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Compliance News: TJC Provides more Assistance with Problematic Compliance Issues

| David Stymiest

The November 2015 Compliance News issue discussed the joint work that both ASHE and TJC had performed in providing assistance on major physical environment compliance problem areas.

The TJC Physical Environment Portal (TJC PE Portal) is still available at TJC’s website under the main TOPICS heading.  Interested parties can sign up at that location to obtain TJC e-Alerts on new information when it is issued.  Although the information specifically addresses the most problematic TJC Environment of Care chapter and Life Safety chapter standards and Elements of Performance (EPs), much of it is generic enough to be helpful to those concerned with CMS physical environment and life safety compliance as well. The TJC PE Portal and its related e-Alerts are available to the public.

ASHE’s FOCUS on COMPLIANCE (ASHE FOC) web page is available at ASHE’s website (www.ashe.org) under the main NEWS & RESOURCES heading.  Interested parties can sign up to receive email alerts from ASHE when new physical environment compliance resources are added, and do not need to be ASHE members to receive the alerts.  The majority of ASHE’s posted resources are available to all persons; however a few of the resources are available only to ASHE members.

Each web page links to the other organization’s web page for easy migration between them.  Both web pages already have numerous helpful resources posted.

In addition to the resources mentioned in the November 2015 Compliance News issue, TJC has continued to post very useful new compliance discussions and advice at TJC’s PE Portal webpage.  Among the new postings are topics covering:

Built Environment

  • Standard EC.02.06.01 scoring information identifying the two most commonly-found noncompliant Elements of Performance (EPs.)
  • TJC Fireside Chat videos (directed towards facilities PE personnel) for both problematic EPs
  • Examples of improved compliance
  • Links to ten previously-published articles and samples discussing TJC compliance requirements, clarifications and expectations regarding specific built environment topics
  • TJC Fireside Chat videos (directed towards Leadership) for both problematic EPs
  • A Leadership awareness document for those two EPs that addresses Leadership Orientation, Practical Applications, Evaluation of Compliance, and Additional Information
  • Discussion of commonly-encountered Clinical Impacts regarding ventilation, humidity and temperature related to the problematic EPs

Fire Protection

  • Standard EC.02.03.05 scoring information identifying the six most commonly-found noncompliant Elements of Performance (EPs.)
  • A PowerPoint presentation on Features of Fire Protection Associated with the Fire Alarm System
  • Links to nine previously-published articles discussing TJC compliance requirements, clarifications and expectations regarding specific fire protection topics
  • TJC Fireside Chat video (directed towards facilities PE personnel) for the most common problem areas
  • Examples of improved compliance
  • TJC Fireside Chat videos (directed towards Leadership) for the most common problem areas
  • A Leadership awareness document for the most common problem areas that addresses Leadership Orientation, Practical Applications, Evaluation of Compliance, and Additional Information
  • Discussion of commonly-encountered Clinical Impacts regarding features of fire safety testing requirements, and a detailed discussion of building compartmentation

Life Safety General Requirements (TJC Standard LS.02.01.10)

  • Standard LS.02.01.10 scoring information identifying the three most commonly-found noncompliant Elements of Performance (EPs.)
  • Examples of improved compliance
  • Link to a previously-published article on Managing Door Maintenance
  • Link to s previously-published article on Managing Barrier Integrity

TJC’s posted schedule for addressing additional PE compliance postings indicates that TJC will address the following topics next:

  • LS Protection Standard LS.02.01.30
  • Automated Suppression Systems Standard LS.02.01.35
  • Hazardous Materials & Waste Management Standard EC.02.02.01

The ASHE FOC web page offers new resources as well that relate to the same topics discussed above.  A future Compliance News article will discuss the new ASHE-provided assistance since the November 2015 Compliance News issue was published.

The information being provided is clearly useful and should be reviewed by hospital personnel responsible for the physical environment.   We recommend that the above-linked web locations be bookmarked for future reference.  We also recommend that those interested in obtaining future information when it is posted subscribe to the related (ASHE or TJC or both) email alerts.

Questions regarding this article may be addressed to the author at DStymiest@ssr-inc.com.

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