The Joint Commission’s expectation, as written in the elements of performance, may reflect a slight variation. In some cases, there are new documentation requirements or additional notes to explain compliance.
In the Environment of Care chapter, new EPs appear in some existing standards that include (but are not limited to):
- EC.02.03.03 EP 3: All fire drills must be unannounced
- EC.02.03.05 EP 27: Monthly testing of elevator fire fighters’ operations
- EC.02.05.01 EPs 2, 20, and 21: Documented NFPA 99 risk assessments of utility systems and ORs as wet locations
- EC.02.05.05 EP 7: Monthly testing of any line isolation monitors
- EC.02.05.07 EP 2: Annual testing of battery operated task lighting in deep sedation and anesthesia locations
One of the most important changes, and one that can have a big impact on healthcare organizations, is found in the LS.03 ambulatory healthcare life safety standards. In every standard starting with LS.03.01.10, note 2 states,
“For hospitals that use Joint Commission accreditation for deemed status purposes: This standard applies to outpatient surgical departments associated with hospitals, regardless of the number of patients rendered incapable.”
This brings The Joint Commission standards in line with the long-held CMS interpretation. Take a close look at any sites under your organization’s accreditation certificate. Even one person rendered incapable of self-preservation in an outpatient surgery setting requires an ambulatory healthcare occupancy type and will be surveyed accordingly.
In addition, the elements of performance in the Life Safety chapter have been renumbered, in many cases, to align with the sequence reflected in the Life Safety Code®.
So, get out those reading glasses and a cup of coffee and spend some dedicated time reviewing this required reading!
Remember, you’re not alone; we’re here to help. Contact us to schedule a mock survey, document review, life safety assessment, or many other customizable services. Feel free to reach out to us even if you have a question on how to comply with a standard. MSL exists to make healthcare organizations, like YOU, safe beyond compliance.