• EC: Clarifications and Expectations: Ensuring Full Compliance with the Life Safety Code^® Tips on meeting recurring compliance issues[®] [REF: E&M, SFT] EC News July 2013, Vol 16, #7, Pg 5

Although TJC standards in the LS Chapter do not specifically address all the requirements of the Life Safety Code, it is TJC’s intent for organizations to fully comply with them all.  To that end, a number of standards in the LS chapter include “full compliance EP” that reference the expectation for organization compliance with “all other” aspects of the LSC.  Apparently, there have recently been recurring compliance issues related to requirements in the LSC that are not individually spelled out in the LS Chapter.  Several examples are given in the article and related to the following “full compliance EPs”:
• EP 32 of LS.02.01.20 – Egress door widths
• EP 25 of LS.02.01.30 – smoke barrier door fire ratings, width and swing          direction
• EP 4 of LS.02.01.34 – Pull station box visibility and accessibility
• EP 14 of LS.02.01.20 – Adequacy of sprinkler system water supply
• EP 4 of LS.02.01.70 – Missing no smoking signs, lack of proper ashtrays where required and the fire resistance rating of curtains
• EP of LS.02.01.20 – Egress door widths
The key point here is that there is a TJC expectation of “full and complete compliance with the NFPA’s Life Safety Code” whether or not they are specified in the LS Chapter.  A corollary to this is that organizations must have a deeper knowledge of the LSC than is provided by merely reading the LS Chapter.
Tip:  Distribute the above list to relevant FSA leads and encourage them to review the full article.  Since it is apparent that surveyors are looking for and making findings in these areas, hospitals should test their own knowledge and more carefully assess levels of compliance for these issues.