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Compliance News: TJC Releases Newly Updated LS & EC Document List and Review Tool

| David Stymiest

TJC recently released its newly updated Life Safety & Environment of Care Document List and Review Tool, marked REVISED: 4/30/2018.  The individual pages of the list are each marked with a 3/13/2018 revision date, which correlates to the TJC speaker’s 3/27/2018 PDC Conference general session reference to those revisions.

This is the list of documents that TJC-accredited hospitals must provide to TJC’s Life Safety Code Surveyor (LSCS) very early on day one of a LSCS survey visit.

The revisions reflect many of the 2018 changes to TJC’s EC Chapter and LS Chapter elements of performance.  The list of specific items below is not all-inclusive; readers are cautioned to obtain and review the source document.

Additionally, and perhaps most importantly, the revisions also indicate the probability of document review for certain elements of performance that were previously not part of that intensive high-speed document review session.

Among the new topics that are apparently now going to be included in that LSCS intensive document review session are topics that many organizations are still struggling with, including the following:

  • 02.05.01, EP-3: written inventory of all operating components of utility systems
  • 02.05.01, EP-4: identifying all high risk operating components on the inventory
  • 02.05.01, EP-5: manufacturer recommendations for inspection, testing & maintenance (ITM) activities and frequencies vs. Alternative Equipment Maintenance (AEM) program
  • 02.05.05, EP-4: manufacturer recommendations at 100% completion rate; high risk AEM ITM at 100% completion rate
  • 02.05.05, EP-5: infection control components ITM (both manufacturer recommendations and AEM_ at 100% completion rate
  • 02.05.06, EP-6: non-high risk AEM at 100%

Other topics previously not included within this document review session are the following:

  • Medical Equipment Risk items
    • 02.04.01, EP-2: written inventory of all medical equipment
    • 02.04.01, EP-3: identifying all high risk medical equipment on the inventory
    • 02.04.01, EP-4: manufacturer recommendations for inspection, testing & maintenance (ITM) activities and frequencies vs. Alternative Equipment Maintenance (AEM) program
  • Medical Equipment ITM items
    • 02.04.03, EP-2: high risk manufacturer recommendations at 100% completion rate; high risk AEM ITM at 100% completion rate
    • 02.04.03, EP-3: identifying non-high risk medical equipment on the inventory; non-high risk AEM ITM at 100%
    • 02.04.03, EP-4: sterilizer ITM
    • 02.04.03, EP-10: hyperbaric facility compliance with NFPA 99-2012, Chapter 14
  • 02.05.07, EP-1: more emergency power system ITM: emergency lighting, exit signs required for egress, task lighting,
  • 02.05.07, EP-2: addition of battery-powered task lighting testing in deep sedation and general anesthesia areas
  • 02.05.07, EP-7: addition of manual transfer switches (I assume these are only manual transfer switches within an Emergency Power Supply System.)

Accredited organizations can obtain the new list by logging into their TJC portal and then following: > Survey Process, > Survey Activity Guide, >Additional Resources

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