TJC recently published the January 1, 2018 changes to its online Hospital Accreditation Standards Environment of Care (EC) and Life Safety (LS) chapters. With a few exceptions, those changes were driven by the CMS September 2016 publication of the NFPA 101-2012 and NFPA 99-2012 K-Tags according to previous TJC announcements.

This article discusses only the new EPs contained within the EC Chapter. Other changes will be discussed within future articles.

New Standard EC.01.01.01 (minimizing risks within the EOC), Element of Performance 3 (EP-3) contains the requirements for equipment and systems inspection, testing and maintenance (ITM) libraries.

Standard EC.02.01.03 (smoking prohibition) has a new EP-4 banning several types of ignition sources from respiratory therapy locations. The same standard also has two new EPs (new EP-11 and new EP-12) regarding requirements related to reducing surgical fire loss prevention. The apparent basis for the surgical fire loss prevention requirements is NFPA 99-2012 section 15-13, which is also referenced by EP-12. And finally, this same standard also has a new EP-13 invoking all of the NFPA 99-2012 Chapter 15 (Features of Fire Protection) requirements.

Standard EC.02.03.05 (fire alarm / fire protection systems ITM) has a new EP-27 regarding the monthly testing of elevator fire fighters emergency recall. This testing has historically been required under the Life Safety Code®.

Standard EC.02.04.03 (medical equipment ITM) has a new EP-8 regarding required marking of equipment within oxygen-enriched atmospheres. Also within this standard, new EP-10 invokes NFPA 99-2012 Chapter 14 (hyperbaric facilities.) And new EP-26 addresses anesthesia apparatus maintenance.

Standard EC.02.05.01 (managing utility system risks) has a new EP-2 invoking NFPA 99-2012 Chapter 4’s requirements pertaining to risk Categories 1-4. New EP-21 addresses electrical distribution risk categories.

Also within Standard EC.02.05.01 is new EP-20 invoking the NFPA 99-2012 operating room wet procedure location risk assessments. New EP-22 addresses electrical receptacles and new EP-23 addresses power strip requirements. New EP-24 discusses extension cords. And within inhalation general anesthesia locations, new EP-25 addresses requirements for medical gases and vacuum systems; and new EP-26 addresses the Essential Electrical System (EES) requirements.

Standard EC.02.05.03 (equipment to be connected to the EES branches) has a new EP-4 discussing specific life safety (LS) branch requirements serving areas containing life support systems. Also within this standard is a strangely-worded new EP-12 that basically appears to invoke the emergency power design requirements of NFPA 99-2012 paragraph 6.4.2.2. New EP-16 requires battery lamps and flashlights in areas that do not have emergency lighting.

Standard EC.02.05.03 also has 2 new EPs that originated as Standards Revisions for Phase I Medication Management Maintenance. These 2 new EPs will also take effect on January 1, 2018. New EP-14 requires implementation of a policy to provide emergency power backup for essential medication dispensing equipment, while new EP-15 requires the same thing (implementation of a policy) for essential refrigeration for medications. Both EPs have details with examples of the types of equipment described.

Standard EC.02.05.05 (utility system ITM) has a new EP-7 regarding line isolation monitor testing and maintenance.

Standard EC.02.05.09 (medical gas and vacuum) has several new EPs. New EP-1 discusses the medical gas and vacuum risk categories. New EP-2 discusses category-related warning requirements. New EP-3 discusses requirements for containers, cylinders and tanks. New EP-4 and EP-5 discuss location labeling requirements and first-in first-out cylinder utilization. New EP-6 discusses requirements when a cylinder pressure is used for determining when a cylinder is empty. New EP-13 discusses transfilling requirements.

Standard EC.03.01.01 (staff roles and responsibilities) has a new EP-1 regarding continuing education and training for staff with responsibilities within the previous standards of the EC chapter.

However, there is still more to the story. Don’t forget about the actual CMS K-Tags. SSR’s February 14, 2017 article entitled Compliance News: CMS 2012 Codes K-Tags Available discusses and lists those CMS K-Tags. Both CMS and the accrediting organizations are surveying to 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.