TJC Life Safety & Environment of Care Document Review Tool 2024

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• LS.01.01.01EP1. Indivdual assigned to assess Life Safety Code

  Yes

  No

  N/A

• LS.01.01.01EP2- Building assessment to determine compliance with Life Safety Chapter

  Yes

  No

  N/A

• LS.01.01.01EP3- Current and accurate drawing

  Yes

  No

  N/A

• LS.01.01.01EP5- Deemed hospitals: Documentation of inspections and approvals made by state or local AHJs

  Yes

  No

  N/A

• LS.01.01.01EP7- The hospital maintains current basic building information

  Yes

  No

  N/A

EC.02.01.01 HOSPITAL MANAGES SAFETY AND SECURITY RISKS

• The hospital conducts annual worksite analysis related to workplace violence prevention program .

  Yes

  No

  N/A

EC.02.03.01 HOSPITAL MANAGES FIRE RISK

• EC.02.03.01EP9- The written Fire response plan describes specific roles of staff and LIPs at and away from fire.

  Yes

  No

  N/A

• When and how to sound and report fire alarms

  Yes

  No

  N/A

• How to contain smoke and fire

  Yes

  No

  N/A

• How to use fire extinguisher

  Yes

  No

  N/A

• How to assist and relocate patients

  Yes

  No

  N/A

• How to evacuate to areas of refuge

  Yes

  No

  N/A

EC.02.03.05 FIRE PROTECTION AND SUPPRESSION TESTING & INSPECTION

• EC.02.03.05.EP1- Supervisory signals (quarterly)

  Yes

  No

  N/A

• EC.02.03.05.EP2- Water flow device (Semiannual)

  Yes

  No

  N/A

• EC.02.03.05.EP2-B- Tamper Switches (Semiannual)

  Yes

  No

  N/A

• EC.02.03.05.EP3- Duct, heat, smoke detectors and manual fire alarm boxes (Annually)

  Yes

  No

  N/A

• EC.02.03.05.EP4- Notification Devices (Annually)

  Yes

  No

  N/A

• EC.02.03.05.EP5- Emergency services notification transmission equipment (Annually)

  Yes

  No

  N/A

• EC.02.03.05.EP6- Electric motor driven fire pump (Weekly)

  Yes

  No

  N/A

• EC.02.03.05.EP7- Water storage tank high and low level alarms (semiannually)

  Yes

  No

  N/A

• EC.02.03.05.EP8- Water storage tank low water temp alarms (cold weather only) (monthly)

  Yes

  No

  N/A

• EC.02.03.05.EP9- Sprinkler systems main drain test on all risers. (Annually)

  Yes

  No

  N/A

• EC.02.03.05.EP10- Fire Department connections inspected (Quarterly)

  Yes

  No

  N/A

• EC.02.03.05.EP11- Fire pump tested under flow (Annually)

  Yes

  No

  N/A

• EC.02.03.05.EP12- Standpipe flow test every 5 years

  Yes

  No

  N/A

• EC.02.03.05.EP13- Kitchen suppression system (Semiannual)

  Yes

  No

  N/A

• EC.02.03.05.EP14- Gaseous extinguishing system inspected (Annually)

  Yes

  No

  N/A

• EC.02.03.05.EP15- Portable fire extinguisher inspected monthly

  Yes

  No

  N/A

• January

  Yes

  No

  N/A

• February

  Yes

  No

  N/A

• March

  Yes

  No

  N/A

• April

  Yes

  No

  N/A

• May

  Yes

  No

  N/A

• June

  Yes

  No

  N/A

• July

  Yes

  No

  N/A

• August

  Yes

  No

  N/A

• September

  Yes

  No

  N/A

• October

  Yes

  No

  N/A

• November

  Yes

  No

  N/A

• December

  Yes

  No

  N/A

• EC.02.03.05.EP16- Portable fire extinguisher maintained annually (Annually)

  Yes

  No

  N/A

• EC.02.03.05.EP17- Fire hose hydro tested every 5 years after install, every 3 years there after

  Yes

  No

  N/A

• EC.02.03.05.EP18- Smoke and fire dampers tested and verify closure (Every 6 years)

  Yes

  No

  N/A

• EC.02.03.05.EP19- Smoke Detection shutdown devices for HVAC tested (Annually)

  Yes

  No

  N/A

• EC.02.03.05.EP20- All horizontal and vertical roller and horizontal doors tested. (Annually)

  Yes

  No

  N/A

• EC.02.03.05.EP25- Inspection and testing of fire door assembly (Annually)

  Yes

  No

  N/A

• EC.02.03.05-EP27- Elevators with firefighters operation (monthly)

  Yes

  No

  N/A

• EC.02.03.05.EP28- Documation of maintenance testing and inspecting for EP1-20 and 25

  Yes

  No

  N/A

EC.02.05.07 EMERGENCY POWER SYSTEMS MAINTAINEDAND TESTED

• EC.02.05.07.EP1- At least monthly preforms functional test of emergency lighting system and exit signs required for egress and task lighting for minimum duration of 30 seconds along with visual inspection of other exit signs. (Monthly)

  Yes

  No

  N/A

• EC.02.05.07.EP2- Every 12 months preform functional test of battery powered lights on inventory. (Annually)

  Yes

  No

  N/A

• EC.02.05.07.EP3- Functional test of level 1 SEPSS

  Yes

  No

  N/A

• EC.02.05.07.EP4- Emergency power supply system inspected weekly

  Yes

  No

  N/A

• EC.02.05.07.EP5- Emergency generators tested monthly for 30 minutes under load (plus cool down)

  Yes

  No

  N/A

• EC.02.05.07.EP6- Annual load bank test

  Yes

  No

  N/A

• EC.02.05.07.EP7- All ATS monthly 12 times per year with results and completion dates

  Yes

  No

  N/A

• EC.02.05.07.EP8- Fuel quality test (Annually)

  Yes

  No

  N/A

• EC.02.05.07.EP9 Generator 4-hour test performed (Every 36 months)

  Yes

  No

  N/A

• EC.02.05.07.EP10- Generator load test 4 hours at 30% (every 36 months)

  Yes

  No

  N/A

EC.02.05.09 MEDICAL GAS AND VACUUM SYSTEMS ARE INSPECTED AND TESTED

• EC.02.05.09.EP7- Test and inspect and maintain critical components of pipped medical gas and vacuum systems, waste anesthetic gas disposal and support gas systems on inventory, (per policy)

  Yes

  No

  N/A

• EC.02.05.09.EP8- Location and signage for bulk oxygen systems (on building tour)

  Yes

  No

  N/A

• EC.02.05.09.EP9- Emergency oxygen supply connection (On building tour)

  Yes

  No

  N/A

• EC.02.05.09.EP10- Review medical gas installation/modification/breech certification results for cross connection, purity, correct gas and pressure. (As applicable)

  Yes

  No

  N/A

• EC.02.05.09.EP11- Medical gas supply and zone valves are accessible and clearly labeled. (On building tour)

  Yes

  No

  N/A

• EC.02.05.09.EP12- handling, transfer, storage, labeling transfilling of cylinder (Per policy)

  Yes

  No

  N/A

EC.02.03.03 FIRE DRILLS

• EC.02.03.03.EP1- Fire drill once per shift per quarter in health care occupancies. Quarterly in each building defined as ambulatory health care occupancy (Quarterly)'

  Yes

  No

  N/A

• EC.02.03.03.EP2- Fire drill every 12 months from date of last drill (Annually)

  Yes

  No

  N/A

• EC.02.03.03.EP4- Staff participated in the drills according to the hospital fire response plan,

  Yes

  No

  N/A

• EC.02.03.03.EP5- Critiques include fire safety equipment and building features and staff response.

  Yes

  No

  N/A

EC.02.05.01 MANAGE RISKS ASSOCIATED WITH UTILITY SYSTEMS

• EC.02.05.01.EP15- In critical care area designed to control airborne contaminants, the ventilation system provides appropriate pressure relationships, air exchanges rates, filtration efficiencies temperature and humidity.

  Yes

  No

  N/A

EC.02.05.02 MANAGES RISKS ASSOCIATED WITH UTILITY SYSTEMS- WATER MANAGEMENT PROGRAM

• EC.02.05.02.EP1- Verify individual or team responsible for oversight and implementation of the water management program

  Yes

  No

  N/A

• EC.02.05.02.EP2- Review water management program to verify the following components are included. Diagram of water supply sources, treatment systems, processing steps, control measures and end use points. Water risk management plan identifies areas where potential hazard conditions may occur. Plan for addressing the use of water in areas of building where water may have been stagnant for a period of time. Evaluation of immunocompromised patients. Monitoring protocols and acceptable ranges for control measures.

  Yes

  No

  N/A

• EC.02.05.02.EP3- Verify that the water management program includes documentation of the following: Results od all monitoring activities. Corrective action and procedures to follow if test results are outside of acceptable limits. Corrective action taken when control limits are not maintained.

  Yes

  No

  N/A

• EC.02.05.02.EP4- Verify water management program reviewed annually and when changes have been made to the water system that add risks.

  Yes

  No

  N/A

EC.02.04.01 MANAGEMENT OF MEDICAL EQUIPMENT RISKS

• EC.02.04.01.EP2- Non-deemed status requirement: maintains either a written inventory of all medical equipment or written inventory of selected equipment categorized by physical risk associated with use and equipment history Evaluates new types of equipment before initial use to determine whether they should included in the inventory, or deemed status requirement: Maintains a written inventory of all medical equipment.

  Yes

  No

  N/A

• EC.02.04.01.EP3- High-risk medical equipment identified on inventory

  Yes

  No

  N/A

• EC.02.04.01.EP4- Inventory includes activities and associated frequencies for maintaining, inspecting and testing all medical equipment on inventory, Activities and associated frequencies are in accordance with the manufacturers recommendations or with strategies of a alternative equipment maintenance (AEM) program.

  Yes

  No

  N/A

• Yes

  No

  N/A

EC.02.04.03- MEDICAL EQUIPMENT INSPECTION, TESTING AND MAINTENANCE

• EC.02.04.03.EP2- All high-risk medical equipment

  Yes

  No

  N/A

• EC.02.04.03.EP3- Non-High-Risk equipment

  Yes

  No

  N/A

• EC.02.04.03.EP4- Conducts performance testing and maintains all sterilizers

  Yes

  No

  N/A

• EC.02.04.03.EP10- All occupancies containing hyperbaric facilities comply with construction equipment, administration, and maintenance requirements of NFPA 99 chapter 14

  Yes

  No

  N/A

EC.02.05.05. UTILITY SYSTEM INSPECTION, TESTING AND MAINTENANCE

• EC.02.05.05.EP4- High-risk utility system components on the inventory with completion date and results of activates documented. Note 1: a high risk utility system includes components for which there is a risk of serious injury or even death to a patient or staff member should it fail, which includes life-support equipment. Note 2: Required activites and associated frequencies for maintaining inspecting and testing of utility system components completed in accordance with manufacturers recommendations, must have 100% completion rate. Note 3: Scheduled maintenance activities for high-risk utility systems components in an alternative equipment maintenance progrqam inventory must have 100% completion rate.

  Yes

  No

  N/A

• EC.02.05.05.EP5- Infection control utility system components on the inventory with completion date and results of activities documented. Note 1: required activities and associated frequencies for maintaining, inspecting, and testing of utility systems. Components completed in accordance with manufacturers recommendations must have 100% completion rate. Note 2: scheduled maintenance activities for infection control utility systems components in an alternative equipment maintenance program inventory must have 100% completion rate.

  Yes

  No

  N/A

• EC.02.05.05.EP6- non-high-risk utility system components on the inventory with completion, date, and results of activities documented. Note: Schedule maintenance activities for non-high risk utility system components in an alternative equipment maintenance program inventory must have 100% completion rate AEM frequency is determined by hospital AEM program.

  Yes

  No

  N/A

• EC.02.05.05.EP7- line isolation monitors if installed are tested at least monthly by actuating the LIM test switch. For LIM circuits with automated self testing a manual test is performed at least annually.

  Yes

  No

  N/A

EC.02.01.01 THE HOSPITAL MANAGES SAFETY AND SECURITY RISKS

• EC.02.01.01.EP1-The hospital implements is processed to identify safety and security risk associated with the environment of care they could affect patients, staff, and other people coming into the hospital

  Yes

  No

  N/A

• EC.02.01.02.EP3- The hospital takes action to minimize or eliminate identified safety and security risk in the physical environment

  Yes

  No

  N/A

EC.01.01.01 THE HOSPITAL PLANS AND ACTIVITES TO MINIMIZE RISKS IN BTHE ENVIRONMENT OF CARE

• EP’s 1-9 - The hospital has written planned for managing the following: EP4 environmental safety, EP5 security, EP6 hazardous materials, EP7 fire safety, EP8 medical equipment, EP9 utility systems. Note1: One or more person can be assigned to manage risk associated with management plans described in the standard. Note 2: For hospitals that use joint commission accreditation for deemed status purpose the hospital comp with the 2012 edition of NFPA 99: Healthcare facilities code chapter 7, eight, 12, and 13 of the healthcare facilities code do not apply. Note 3: for further information on waiver and equivalency request see NFP 99, 20 12 1–4

  Yes

  No

  N/A

EC.04.01.01 THE HOSPITAL COLLECTS INFORMATION TO MONITOR CONDITIONS IN THE ENVIRONMENT

• EC.04.01.01.EP15- every 12 months, the hospital evaluates, each environment of care, management plan, including a review of plans, objectives, scope, performance, and effectiveness

  Yes

  No

  N/A

EC.04.01.03 THE HOSPITAL PLANS ACTIVITIES TO MINIMIZE RISKS IN ENVIRONMENT OF CARE

• EC.04.01.03.EP2- The hospital uses the results of data analysis to identify opportunities to resolve environmental safety issues.

  Yes

  No

  N/A

EC.04.01.05 THE HOSPITAL IMPROVES ITS ENVIRONMENT OF CARE

• EC.04.01.05.EP1- The hospital takes action on the identified opportunities to resolve for your mental safety issues.

  Yes

  No

  N/A

LS.01.02.01N INTERIM LIFE SAFETY MEASURES (ILSM)

• LS.01.02.01.EP1- ILSM policy identifying one and what extent ILSM implemented

  Yes

  No

  N/A

• LS.01.02.01.EP2- alarms out of service for or more hours in 24 hours or sprinklers out of service more than 10 hours and 24 hours in an occupied building – firewatch/fire department notification.

  Yes

  No

  N/A

• LS.01.02.01.EP3- Science for alternate exit posted

  Yes

  No

  N/A

• LS.01.02.01.EP4- Daily inspection over route of egress

  Yes

  No

  N/A

• LS.01.02.01.EP5- Temporary but equivalent systems while system is impaired

  Yes

  No

  N/A

• LS.01.02.01.EP6- Additional firefighting equipment provided

  Yes

  No

  N/A

• LS.01.02.01.EP7- smoke tight non-combustible temporary barriers

  Yes

  No

  N/A

• LS.01.02.01.EP8- increased surveillance implemented

  Yes

  No

  N/A

• LS.01.02.01.EP9- Storage and debris removal

  Yes

  No

  N/A

• LS.01.02.01.EP10- Additional training on firefighting equipment

  Yes

  No

  N/A

• LS.01.02.01.EP11- Additional fire drill per shift per quarter

  Yes

  No

  N/A

• LS.01.02.01.EP12- temporary systems tested and inspected monthly

  Yes

  No

  N/A

• LS.01.02.01.EP13- Additional training and building deficiencies, construction hazards, temperature measures

  Yes

  No

  N/A

• LS.01.02.01.EP14- Training for impaired, structural or impaired component fire safety Features.

  Yes

  No

  N/A

• LS.01.02.01.EP15- Other ILSM’s

  Yes

  No

  N/A

EC.02.02.01 THE HOSPITAL MANAGES RISKS RELATED TO HAZARDOUS MATERIALS AND WASTE

• EC.02.02.01.EP1- The hospital maintains a written, Current inventory of hazardous materials and waste that it uses, storage, or generates. The only materials that need to be included on the inventory are those whose handling, use and storage are dressed by law and regulation.

  Yes

  No

  N/A

• EC.02.02.01.EP3- The hospital has written procedures, including the use of precautions and personal protective equipment, to follow and response to hazard material and waste bills or exposure

  Yes

  No

  N/A

• EC.02.02.01.EP11- her managing has materials and ways, the hospital has the permits, license, manifest, and safety data sheets required by law and regulation

  Yes

  No

  N/A

EC.02.01.01 THE HOSPITAL MANAGES SAFETY AND SECURITY RISKS

• EC.02.01.01.EP1- The hospital implements its process to identify safety and security risk associated with the environment of care that could affect patients, staff, and other people coming to the hospital facility. NOTE: Risks are identified from internal sources, such as ongoing monitoring of the environment, result of root Causes an analysis, results of proactive risk, assessment of high risk processes, and from credible external sources, such as sentinel events

  Yes

  No

  N/A

• EC.02.01.01.EP3- The hospital takes action to minimize or eliminate identified safety and security risk in the physical environment

  Yes

  No

  N/A

• EC.02.01.01.EP9- The hospital has written procedures to follow in the event of a security incident, including an infant or pediatric abduction

  Yes

  No

  N/A

• EC.02.01.01.EP10- when a security incident occurs, the hospital follows its identified procedures

  Yes

  No

  N/A