TJC recently published the July 1, 2017 changes to its online Hospital Accreditation Standards Environment of Care (EC) and Life Safety (LS) chapters.

Published changes include some clarifications and corrections to previously-issued changes, such as EC.02.05.01 Element of Performance 6 (EP-6) regarding inspection, testing and maintenance (ITM) for non-high-risk utility system components.  This change modified the previously-permitted 90% on-time ITM completion rate for non-high-risk components managed through an Alternative Equipment Maintenance (AEM) Program to the new CMS-imposed requirement of “must have a 100% completion rate.”  The new note within this EP also states “AEM frequency is determined by the hospital AEM program.”  ASHE members who did not attend the March 2017 PDC conference could review a recent on-demand ASHE-sponsored TJC webinar where TJC Director of Engineering George Mills clarified the impact behind the statement regarding AEM frequency.

Similar changes occurred within medical equipment standards.

Another change occurred within LS.01.01.01 EP-1, where a new added sentence states “Note: For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital complies with the 2012 Life Safety Code.”  Although not a surprise since we all knew this anyway, the added language also has the impact of turning that EP into a “wild card” EP where miscellaneous LS Code violations could be scored.

Under the Interim Life Safety Measures standard (LS.01.02.01), EP-15 has a new Note 1 stating “Note 1: The hospital’s ILSM policy addresses Life Safety Code Requirements for Improvement (RFI) that are not immediately corrected during survey.”  It appears that this new note will require changes to many existing ILSM Policies.

However, there is still more to the story.  Don’t forget about the other pending changes necessary to further align TJC’s EPs with the CMS K-tags.  SSR’s March 16, 2017 article entitled Compliance News: More Pending Changes due to CMS 2012 Codes K-Tags discusses those still-pending changes.  It is worth mentioning again that accrediting organizations are surveying now to all associated requirements within or mandated by the adopted 2012 codes.  It is incumbent on organizations to have the appropriate codebooks and related updated NFPA standards, and to be aware of all changes that result from the 2012 codes.

You may contact the writer at DStymiest@ssr-inc.com if you have questions on this content.