A
s noted in “The Accreditation Process” (ACC) chapter of the program manuals for hospitals
improvement, and remedial action that may be required.”
In response to customer feedback,
To help staff prepare for this doc- ument review, The Joint Commission
Survey Activity Guide
updated the to
and critical access hospitals, a Life Safety Code® * Surveyor will be assigned to every hospital survey. The chapter adds that this surveyor “is responsible for evalu- ating specific environment of care and Life Safety Code accreditation criteria and educating the organization during the survey about related compliant and not compliant areas, opportunities for
The Joint Commission recently clarified expectations regarding on-site evalua- tions of Life Safety and Environment of Care compliance. One major change is that staff must be available to assist the Life Safety Code Surveyor with document review immediately upon arrival so that he or she may provide a thorough and efficient facility assessment.
include a Life Safety and Environment of Care—Document List and Review Tool (an excerpt of this list is shown below).
This new resource, which is designed to help organizations in conducting continuous compliance and survey
readiness efforts, lists selected documents that will be reviewed by the Life Safety Code Surveyor. The resource is posted on
Download this tool at: http://www.jointcommission.org/life_safety_code_information_resources/
Life Safety and Environment of Care - Document List and Review Tool
Legend: C=Compliant; NC=Not compliant; NA=Not applicable; IOU=Surveyor awaiting documentation
STANDARD | See Legend | DOCUMENT | ||||||||
LS.01.01.01 | C | NC | NA | IOU | Buildings serving patients comply with NFPA 101 (2000 edition) | YES | NO | |||
EP 1 | Individual assigned to assess LSC compliance | |||||||||
EP 2 | Current e-SOC maintained | |||||||||
EP 3 | Timely completion of PFIs | |||||||||
EP4 | Documentation of inspections and approvals made by state or local AHJs | |||||||||
COMMENTS: | ||||||||||
LS.01.02.01 | C | NC | NA | IOU | Interim Life Safety Measures (ILSM) | Addressed in Policy? | Implemt. as required? | |||
YES | NO | YES | NO | |||||||
EP 1 | Alarms / sprinklers out of service 4 or more hrs in 24 hrs - Fire watch / Fire Dept. notification | |||||||||
EP 2 | Signs for alternate exits posted | |||||||||
EP 3 | ILSM policy identifying when and to what extent ILSM implemented | |||||||||
EP 4 | Daily inspection of routes of egress (See also 19.7.9.2 RE: daily inspections) | |||||||||
EP 5 | Temporary but equivalent systems while system is impaired | |||||||||
EP 6 | Additional fire fighting equipment provided | |||||||||
EP 7 | Smoke tight non-combustible temporary barriers | |||||||||
EP 8 | Increased surveillance implemented | |||||||||
EP 9 | Storage and debris removal | |||||||||
EP 10 | Additional training on fire fighting equipment | |||||||||
EP 11 | Additional fire drill per shift per quarter | |||||||||
EP 12 | Temporary systems tested and inspected monthly | |||||||||
EP 13 | Additional training on bldg deficiencies, construction hazards, temp measures | |||||||||
EP 14 | Training for impaired structural or impaired compartment fire safety features | |||||||||
COMMENTS: | ||||||||||
Legend: C=Compliant; NC=Not compliant; NA=Not applicable; IOU=Surveyor awaiting documentation
* Life Safety Code® is a registered trademark of the National Fire Protection Association, Quincy, MA.
(continued on page 10)
Copyright 2015 The Joint Commission
Page 9
The Joint Commission website at http:// www.jointcommission.org/life_safety
_code_information_resources/ as well as on the Joint Commission Connect™ extranet site.
In addition, the Life Safety Survey Agenda has been revised to include more detail on the activities that will be con- ducted by the Life Safety Code Surveyor. Please note that the sample agenda, below (with new language underlined), is based on a typical two-day hospital or critical access hospital survey. The num-
ber of days may be different, depending on the hospital’s size; organizations
will see a customized agenda on their extranet site.
792-5819. | EC |
Questions may be directed to Jim Kendig, Field Director, Life Safety Code Surveyors, at jkendig@jointcommission
.org or 630- 
Time | If Day 1 Occurs on Day 1 of Hospital Survey | If Day 1 Occurs on Day 2, 3, or 4 of Hospital Survey |
8:00–8:15 a.m. | Facility Orientation
| Daily Briefing (introductions only) |
8:15–9:00 a.m. | Facility Orientation
| |
9:00–9:15 a.m. | Opening Conference (introductions only) | |
9:15–10:30 a.m. | Facility Orientation (continued) | |
10:30 a.m.–12:30 p.m. |
|
|
12:30–1:00 p.m. | Surveyor Lunch | Surveyor Lunch |
1:00–4:00 p.m. | Life Safety Code Building Assessment (continued) | Life Safety Code Building Assessment (continued) |
4:00–4:30 p.m. | Surveyor Team Meeting/Planning Session† | Surveyor Team Meeting/Planning Session† |
* Provides organization time to correct issues while surveyor is on site † Time for required interaction with survey team | ||
Time | If Day 2 Occurs on Day Other Than Last Day of Hospital Survey | If Day 2 Occurs on Last Day of Hospital Survey |
8:00–8:30 a.m. | Daily Briefing | Daily Briefing |
8:30–12:00 p.m. | Life Safety Code Building Assessment | Life Safety Code Building Assessment |
12:00–12:30 p.m. | Surveyor Lunch | Surveyor Lunch |
12:30–2:30 p.m. | Three possibilities (depending on organization size):
| Three possibilities (depending on organization size):
|
2:30–3:30 p.m. | Document Findings | Document Findings |
3:30–4:00 p.m. | Interim Exit Conference | CEO Exit Briefing and Organization Exit Conference |
4:00–4:30 p.m. | Surveyor Team Meeting/Planning Session* | |
* Time for required interaction with survey team | ||
Page 10 Copyright 2015 The Joint Commission