Joint Commission Announces Three Revisions to Life Safety Chapter

PUBLISHED: Feb 14, 2018
Relevant to: Ambulatory Care, Critical Access Hospitals, Hospice, Hospitals, Long Term Care

The Joint Commission has announced three revisions to their Life Safety Environment of Care chapters that are effective March 11, 2018.

  • Revision 1: TJC clarifies “nonrated” doors. According to TJC, “Nonrated doors, including corridor doors to patient care rooms and smoke barrier doors, are not subject to the annual inspection and testing requirements of either NFPA 80 or NFPA 105.” This revision is applicable to Ambulatory Health Care, Behavioral Health Care, Critical Access Hospital, Home Care and Hospital accreditation programs. Note that those organizations using TJC for deemed status should still be routinely inspected in compliance with the organization’s overall facility maintenance program.
  • Revision 2: TJC has added a new requirement for Ambulatory Care, Critical Access Hospital, Hospital, and Office-Based Surgery accreditation programs which requires organizations to manage the environmental features of areas that administer inhaled anesthetics. Specifically:
    • Heating, cooling, and ventilation must be in in accordance with ASHRAE 170
    • Medical supply and equipment manufacturers’ instructions should be considered before reducing humidity levels to those allowed by ASHRAE.
    • Existing smoke control systems automatically vent smoke, prevent the recirculation of smoke originating within the surgical suite, and prevent the circulation of smoke entering the system intake, without interfering with exhaust function.
    • New occupancies have no smoke control requirement.
    • Existing smoke control systems are maintained per NFPA 101-2012: 20/; NFPA 99-2012: 9.3.1 (note: this is for organizations that use TJC for deemed status)
  • Revision 3: TJC has revised a requirement for corridor door latches to ensure consistency and alignment with CMS requirements. The specific requirement varies for each applicable accreditation program (Home Care, Nursing Care Center, Hospital, Critical Access Hospital, Behavioral Health).

Included with today’s notice are example policies related to these revisions. A link to the prepublication standards is provided below.

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