Cashins & Associates Blog

Prepare Your Facility for Joint Commission Review for Life Safety

Posted by Mike Cashins on Mon, Apr, 08, 2013 @ 13:04 PM

Hospital ChecklistPreparing Your Facility for a Joint Commission Review for Life Safety, by using a Tour Checklist

It’s a normal day at your healthcare facility, doctors and nurses are busy about tending to patients.  Then, an official looking group of people step onto the campus; it is a Joint Commission survey team.  Is your campus prepared?

The Joint Commission: What it is and what it does

The Joint Commission is a non-profit organization that certifies that all required safety measures of health care facilities are met. Joint Commission survey teams are required to survey facilities once every 39 months to make sure that all standards and guidelines are being met and followed.  With the new Joint Commission Standards in full effect, the surveyor for life safety will now be scheduled for an extra day, allowing them more time to tour your facility.

Interim life safety measures

An important task is documenting all interim life safety measures, especially in the case of ongoing construction. Nothing draws a Joint Commission survey team’s attention like new construction. If a Joint Commission team arrives for a survey and there is ongoing construction at your facility, whether new or renovation, they will want the facility to produce an interim life safety plan that the Pre-Construction Risk Assessment or Infectious Control Risk Assessment group has reviewed and certifies to ensure that the site remains safe and secure while construction is going on. The survey team wants to make sure that egress around the work site is maintained. They will also review that all your utility systems are maintained during the construction duration and that you have a documented plan.

The Joint Commission - Life Safety Specialist

An important part of the Joint Commission hospital review team is the Life Safety Specialist (LSS).  The LSS will usually arrive with the review team on the first or second day.  The LSS is permitted to stay one extra day longer according to the new Joint Commissioning Standards.

According to the American Society of Healthcare Engineers (ASHE) the LSS will be present for two days if the facility is more than 750,000 square feet and one day if it is less than 750,000 square feet.  However with the new ruling from The Joint Commission the LSS can stay an extra day for either size facility.  The LSS will mainly focus on Life Safety Codes and construction related work.  The LSS will most likely wish to tour any construction project that is currently active.

The review, tour, and checklist

According to ASHE the LSS tour will typical start at the highest floor level of the facility.  This area includes:

  • Penthouses
  • Mechanical room
  • Elevator control room
  • The roof

The LSS will inspect elevator areas as they progress but will most likely use the stairwell that is most commonly used.  The lower basement levels of the facility, the LSS will review:

After reaching the lowest level the LSS will then proceed back to the highest patient floor level.

  • Kitchen/dietary departments
  • Loading docks
  • Fire pump rooms
  • Emergency generators
  • Fire panels,
  • Compressed gas storage rooms
  • Infectious waste storage.   

During this portion of the survey the LSS is reviewing the fire doors, smoke doors, rated walls between smoke compartments, storage areas utility chases and hazardous areas for safety and security.  The will record their findings using a facility tour checklist, which according to ASHE includes the following areas:

  • Stairwells
  • Smoke doors and compartments
  • Fire doors and compartments
  • Electric and communication closets
  • Mechanical rooms
  • Fire pumps and panels
  • Chemical and medical waste storage
  • Compressed gas storage
  • Emergency generators
  • Kitchen/dining facilities
  • Loading docks
  • Corridor storage
  • Penthouses
  • Construction and outside roof areas

Knowing what the LSS is looking for gives you an idea of the extensive safety requirements mandated for hospitals and healthcare facilities. 

How can Cashins & Associates, Inc. help?

In the services Cashins & Associates, Inc. provides, we help you with updating life safety documents for the required Joint Commission Life Safety audit. These Life Safety drawings that we review need to include occupancy separations, fire rated walls, and accurate square footage totals. We also review exits, egress widths, fire alarm pull stations locations, and fire alarm strobe/horn locations surveys. We also assist with fire penetration review by looking at above-ceiling areas that will be reviewed by the Joint Commission survey team. Be prepared and let Cashins help you.

If you have any questions please submit a web form and one of our experts will contact you.

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Topics: Hospital

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