Audit

The hospital manages safety and security risks.

EC.02.01.01 EP5
The hospital maintains all grounds and equipment.

The hospital manages its environment during demolition, renovation, or new construction to reduce risk to those in the organization.

EC.02.06.05 EP2
When planning for demolition, construction, or renovation, the hospital conducts a reconstruction risk assessment for air quality requirements, infection control, utility requirements, noise, vibration, and other hazards that affect care, treatment, and services.

EC.02.06.05 EP3
The hospital takes action based on its assessment to minimize risks during demolition, construction, or renovation.

LS.01.02.01 EP4
Inspects exits in affected areas on a daily basis.

LS.01.02.01 EP5
Provides temporary but equivalent fire alarm and detection systems for use when a fire system is impaired.

LS.01.02.01 EP6
Provides additional firefighting equipment.

LS.01.02.01 EP7
Uses temporary construction partitions that are smoke-tight, or made of noncombustible or limited-combustible material that will not contribute to the development or spread of fire.

LS.01.02.01 EP8
Increases surveillance of buildings, grounds, and equipment, giving special attention to construction areas and storage, excavation, and field offices.

LS.01.02.01 EP9
Enforces storage, housekeeping, and debris-removal practices that reduce the building’s flammable and combustible fire load to the lowest feasible level.

LS.01.02.01 EP10
Provides additional training to those who work in the hospital on the use of firefighting equipment.

LS.01.02.01 EP11
Conducts one additional fire drill per shift per quarter.

LS.01.02.01 EP12
Inspects and tests temporary systems monthly.

LS.01.02.01 EP13
The hospital conducts education to promote awareness of building deficiencies, construction hazards, and temporary measures implemented to maintain fire safety.

LS.01.02.01 EP14
The hospital trains those who work in the hospital to compensate for impaired structural or compartmental fire safety features.

The hospital designs and manages the physical environment to comply with the Life Safety Code.

LS.01.01.01 EP2
The hospital maintains a current electronic Statement of Conditions.

LS.01.01.01 EP3
When the hospital plans to resolve a deficiency through a Plan for Improvement (PFI), the hospital meets the time frames identified in the PFI accepted by The Joint Commission.

The hospital conducts fire drills.

EC.02.03.03 EP1
The hospital conducts fire drills once per shift per quarter in each building defined as a health care occupancy.

EC.02.03.03 EP5
The hospital critiques fire drills to evaluate fire safety equipment, fire safety building features, and staff response to fire.

The hospital maintains fire safety equipment and fire safety building features.

EC.02.03.05 EP1
At least quarterly, the hospital tests supervisory signal devices (except valve tamper switches).

EC.02.03.05 EP2
Every 3 months, the hospital tests valve tamper switches and water-flow devices.

EC.02.03.05 EP3
Every 12 months, the hospital tests duct detectors, electromechanical releasing devices, heat detectors, manual fire alarm boxes, and smoke detectors.

EC.02.03.05 EP4
Every 12 months, the hospital tests visual and audible fire alarms, including speakers.

EC.02.03.05 EP5
Every quarter, the hospital tests fire alarm equipment for notifying off-site fire responders.

EC.02.03.05 EP6
For automatic sprinkler systems: Every week, the hospital tests fire pumps under no-flow conditions.

EC.02.03.05 EP9
For automatic sprinkler systems: Every 12 months, the hospital tests main drains at system low point or at all system risers.

EC.02.03.05 EP10
For automatic sprinkler systems: Every quarter, the hospital inspects all fire department water supply connections.

EC.02.03.05 EP11
For automatic sprinkler systems: Every 12 months, the hospital tests fire pumps under flow.

EC.02.03.05 EP12
Every 5 years, the hospital conducts water-flow tests for standpipe systems.

EC.02.03.05 EP13
Every 6 months, the hospital inspects any automatic fire-extinguishing systems in a kitchen.

EC.02.03.05 EP15
At least monthly, the hospital inspects portable fire extinguishers.

EC.02.03.05 EP16
Every 12 months, the hospital performs maintenance on portable fire extinguishers.

EC.02.03.05 EP18
The hospital operates fire and smoke dampers 1 year after installation (commencing Jan 2010) and then at least every 6 years to verify that they fully close.

EC.02.03.05 EP19
Every 12 months, the hospital tests automatic smoke-detection shutdown devices for air-handling equipment.

EC.02.03.05 EP20
Every 12 months, the hospital tests sliding and rolling fire doors for proper operation and full closure. The completion date of the tests is documented.

The hospital designs and manages the physical environment to comply with the Life Safety Code.

LS.01.01.01 EP4
For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital maintains documentation of any inspections and approvals made by state or local fire control agencies.

The hospital protects occupants during periods when the Life Safety Code is not met or during periods of construction.

LS.01.02.01 EP1
The hospital notifies the fire department (or other emergency response group) and initiates a fire watch when a fire alarm or sprinkler system is out of service more than 4 hours in a 24-hour period in an occupied building. Notification and fire watch times are documented.

Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.

LS.02.01.10 EP8
Ducts that penetrate a 2-hour fire-rated separation are protected by dampers that are fire-rated for 1 1/2 hours.

The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.

LS.02.01.30 EP20
In existing buildings, ducts that penetrate smoke barriers are protected by approved smoke dampers that close when a smoke detector is activated. The detector is located either within the duct system or in the area serving the smoke compartment.

The hospital provides and maintains fire alarm systems.

LS.02.01.34 EP1
The fire alarm signal automatically transmits to a Central Monitoring station as described in NFPA 72-1999; 5-2

The hospital maintains the integrity of the means of egress.

LS.02.01.20 EP27
Means of egress are adequately illuminated at all points, including angles and intersections of corridors and passageways, stairways, stairway landings, exit doors, and exit discharges.

LS.02.01.20 EP28
Illumination in the means of egress, including exit discharges, is arranged so that failure of any single light fixture or bulb will not leave the area in darkness.

The hospital manages risks associated with its utility systems.

EC.02.05.01 EP7
The hospital maps the distribution of its utility systems.

EC.02.05.01 EP10
The hospital's procedures address shutting off the malfunctioning system and notifying staff in affected areas.

The hospital has a reliable emergency electrical power source.

EC.02.05.03 EP1
The hospital provides emergency power for the following utilities and systems: Alarm systems, as required by the Life Safety Code.

EC.02.05.03 EP2
Exit route and exit sign illumination, as required by the Life Safety Code.

EC.02.05.03 EP3
Emergency communication systems, as required by the Life Safety Code.

EC.02.05.03 EP4
Elevators (at least one for nonambulatory patients).

EC.02.05.03 EP5
Equipment that could cause patient harm when it fails, including life-support systems; blood, bone, and tissue storage systems; medical air compressors; and medical and surgical vacuum systems.

EC.02.05.03 EP6
Areas in which loss of power could result in patient harm, including operating rooms, recovery rooms, obstetrical delivery rooms, nurseries, and urgent care areas.

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.