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Compliance News: TJC 2018 Survey Activity Guide Changes

| David Stymiest

TJC recently updated its Survey Activity Guide (SAG) for 2018.  Contained within that updated SAG is an updated Life Safety and Environment of Care Document List and Review Tool, found on SAG pages 101-108.

It appears that the new LS/EC Document List and Review Tool included some of the January 2018 changes to TJC’s elements of performance, but not all the 2018 EP changes.  We will be watching to see if TJC catches the remaining EP changes with another updated SAG, as TJC did during the first quarter of 2017.

One unexpected change is the additional requirements included within the documentation expected for EC.02.05.01, EP-14, which covers minimizing pathogenic biological agents in water systems.

The 2018 SAG has the following new explanatory requirements, which appears to reflect the June 2017 CMS Survey & Certification Letter 17-30 entitled “Requirement to Reduce Legionella Risk in Healthcare Facility Water Systems to Prevent Cases and Outbreaks of Legionnaires’ Disease (LD)”.  Refer to the updated SAG for actual TJC language.

TJC will be requesting the following policies, procedures and reports:

  • Risk assessment identifying where Legionella and other opportunistic waterborne pathogens could grow and spread within water systems
  • Water management program that considers both ASHRAE 188 and the CDC toolkit (CDC document entitled Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings – A PRACTICAL GUIDE TO IMPLEMENTING INDUSTRY STANDARDS)
  • Testing protocols and acceptable ranges for control measures: including Documented results of testing; and Corrective actions taken when control limits are not maintained

Also in the SAG’s What’s New for 2018 section on PDF pages 4 & 5, TJC indicated the following changes that may also be of interest to health care facility managers and directors: 

  • Hospital document list: new items related to EM chapter changes
  • Critical Access Hospital document list: new items related to EM chapter changes
  • Emergency Management survey discussion topics were changed to align with the CMS EPFR (Emergency preparedness Final Rule)

Questions related to this article may be directed to the author, David Stymiest, PE, CHFM, CHSP, FASHE, at