TJC Releases Top 5 Most Challenging Requirements for First Half of 2018

PUBLISHED: Oct 24, 2018
Relevant to: Critical Access Hospitals, Hospitals

The Joint Commission (TJC) recently released its list of the top five requirements identified as most challenging during surveys and reviews in the first half of 2018 (Jan 1 through June 30) for all accreditation programs. Today’s StayAlert! notice reviews the requirement hospitals found most challenging.

LS.02.01.35 requires hospitals to provide and maintain systems for extinguishing fires. According to TJC, 88% of hospitals surveyed in the first half of 2018 were non-compliant with this requirement. Fire safety can be particularly challenging because while many features of a fire safety program are automatic (e.g., sprinkler systems) others require staff training and competency for use (e.g., portable fire extinguishers). Fire safety programs must include both maintenance and inspection of the automated aspects of fire extinguishing systems and routine and regular staff training and education on fire extinguishing systems.

Hospitals should have specific policies outlining the maintenance and inspection of fire extinguishing systems. Policies should also address portable fire extinguishers, including location, signage and training on use.

Hosptials should also be aware of specific risks to their fire extinguishing systems such as items (e.g., holiday decorations) being hung from sprinkler systems, obstructions being stored within eighteen inches of a sprinkler head and inadequate sprinkler maintenance.

Included with today’s notice are example policies and procedures related to the provision and maintenance of fire extinguishing systems.

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