Top 10 Cited Joint Commission Standards for Healthcare Facilities

Posted September 22, 2015 by Koorsen Fire & Security



Top 10 Cited Standards

  1. Built Environment: EC.02.06.01 - The healthcare facility establishes and maintains a safe, functional environment. 
  2. Utility Systems: EC.02.05.01 - The healthcare facility manages risks associated with its utility systems.
  3. Infection Control: IC.02.02.01 - The healthcare facility reduces the risk of infections associated with medical equipment, devices, and supplies.
  4. Means of Egress: LS.02.01.20 - The healthcare facility maintains the integrity of the means of egress. 
  5. Record of Care, Treatment & Services: RC.01.01.01 - The healthcare facility maintains complete and accurate medical records for each individual patient. 
  6. Fire Safety Systems: EC.02.03.05 - The healthcare facility maintains fire safety equipment and fire safety building features. 
  7. General Building Requirements: LS.02.01.10 - Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat. 
  8. Extinguishment: LS.02.01.35 - The healthcare facility provides and maintains systems for extinguishing fires. 
  9. Protection: LS.02.01.30 - The healthcare facilitiy provides and maintains building features to protect individuals from the hazards of fire and smoke.
  10. Hazardous Materials & Waste: EC.02.02.01 - The healthcare facility manages risks related to hazardous materials and waste.


NOTE: While this article was originally posted in 2014, the top cited Joint Commission standard largely remains unchanged for 2017. To ensure your healthcare facility is in compliance with standards pertaining to fire protection and life safety, contact Koorsen Fire & Security today. 

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Healthcare facilities have special considerations when it comes to complying with fire codes, and maintaining compliance can be complex. Healthcare facilities make every effort to stay compliant, as failure to do so can impact your ability to obtain or retain the accreditation, certification or licensure your facility requires to stay in business.

When the top 10 citations issued by Joint Commission surveyors to healthcare facilities were compiled, not surprisingly, a full five of these related to fire and life safety regulations and standards. William Koffel, the chair of the NFPA Technical Committee on NFPA 25 and NFPA Life Safety Correlating Committee, published a piece in Health Facilities Management Magazine to discuss these citations, and some strategies you can use to avoid them in the future. Below, we'll take a look at some of his findings to help you improve your results the next time a surveyor inspects your facility.


#4: Means of Egress

Getting out quickly and safely during a fire is very important, which requires you to have unobstructed means of egress. The fourth most common citation in 2014, focusing some attention on the regulations regarding this topic is a good use of your time. Citations that fall under this standard include items like locked doors, exit doors being kept open with door stops and too many items filling up the hallway.

While you're allowed to have some things like crash carts and mobile workstations (that are being used for charting or to help with distributing medicine to patients), there are regulations governing how long they can stay and what items are permitted. Typically, any carts with wheels that are currently in use are allowed, such as isolation carts outside a patient's room, housekeeping carts, crash carts (which are seen as always in use, so they can remain in the corridor at all times) and computer workstations on wheels. Carts can be placed in the hallway for up to 30 minutes, but if they go unused for any longer than that, it is considered a violation.1

One strategy suggested by Koffel to ensure your means of egress is unobstructed, is to consider upgrading your stairwell doors so they close automatically when smoke is detected by a nearby smoke detector. This can eliminate violations, and make compliance for this item automatic.


#6: Fire Safety Systems

The sixth most common citation, fire safety systems are an important part of your plan to protect the staff and patients at your healthcare facility. With injured, mobility impaired, or incapacitated patients in the building, it is important that the fire safety systems be up to code and working properly. This means that adequate warning will be given if a fire occurs, and that systems like the fire sprinklers will either extinguish the blaze or slow its progression. This ensures no staff or patients are injured, and there is enough time to evacuate the building if necessary.

EC.02.03.05 covers the inspection, maintenance and testing that's required for items like your fire alarm system and portable fire extinguishers. One item that is often overlooked – leading to citations - is failing to have the proper tests performed by a qualified service company at the required intervals.

While you may schedule an annual inspection each year, some equipment must have special tests or inspections performed at the three or five year mark (such as hydrostatic tests for certain types of portable fire extinguishers or a dedicated inspection to look for obstructions in your fire sprinkler system).

Talk to a trusted fire and life safety service company in your area, to ensure that you haven't missed any of these required inspections or tests.


#7: General Building Requirements

This standard pertains to materials used in your facility's construction, proper fire barriers and other related topics. Koffel suggests examining your life safety drawings to ensure that these are accurate and up-to-date. This is an efficient way to determine if things like the required firestop systems for penetrations in the structure are present, or if these need to be added or improved.


#8: Extinguishment

Though this was the eighth most common citation in 2014, still a full 43% of facilities were hit with noncompliance of this standard. This standard covers items related to extinguishing systems, such as providing the proper support for automatic sprinkler pipes, ensuring that the sprinklers themselves aren't damaged and allowing for enough clearance below the sprinkler deflectors. This last one is an especially common issue, as healthcare facilities always require a great deal of storage.

One common mistake is to assume that the usually required 18 inches of clearance below the sprinkler deflector, means you can store items higher than this in other areas of the room. Instead, Koffel instructs that you should never stack boxes, or have shelving units or any other obstruction reach higher than 18 inches below the height of the sprinkler deflectors – no matter where they're located on the ceiling. This will help you to avoid citations and maintain compliance. In fact, Koffel suggests that you paint a clear line at the highest point where items can be stored at, for a visual reminder to all staff in the facility.


#9: Protection

Number nine on the list of top 10 standard citations for 2014, protection pertains to items like hazardous zones, allowed vertical openings and requirements for corridor doors. Again, Koffel suggests that accurate life safety drawings can help you maintain compliance, by providing the documentation you'll need to show to the Joint Commission surveyor during their inspection. Also, he points out that automatic fire sprinkler systems may have contributed to the decrease in citations from 2013 to 2014 for this standard (LS.02.01.30), which may be a recommendation for including them in your overall fire protection plan in a greater capacity.


Maintain Compliance and Avoid Citations

The information and strategies covered above should help to maintain compliance and avoid citations. While staying informed is a good policy, the best plan is to partner with a quality fire and life safety service company, who will know all of the recent changes and requirements set forth in the code. Koorsen Fire & Security is well-respected for its expertise, with its associates being the most highly trained technicians in the business. If you want to make compliance a priority, Koorsen Fire & Security is a terrific choice, as we'll perform a thorough inspection and let you know what actions are needed.

Schedule your free consultation today – so your facility will be in full compliance when the next surprise inspection occurs. Call 1-888-KOORSEN or contact us online today.


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Topics: Healthcare Industry, NFPA

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Disclaimer: The information in this article is for informational purposes only. It is believed to be reliable, but Koorsen Fire & Security assumes no responsibility or liability for any errors or omissions in the content of this article. It does not constitute professional advice. The user of this article or the product(s) is responsible for verifying the information's accuracy from all available sources, including the product manufacturer. The authority having jurisdiction should be contacted for code interpretations.