Standard issues

Approximately every six months the Joint Commission releases a "Top Ten" list of most frequently cited standards during surveys in its various accreditation programs.

A glance at the lists indicates that those recommendations near the top are occurring in more than 50 percent of the hospitals surveyed. In the hospital accreditation program, standards in the Life Safety (LS) and Environment of Care (EC) chapters make up four of the top five recommendations and five of the top 10. For the critical access hospital program, those same two chapters represent nine of the top 10.

Clearly, hospitals of any size should pay heed to these lists by making note of the most frequent problems and learning how they can be avoided.

Critical for compliance

The critical issues for compliance with each of these most frequently cited standards are reviewed by standard, regardless of whether they occur in the hospital program, critical access hospital program or both. Readers should consult the standards for complete requirements.

LS.02.01.20: The [organization] maintains the integrity of the means of egress. What hospital doesn't struggle with corridor clutter? With more and more medical and safety equipment available, and that equipment seemingly increasing in size, few hospitals have been planned with adequate storage space. But corridors must be maintained with 8 feet of clear width, according to the 2000 edition of the Life Safety Code.

Wheeled carts in use are considered to be a generally accepted exception. These include:

• Crash carts, considered to always be in use;
• Isolation carts, when there is a person in isolation in the room;
• Linen and housekeeping carts, while they are actively being used to service patient rooms;
• Computers on wheels/workstations on wheels (COWs/WOWs) while nurses are going back and forth to use them for charting.

At all other times, these items must be stored somewhere other than the corridor. The Joint Commission uses a 30-minute parking rule. An item may be temporarily located in the corridor for up to 30 minutes; any longer is a violation of this standard.

Another word about those pesky COWs/WOWs, which have become so critical to the efficient functioning of the nursing unit. If they are charging in the corridor, they are a problem in and of themselves. If chairs are pulled up to them, they become desks in the corridor.

Somehow, many of the items that are routinely found in corridors miraculously "disappear" at the time of the survey. That's a little more difficult now that all surveys are unannounced. No longer can one hire a truck to park them elsewhere. But they do find a home somewhere.

If a health care organization tends to store things in a corridor, it should at least have a fire plan in place to remove them when an alarm sounds. Staff members should be trained in this process, which should be included in fire drills. When new space is planned, be sure to include appropriate storage. And for now, hope for surveyor discretion.

LS.02.01.10: Building and fire protection features are designed and maintained to minimize the effects of fire, smoke and heat. Citations for this standard typically relate to building type, fire-rated doors and penetrations in fire barriers.

Building type issues are addressed in the National Fire Protection Association's NFPA 101 (2000) at 18/19.1.6.2. They relate to the number of stories permitted and sprinklers required in a facility based on the fire resistance rating of key components of the construction.

It sounds simple, but hospitals can get into trouble for fireproofing material missing from structural steel — either completely or just in a few areas. Particularly in critical access hospitals, sometimes additions or renovations are done by local contractors or carpenters and may not be done according to code. Often, this is due to lack of knowledge or because of expediency or cost. Either of these two errors can change the building type of the entire facility to that of the least common denominator.

Of course, penetrations in fire barriers also need to be filled with appropriate fire-stopping material.

Then there is the issue of fire-rated doors. Carts often bang into them on a regular basis, damaging the hardware and preventing proper closing. Those things happen, and an effective building maintenance program or other management strategy is required to keep up.

What about the door wedges or tie-opens? If facility staff are finding them consistently in the same locations, consider whether an automatic closer is required on a particular door. Or perhaps a magnetic hold-open device is in order. And how often have staff found door latches taped into nonfunctionality or otherwise overridden, for the sake of convenience? Again, consider alternatives to automatic closers, but hospital staff training also is required.

LS.02.01.30: The [organization] provides and maintains building features to protect individuals from the hazards of fire and smoke. There are a few issues involved in frequent recommendations of this standard. Again, the first is penetrations, this time in smoke barriers. They need to be filled with appropriate fire-stopping material.

One ongoing problem regarding smoke and fire barriers is the struggle with information technology (IT) departments about copious amounts of cable they may be running throughout a building. It is essential to develop a working relationship with IT staff so that the facilities department is aware of any cable-pulling activity.

An above-the-ceiling work permit process can be very helpful, especially when coupled with an enforcement program which involves all staff members being on the lookout for people working above the ceiling without a permit hanging from the ladder.

This standard also includes hazardous areas. Common citations can include:

• Storage in mechanical rooms;
• Vacant patient rooms being used for storage without the appropriate changes in fire protection and associated equivalencies;
• Other improper fire protection.

Don't forget that smoke-barrier doors, suites, corridor doors and other elements also are included in this standard.

EC.02.03.05: The [organization] maintains fire safety equipment and fire safety building features. Maintenance, testing and inspection of features of fire protection, as required in this standard, is a struggle for many organizations. Testing sometimes has not been done, or has not been done properly, but in many cases the issue is poor documentation.

This standard often is addressed with the assistance of a third-party vendor, which is a totally acceptable solution, but the Joint Commission is hitting extremely hard on the documented results, including accuracy, completeness and clarity. Failure to have access to documentation or failure to completely understand it will be cited not only for this standard in the EC chapter, but also for LD.04.01.05 in the Leadership chapter. And nobody wants to be responsible for a Leadership recommendation.

All tests performed under this standard should have an itemized inventory of devices, with a result listed for each device tested. The health care organization also must be able to document that action was taken on any failures identified during the testing process. Read each element of performance carefully. Many have multiple parts, and each must be tested and documented.

Organization and presentation is absolutely critical to the survey outcome for this standard. Fumbling through multiple books to find a test or reading through multiple pages of a vendor's report to find the desired result can be deadly. Take time in advance of the survey to review the documents.

Facility professionals must make sure they can prove that each test was done at the appropriate time interval, and that they can locate the records quickly and easily. A tabbed notebook with a year's worth of organized and easy-to-follow results for each element of performance will set the stage for a good outcome. Also, facility professionals must be sure they understand each test that the vendor is performing and can speak to it.

Finally, remember the organization's remote sites. They may not be required to have various features of fire protection, but if they do have them, they must be tested according to this standard.

LS.02.01.35: The [organization] provides and maintains systems for extinguishing fires. Several factors may contribute to citations under this standard. Typically, they do not involve the installation of an appropriate automatic sprinkler system — more likely it's in the details.

The culprit may be cables or wires, likely from IT, that are draped across sprinkler pipes. The sprinkler heads themselves may be corroded, painted or outdated. A thorough inspection of the heads and the system above the ceiling should identify any issues.

In nearly every facility there are at least a few instances where the required 18-inch sprinkler clearance is violated. According to NFPA 13, storage may extend to the ceiling on perimeter walls in a sprinklered room as long as the storage is not directly under the sprinkler head. Some organizations choose to enforce the clearance in the entire room, so any recommendation in that regard will be a matter of organizational policy.

Another common citation involves Type K fire extinguishers, which are required to be placed within 30 feet of grease-producing cooking devices. NFPA 10 also requires specific signage over those extinguishers stating that the hood extinguishing system must be used before the K extinguisher.

EC.02.05.07: The [organization] inspects, tests, and maintains emergency power systems. Usually health care organizations have their emergency generator testing pretty much in order. Occasionally, there are a few things that go wrong, like running for not quite 30 minutes or being a little careless on the 20- to 40-day intervals each month.

When something goes wrong with the generator itself, it is essential to document what was done to correct the problem and then perform a retest. If, at any time during that period, patients would be at risk if the normal electrical power failed, interim arrangements must be made for their protection.

There are a couple of other sticky wickets in this standard.

Battery-operated egress lighting is one of them. This requires a 30-second monthly test and a 90-minute annual test. The annual test may be replaced by a documented annual battery replacement program, with 10 percent of the lights still tested for 90 minutes. Here is another occasion when facility professionals must be sure to remember remote sites.

Remember that this requirement is for egress lighting only. It does not include task lighting that may be found in the OR or at the generator site. It may be prudent to perform the testing on these lights as well to assure proper functioning when it is needed — but this testing is not required by the Joint Commission.

The automatic transfer switches are another frequent problem. They must be tested monthly along with the generator at a 20- to 40-day interval. As for the features of fire protection tested under EC.02.03.05, the test of each switch must be documented individually and the switch used to start the generator for that month also should be indicated.

EC.02.03.01: The [organization] manages fire risks. The first element of performance (EP) in this standard sounds rather generic: "The organization minimizes the potential for harm from fire, smoke, and the products of combustion." This is a direct-impact EP, where several common findings are scored.

The first of these is improperly stored gas cylinders. This can involve more than 12 E cylinders being stored in a smoke compartment, unsecured gas cylinders or improper storage of larger volumes of gas. Gas cylinder storage should be according to the 2005 edition of NFPA 99.

Open junction boxes, hanging wires and damaged electrical outlets also may be scored here.

EP 4, another direct impact, applies only to the health care organization's business occupancies, and they will be scored for any blocked or locked exits there. This business occupancy-specific EP has been added because there are no Life Safety standards that apply to these occupancies.

This standard also would be scored for lack of an appropriate fire response plan, so facility professionals should be sure all required content is included.

EC.02.05.09: The [organization] inspects, tests, and maintains medical gas and vacuum systems. This is a unique standard because organizations are required to define the interval at which this testing occurs. That step frequently is omitted in the policy and in the management plan.

Some aspects of the testing required for normal functioning of the system (listed in EP 1) occasionally are overlooked, even if the schedule is defined. Facility professionals should be sure that their program includes all of the required elements.

Third-party documentation can be at issue here, too. Sometimes the third party is another department of the hospital. Facility professionals in charge of the program should follow up to be sure that everything is being done as expected. As with any other testing, if a problem is identified, also identify the solution.

Remember that the piped medical gas system includes the tank farm, so all must be in order in that location, too.

Labeling of the emergency shut-off valves seems like a simple proposition, but often there are hang-ups. When the use of a room is changed, be sure that the associated medical gas valve is labeled for the current use of a room. For example, if the operating rooms (ORs) recently were renumbered due to a renovation, the current room designations should be included on the valve. Any valves that serve spaces that are now used as offices, storerooms or similar occupancies should be labeled "out of service" and have the valve handles removed.

EC.02.06.01: The [organization] establishes and maintains a safe, functional environment. Temperature and humidity levels in the ORs, delivery rooms, central sterile, endoscopy, cath lab and substerile storage areas are being evaluated closely by Joint Commission surveyors, along with appropriate pressure differentials. This closer look may relate directly to the increased frequency of citations.

Facility professionals should be sure that the temperature and humidity are recorded at least daily. If they are manually recorded, verify that they are being done each day. If documented by a building automation system, verify that a retrospective log can be produced. Verify that the pressure differentials are checked at least annually.

Other citations may include furniture and equipment in a state of disrepair. Facility professionals should specifically look for torn upholstery, which also can be cited as an infection control issue because it is difficult to clean.

Ongoing vigilance

It takes ongoing vigilance to monitor all requirements of the EC and LS standards, but considering how frequently these standards are cited, they merit the extra attention.

Susan B. McLaughlin, FASHE, CHFM, CHSP, is managing director of MSL Healthcare Consulting Inc., Barrington, Ill., and a former associate director of standards interpretation at the Joint Commission. She can be reached at smclaughlin@mslhealthcare.com.