* EC: The importance of maintaining the integrity of the means of egress (PDF) [REF: EC, LD] EC News, May 2016, Vol 19, #1, Pg 1 JCe1605_B7

LS.02.01.20 has been among the 4 most frequently cited TJC hospital standards for the last 5 years. The most problematic elements of performance have been numbers 13 (exit obstruction), 1 (unlocked doors) and 12 (corridor obstruction).  It has been similarly challenging among our psychiatric hospitals but EP 30  (signage) has been more prominent. In its review of requirements and recommendations related to the problematic EPs, the article also provided several useful nuggets of knowledge worth remembering, such as:

• Crash carts can remain in the egress path because they are always considered “ in use”
• if categorical waiver provisions are in use, the organization must declare this and indicate where they are and use at the beginning of survey
• Doors within a means of egress may not be a locked less 1- the doors have delayed–egress locks, 2- they are access– controlled egress doors or 3 – staff carry door keys at all times.
Beyond this, the article provides references back to the following five more detailed articles relating to this subject:
• Physical Environment Portal module—Means of egress
• Clarifications and Expectations Part 1 and Part 2 article on reducing corridor clutter / and
• Article on when to lock or not lock doors
• Clarifications and Expectations article on the CMS Life Safety Code waivers
• Leadership awareness article on LS.02.01.20, EPs 1 and 13

Tip: Make sure your environmental rounds checklist includes observations related to EPs 1, 12, 13 and 30.