Life Safety Code Clarifications — 4 Tricky Issues

by Jen Cowel

Life Safety Code Clarifications — 4 Tricky Issues

by Jen Cowel

by Jen Cowel

Perspectives includes another in their series on Life Safety Code Clarifications and Expectations. This month, it reviews LS.02.01.30, including both current and potentially new requirements effective January 1, 2018. The CMS and TJC are still negotiating new requirements.

ED Occupancy Type

A second article details four life safety code clarifications. First, it clarifies emergency department occupancy. Either healthcare or ambulatory definitions are allows. But, a business occupancy definition is not.

This may be a concern for organizations with remote emergency departments.

Door Inspections

The second clarification is on the annual door inspection process required by EP 25 in EC.02.03.05. Although not published in manuals at the beginning of the year, July 5, 2017 is the date to complete door inspections.

Door Ratings

The third clarification covers information we have written about previously. It provides details on doors that rated for more than the barrier maintained. For example, placing a fire door in the hallway instead of a smoke door, when only a smoke door is mandatory. It’s required that you maintain this door as a fire door and that it’s inspected as a fire door. Yet, removing those features that make it a fire door will then change rule.

Fire Drill Timing

The 4th clarification covers fire drills. It’s essential they occur at different times and under varying conditions. TJC advises at least one hour between drills. But, it’s also important to avoid creating an identifiable pattern. Surveyors are identifying patterns you may not recognize. As a result, it’s a commonly scored item. Using a random number generator to create fire drill times is a good option. Also, keep your random schedule for verification that it was randomly chosen.

Life Safety Code Clarifications

Share these EC/LS articles with facilities leadership. Discussing and analyzing hospital implications will help you maintain compliance.

Finally, do you need joint commission compliance assistance or CMS survey support? Contact Patton Healthcare Consulting for more information.


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