TJC tweaks EC and LS standards, adds specifics to some requirements

by A.J. Plunkett (aplunkett@decisionhealth.com)

Review your Environment of Care (EC) and Life Safety (LS) policies and procedures now that The Joint Commission has issued another round of revisions, prepublished September 21 with an effective date of January 1, 2023.

Only 12 standards are involved in this latest round. Many of the revisions add specifics to long-standing requirements, including several that add new notes under the element of performance (EP). Others are simple tweaks.

For instance, under EC.02.05.01, the standard requiring hospitals to manage utility system risks, EP 23 on the use of power strips in patient care locations will have three new notes with specific information on who can mount power strips on medical equipment assemblies and when hospitals are required to add receptacles rather than use power strips.

Under LS.01.02.01, requiring hospitals to protect occupants during times when the Life Safety Code® is not met or during construction, a new note adds that hospitals must identify what interim life safety measures (ILSMs) in their policy will be implemented when a deficiency is found during survey.

Under EC.01.01.01, a note is added to EP 9 requiring a written plan for managing utility systems that says for programs or services offered in a business occupancy “not owned by the accredited organization, the plan may only need to address how routine service and maintenance for their utility systems are obtained.”

And under EC.02.03.03 requiring fire drills, EP 7 no longer discusses anesthetizing locations, but implicitly states that the requirement is for annual fire drills in operating rooms and surgical suites.

“I think the biggest potential kerfuffle revolves around the requirement to represent the ILSM assessment process in the ILSM policy (which would seem intuitive, but maybe not so much),” said Steven A. MacArthur, a senior consultant with Chartis Clinical Quality Solutions in Danvers, Massachusetts.

“We know they’ve been using the ILSM process for LSC deficiencies that cannot be corrected before the end of the survey, so I suspect this update may be in response to surveyor feedback that a lot of folks don’t have a clearly delineated assessment process. Before, the policy was supposed to identify the criteria, and now it explicitly calls out the assessment process as a specific component,” noted MacArthur.

One change to look for is the requirement to have a written utility management plan for business occupancy areas.

“I can see some folks having to scramble to create a process for managing utility systems in leased spaces,” said MacArthur. “I think there may be more than a few folks that rely on the recalcitrance of landlords when it comes to producing documentation (primarily fire alarm & sprinkler systems).” He warned, “Now they have a place to cite that.”

Other changes could serve to produce more RFIs.

“The power strip change makes me think they’re going to go after how folks are using them in patient areas,” but that remains to be seen, he noted.