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Compliance News: TJC Releases 2012 Codes Changes with Some Surprises

| David Stymiest

TJC released its long-awaited changes to its Life Safety (LS) and Environment of Care (EC) chapters Elements of Performance (EPs) on October 31, 2016.  These documents are entitled “Prepublication Standards – Standards Revisions Related to Life Safety Code Update” and cover six TJC accreditation programs.  The 49-page Hospital Prepublication Standards can be downloaded from that page, and show the Prepublication EPs for both chapters.  The 112-page Hospital Chapter Revisions Comparison Tables can also be downloaded from that page, and show an EP-by-EP comparison between the July 2016 language and the January 2017 language.  That comparison indicates where existing EP language was modified, moved, deleted, split into multiple EPs, consolidated into fewer EPs, or where an EP is new. We believe it is necessary to compare the existing EP wording to the new EP wording to discern some of the less obvious impacts of the changes, where the Hospital Chapter Revisions Comparison Tables are best suited.

The vast majority of the changes should come as no surprise to those who have been reviewing the 2012 Life Safety Code (TM) and 2012 Health Care Facilities Code, along with their multitude of newer referenced NFPA standards. The revisions appear to reflect many of the changes in the two adopted 2012 codes and their numerous referenced standards.  Other requirements stipulated by CMS in its adopting S&C letter are also addressed within the TJC changes.

Some other revisions include changes (in some cases new EPs) reflecting requirements from referenced NFPA standards and TJC expectations that have been included in TJC educational activities and TJC surveys for several years, including such items as medical gas cylinder storage separation, clear and unobstructed access to fire extinguishers, the required content for life safety plans, fire safety equipment inventories, EXIT sign inspections, and the requirement for inspection and testing reports to include the results of those activities.  There are many more such revisions beyond this very short list.

However, there were also a few other new requirements in the documents that may not have been expected.

  • EC.02.06.05 EP2 expands the Preconstruction Risk Assessment (PRA or PcRA) requirement to be conducted prior to general maintenance, not just prior to demolition, construction and renovation.
  • EC.02.05.01 EP1 requires a process to manage the same types of risks addressed by the EC.02.06.05 PcRA when performing utility system repairs or maintenance activities.
  • EC.02.05.06 clarifies requirements for utility equipment Inspection Testing & Maintenance (ITM) compliance rates to be:
    • 100% on-time compliance for all High Risk components, whether done through the Alternative Equipment Maintenance (AEM) program or done in accordance with manufacturer recommendations
    • 100% on-time compliance for all Infection Control components, whether done through the AEM program or done in accordance with manufacturer recommendations
    • 100% on-time compliance for all ITM done in accordance with manufacturer recommendations, whether the equipment is High Risk or Non-High Risk
    • Down to not less than 90% on-time compliance for Non-High Risk components done through the AEM program only if the organization’s policy (presumed to be the utility systems equipment AEM Program policy) permits such deferral.
  • Requirements for medical equipment Inspection Testing & Maintenance (ITM) compliance rates are clarified in EC.02.04.01 / EC.02.04.03 to be:
    • 100% on-time compliance for all High Risk components, whether done through the Alternative Equipment Maintenance (AEM) program or done in accordance with manufacturer recommendations
    • 100% on-time compliance for all ITM done in accordance with manufacturer recommendations, whether the equipment is High Risk or Non-High Risk
    • Down to not less than 90% on-time compliance for Non-High Risk components done through the AEM program only if the organization’s policy (presumed to be the medical equipment AEM Program policy) permits such deferral.
  • EC.02.03.05 has a new EP1 that appears to be related to the NFPA 99 evolution. CMS has been requiring retrofitting of some older Essential Electrical Systems (EES) that did not comply with the separation of NFPA 99 EES branches for a few years.  The new EP1 may require retrofitting of older EES systems to reflect NFPA 99 branch separation.  This new EP bears close watching – it may become quite costly for some facilities.
  • EC.02.06.05 EP1 will reference the 2014 FGI Guidelines (along with the state rules and regulations) for planning of new, altered, or renovated space.
  • LS.01.01.01 EP2 will require a regular building assessment to determine compliance with the LS Chapter in time frames defined by the hospital.

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

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