TJC recently finalized the January 1, 2018 changes within 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 the major changes to existing EPs within the EC Chapter.  A previous article discussed the new EPs contained within the EC Chapter.  Whenever and wherever those new EPs were added, the existing EPs below those points were renumbered to reflect their new sequence. Those changes occurred in many of the EC Chapter standards as well as within the LS Chapter standards. This type of change makes it particularly difficult for organizations that have been using TJC Standard number and EP number within their own documentation filing systems.

Other changes (such as specific LS Chapter changes) will be discussed within future articles.

Standard EC.02.03.01 (managing fire risks) added text into EP9 requiring periodic instruction of staff and licensed independent practitioners on their duties, and requiring that a copy of the fire response plan be in at least one of the two stipulated areas.

Standard EC.02.03.01 (fire drills): a change within EP3 requires all quarterly fire drills to be unannounced starting in 2018 instead of 50% unannounced as previously required.

Standard EC.02.03.05 (fire alarm / fire protection systems ITM) has corrections within four EPs that change referenced NFPA paragraph numbers and NFPA table numbers.  These changes should be reflected in the relevant work orders and fire alarm / fire protection system ITM procedures.

Also within Standard EC.02.03.05, please note that the door ITM EPs (EP20 and EP25) have not yet been modified to reflect any changes necessitated by the recently-issued CMS S&C Letter 17-38-LSC (Fire and Smoke Door Annual Testing Requirements in Health Care Occupancies.)  We recommend that our readers stay tuned for potential future changes related to the CMS S&C Letter.

Standard EC.02.05.01 (managing utility system risks): EP1 has been modified to require that utility system design and installation according to NFPA codes.  Within EP15 (critical care area airborne contaminants) has been modified to eliminate the listing of sample types of spaces covered by that EP.)

Standard EC.02.05.07 (emergency power supply system and essential electrical system ITM): EP1 has been modified to expand the battery-powered egress lights testing to include emergency lighting systems and EXIT signs required for egress and task lighting, along with a visual inspection of other exit signs.  The task lighting mentioned would include the previously unmentioned NFPA 99 – required O.R. battery lighting, generator room battery lighting, and transfer switch location battery lighting. EP2 also has the same basic expansion of scope.  EP5 now reinforces the requirement for a monthly emergency generator test to begin with a cold start.  EP7 adds manual transfer switches to the list of transfer switches that must be tested monthly.  Organizations should make sure that any such devices be  included within the inventory and then tested monthly.  EP10 has a new Note 2 that invokes Chapter 8 of NFPA 110-2010 for the 3-year 4-hour load test.

Standard EC.02.05.09 (medical gas and vacuum): New EP1 still contains what appears to be serious miswording that does not agree with NFPA 99 Chapter 4 Risk Category definitions. EP7 (previously EP1) has been almost totally modified, with changes that add WAGD systems and support gas systems on the inventory, expand the inventory requirements.  EP7 also appears to invoke ASSE certifications for all persons maintaining the gas and vacuum systems. EP11 has new labeling and marking requirements that align with the CMS K-Tags and NFPA 99-2012 requirements.  EP12 expands the cylinder policy detailed requirements.

Standard EC.02.06.05 (managing risks during demolition, renovation and new construction): EP3 requires that action be taken to minimize risks related to general maintenance that were identified on the general maintenance PreConstruction Risk Assessment now invoked by EP2.

Now that the final EPs have been published, we caution our readers to continue to review 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.