NEHES 2012 conference: Joint Commission updates


New England Healthcare Engineers’ Society Fall 2012 Conference:
Joint Commission Updates

Mike Chisholm, Director of Engineering at Joint Commission



  • Joint Commission, because of CMS, uses NFPA 101 2000 edition. This is not likely to change anytime soon because CMS is not planning on adopting a newer version in the near future.
  • Suites: The first things they look for on the drawings are suite sizes and boundaries clearly marked on drawings.

Most Cited Joint Commission Issues (in descending order)

  1. Penetrations and Fire Rated      Doors – 57% of all survey problems relate to this one
  • This has to do with making sure that all doors, walls, barriers, dampers, etc are clearly labeled or marked if they are rated.
  • Facilities must have a Barrier Management Program
  • Ducts must have fire dampers in rated walls. Any damper that is listed on the hospital’s survey as “inaccessible” must be truly inaccessible due to construction (if you can cut an access panel into the ceiling it is not “inaccessible”).
  1. 2. Corridor Clutter/ Storage
    • “If the floor looks cluttered, it is cluttered” and the surveyor will start digging into things.
    • Crash carts and “in process” carts like iso or chemo carts are allowable in corridors for short periods of time. But anything in an egress corridor longer than 30 minutes is going to be considered storage, and therefore a problem.
    • Linen and latex carts are not allowed to be stored in corridor, except in an alcove. They don’t encourage linen stored in alcove because of soiled issues.
    • Joint Commission suggestion for dealing with storage:
    •                               i.        i. Dead end corridors may be used for storage as long as the storage doesn’t take up more than 50 sq ft of floor space.
    •                              ii.        ii. Talk to departments like IT or purchasing and see if they are purchasing more than needed amounts of equipments (gave COWS as an example). Cut down on equipment at the purchasing source.
    •                             iii.        iii. Take over an “extra” room and use as storage

3. Hazardous Areas

  • Smoke barriers – walls must go to the deck.
  • Hazardous rooms – doors must have closers and be locked at all times.

4. EP’s Fire Safety Testing

  • Hospitals have big issues giving JC proper sprinkler documentation. All sprinklers must be located on drawings and up to date.
  • Hospitals must push sprinkler vendors to provide documentation – including dates of testing and inventory.
  • Need better documentation on air handler shut downs – hospitals should request this from vendors as well.

5. Patient Safety

  •  ITL – Immediate Threat to Life – this puts a hospital’s accreditation in jeopardy. Things that can trigger an “ITL” are significantly compromised:
  •  Fire alarm systems
  •  Sprinkler systems
  •  Emergency power supply system
  •  Medical gas master panel
  •  Exits

6. Fire Safety

  • Make sure you have 18” clear below the bottom of sprinkler heads – not below ceiling (ex. Top of shelving units in a storage room cannot encroach on this 18” clear space, nor can the stuff that is stored). JC suggests painting a red line around the perimeter of a storage room showing what the start of “no-mans land” is. Perimeter shelving going to ceiling is ok as long as there isn’t a sprinkler overhead (which there shouldn’t be).

Miscellaneous Items

  • CMS waivers on items do not transfer to a Joint Commission waiver. DOH waivers do not transfer to Joint Commission waivers.
  • ICRA – the hospital’s ICRA should include information about noise and vibration (didn’t get clarification on this)
  • JC is starting to closely review facilities using the FGI ASHE Table 7.1 in high risk areas like OR, sterile supply…therefore the room must be properly ventilated and have the right pressure relationship to the adjacent rooms.
  • Eyewashes: Joint Commission says that you must put an eyewash in any area where there is corrosive substances being used. They do not want to see eyewashes anywhere else and would like hospitals to push back on their infection control folks about whether there is really a need to put one on each floor because it requires a lot of maintenance and documentation.

One response to “NEHES 2012 conference: Joint Commission updates

  1. I recall that I’ve seen wall types/ratings painted above ceilings at a regular interval. IE: a stencil that says “UL U419 – 1 hour rated fire barrier”. Combined with stickers at each penetration showing the UL system, hourly rating and product used to seal the penetration. Similar at dampers.

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