© Copyright, The Joint Commission 2012 T HE H EALTHCARE E NVIRONMENT U PDATE George Mills, Director Engineering Department The Joint Commission

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2012

THE HEALTHCARE ENVIRONMENT

UPDATE

George Mills, Director

Engineering Department

The Joint Commission

Department of Engineering 2012 - 2

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LS & EC RANKING IN TOP 10 IN 2011

2. 56% LS.02.01.20 EP 13 Corridor Clutter3. 52% LS.02.01.10 EP 9 & 5 Penetrations

& Rated Doors 4. 45% LS.02.01.30 EP 2 Hazardous

Areas5. 40% EC.02.03.05 All EP’s Fire Safety

Testing 10. 31% LS.02.01.35 Sprinkler System


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LS.02.01.20 (56%)

The hospital maintains the integrity of the means of egress.EP 13 Corridor Clutter

Also scoredEPs 16 – 22 Suites issues

Equivalize > 5000 sq ftEP 1 Doors locked in means of

egress


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CORRIDOR STORAGE

“If the corridor looks cluttered…it probably is” Corridor clutter is not a PFI issue Carts Allowed:

Crash Carts Isolation Carts Chemo Carts Based on a HITF the following carts are not

allowed: Linen Hampers Latex Carts

Anything in the egress corridor more than 30 minutes is storage


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CORRIDOR STORAGE

Dead end corridors may be used for storage Less than or equal to 50sqft space

Surge issue: based on policy patients may be treated in the egress corridor during surge conditions

Goal is continuous compliance for patient safetyNOT oscillating compliance


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LS.02.01.10 (52%)

Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.EP 9 PenetrationsEPs 5 – 7 Door issuesEPs 1 & 2 Building Type issuesEP 8 Duct issues


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LS.02.01.30 (45%)

The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.EPs 16 – 23 Smoke Barriers & DoorsEP 2 Hazardous Areas


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EC.02.03.05 (40%)

The hospital maintains fire safety equipment and fire safety building features.Features of fire protection

NOTE: #1 for Critical Access Hospitals


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LD.04.01.05 EP 4: WHAT TO DO WHEN THE DOCUMENTATION ISN’T THERE…

During survey specific documentation is reviewed If the documentation is not available write the observation

as non-compliant Also score LD.04.01.05 EP 4

If the documentation becomes available later in the survey to the survey team, the team can: Consider removing the previous finding if documentation

confirms the activity was completed as per the EP LD.04.01.05 EP 4 may also be removed during survey

If the survey team would prefer not to evaluate the documentation the organization can submit clarification

If the organization clarifies after survey: SIG Engineers will review and evaluate compliance LD.04.01.05 EP 4 remains


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LS.02.01.35 EP 6

There are 18” or more of open space maintained below the sprinkler deflector to the top of storage.

NOTE: Perimeter wall and stack shelving may NFPA 25-1998, 2-2.1.1


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18” RULE

18”18”

OK OK OKWrong

Wall Wall

Ceiling

Perimeter Shelving Perimeter

Shelving


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LIFE SAFETY CODE SURVEYOR

LSCS Background Facilities or Environment of Care based Prefer CHFM certification

All HAP and CAH will be surveyed for a minimum of 2 days by a LSCS Greater than 1.5 million sq ft will be surveyed

for a third day by the LSCS An additional day is added for every three

buildings that are classified as healthcareExample: for a HAP organization with 2 million

square feet of healthcare occupancy and 5 buildings classified as healthcare occupancy:

the number of LSCS days would be 4


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LIFE SAFETY CODE SURVEYOR

Interfaces with survey team member(s) LSCS Survey Focus

Life Safety Chapter EC.02.05.03 EC.02.05.07 EC.02.05.09

May conduct the EC Session May conduct the EM Session

Other “Observations” May also survey

LD.04.01.05 EP 4 Accountability LD.04.04.01 EP 2 Hi-Priority LD.01.03.01 EP 5 Resources


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WHAT TRIGGERS ITL(IMMEDIATE THREAT TO LIFE)

Significantly compromised fire alarm system

Significantly compromised sprinkler system Significantly compromised emergency

power supply system Significantly compromised medical gas

master panel Significantly compromised exits Other situations that place patients, staff or

visitors at extreme danger


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WHAT TRIGGERS ITL(IMMEDIATE THREAT TO LIFE)

PDA01An Immediate Threat to Health or Safety exists for patients or the public within the hospital.

CONT01The Immediate Treat to Health or Safety has been successfully abated and verified through the direct observation or other determining method.


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AFS 10 IS RELATED TO THE SOC AND PFIS

Failure to make sufficient progress on previously accepted PFIs (LS.01.01.01 EP 2)

Failure to develop ILSM policy and implement appropriate ILSMs (LS.01.02.01 EP 3)

Failure to manage previously accepted PFIs affects the Joint CommissionBoth organizations are aware of

deficiencies that have been managed using the PFI process


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DEFICIENCY RESOLUTION Resolution to a deficiency:

Resolve it immediately Correct it within 45 days:

Management process that documents the deficiency and actions to resolve

ILSM must be considered Plan For Improvement located in the

Statement of Conditions™ Corrected within 6 months of the

Projected Completion Date ILSM must be considered


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45 DAY CORRECTIVE ACTION Documented

Origination date Completion date Kept available for rolling 3 years Life Safety deficiencies Must not exceed 45 days If greater than 45 days create a Plan For

Improvement (PFI) If originally a work order, close out as complete

and generate the PFI Must be made available to the Joint Commission

During survey to confirm management of the deficiency

During CMS/Joint Commission validation process upon request


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HOW MANY OPEN PFIS ARE TOO MANY?

The PFI process was created to allow organizations to self assess and create a Plan for Improvement

The self disclosure has never defined how many is too many

The ILSM process was created to allow both the organization and The Joint Commission to be aware of Life Safety Code deficiencies

Failure to make progress on previously accepted PFIs, including failure to implement ILSMs results in Conditional Accreditation


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HOW MANY OPEN PFIS ARE TOO MANY?

Survey Process: There is no limit to the number of PFIs Evaluate both closed and currently open PFIs in

the View All screen Spot check during building tour both some

closed and open PFIs to evaluate how well the organization is managing the PFI process

Evaluate the scope of PFI entries Are there life safety deficiencies Are they greater than maintenance items

(i.e. screws missing from a door hinge)


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STATEMENT OF CONDITIONS: PFI

PFIs should be related to the LS Chapter Corridor clutter is not a legitimate PFI

PFIs should provide specific information No blanket statements

“…penetrations on 3rd floor” Specific references to Life Safety Drawings is

acceptable 32 penetrations as identified on LS

Drawing 3rd Floor, Center Tower dated 3/3/2010

Projected Completion Date is for all listed items (i.e. “32 penetrations”)


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TWO FORMS OF EQUIVALENCIES

Fire Safety Evaluation System (FSES) A process of calculating the features of life

safety and deducting any deficiencies, with the outcome determining if the building is equivalized based on the FSES

Traditional Equivalency A process of field verification identifying

alternative methods of fire safety that off-set the identified deficiency

Field verification from one of the following: Registered architect Fire Protection Engineer Local AHJ responsible for fire safety


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HISTORY AUDIT TRAIL

The History Audit Trail is used by SIG Engineers when considering extensions or other activities related to an organization

Prior to surveying, the surveyor must preview the History Audit Trail to discover if equivalencies or other actions have occurred by SIG Engineers

When surveying, brief but accurate information entered in the File Room is important

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2012 LIFE SAFETY CODE

George Mills, Director

Department of Engineering

The Joint Commission


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NFPA 101-2012

1. Means of Egress Enhanced Patient lift & transport equipment may be

stored in the Means of Egress, provided 5ft clear corridor width is maintained Fire plan addresses management of

storage Accommodates current “equipment in use”


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NFPA 101-2012

2. Fixed seating permitted provided 6ft clear width < 50sqft with 10’ between

groupings Groupings must be on same

side of the egress corridor


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NFPA 101-2012 CORRIDOR COOKING

4. Cooking Facilities One cooking area may be open to the egress

corridor per smoke compartment Any additional cooking areas must be in

protected room similar to hazardous areas Provisions:

No deep fat fryers Safety equipment to de-activate fuel supply Grease baffles installed No solid fuel (i.e. charcoal)


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NFPA 101-2012 FIREPLACES

5. Fireplaces in smoke compartments with patient sleeping rooms

Section 18/19.5.2(2), (3) and (4) Allow the installation of direct vent

gas fireplaces In smoke compartments containing

patient sleeping rooms Installation of solid fuel burning

fireplaces in areas other than patient sleeping areas


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NFPA 101-2012 DECORATIONS

6. Allow the use of Furnishings, Mattresses, and Decorations including Section 18/19.7.5

Allows the installation of combustible decorations on Walls Doors Ceilings

LSC Section 18/19.7.5.6

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GENERAL INTERPRETATIONS

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BUILDING MAINTENANCE PROGRAM (BMP)

The BMP is no longer available to offset findings during survey, but is considered “best practice”

All EPs related to the original ten BMP items are ‘C’ categories


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GENERAL LIFE SAFETY INTERPRETATIONS

Alcohol Based Hand Rub (ABHR) placement:LS.02.01.29 EP 12 and NFPA 101

19.3.2.6 (6) states, The dispensers shall not be installed over or directly adjacent to an ignition source.

The Joint Commission published information in 2006 defining “adjacent to” as no closer than 6inches, center of the dispenser to center of the ignition source


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NFPA 101, 2012: 18/19.3.2.6. (8) Dispensers shall not be installed in the following locations:Above an ignition source for a horizontal

distance of 1 in (25 mm) to each side of the ignition source.

To the side of an ignition source within a 1 in. (25 mm) horizontal distance from the ignition source.

Beneath an ignition source within a 1 in. (25 mm) vertical distance from the ignition source.


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FIRE & SMOKE DAMPER INSPECTIONS

Ensure inaccessible dampers truly are by random sampling

Confirm ILSM policy is implemented for any horizontal exits or egress enclosures that are compromised by inaccessible dampers

Evaluate adequacy of damper accessibility plan


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EC.02.06.05 EP 1 Effective 1/1/2011 the Joint Commission will

recognize the Facilities Guidelines Institute (FGI) Guidelines for Design & Construction of Health Care Facilities

ASHRAE 170 has been attached to the Guidelines Ventilation Table 20 – 60 % RH requirement of relative humidity in

seven affected areas of the Surgical Environment, and one in Diagnostic & Treatment. NOTE CMS has not adopted this, but remains

at 35 – 60%RH The established 60% upper range however

should be maintained for issues such as mold growth.


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RH% TREATMENT AREAS

Class A Operating/Procedure room Class B and C operating rooms Operating/surgical cystoscopic rooms Delivery room (Caesarean) Treatment rooms Trauma room (crisis or shock) Laser eye room Diagnostic & Treatment: Gastrointestinal

Endoscopy Procedure Room


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CENTRAL STERILE LAYOUT Physically separated soiled and clean work rooms

Soiled Work Room: Work surface, sink, washer/sterilizer decontaminators Soiled room is not to have direct contact with the OR

Clean assembly /work room Hand washing station Sufficient workspace and equipment

Self-closing door or pass through is acceptable between soiled and clean work rooms

Storage provisions for humidity, temperature, and ventilation Location of storage may be within the clean assembly/

workroom in a permanently designated space

Guidelines for Design & Construction of Health Care Facilities FGI 2010 edition 3.7-5.1.2 - 3.7-5.1.2.3


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ENDOSCOPY PROCESSING ROOM

May be one room, dedicated to endoscopy equipment processing Sized as per amount of equipment processed Work flow from soiled to clean

Clean should not be exposed to soiled• 3ft min clearance clean from soiled at all times • Droplet contamination is concern

Work surface and sink Hand washing station Sufficient workspace, utilities and equipment

Ventilation Negative air pressure to surrounding areas Minimum 10 ach (2 fresh, outside); direct exhaust NO requirements for temperature or humidity



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ENDOSCOPY PROCESSING ROOM Storage

May be a cabinet in the endoscopy processing room Cabinet must have doors Cabinet must be at least 3ft from potential

droplet contamination• Consider route from processor to the cabinet• Route should not cross through soiled

processing area Storage may be in a separate room

Inventory of Scopes Recommended practice is to include scopes in the

Medical Equipment Inventory



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SCORING

EC.02.05.01 EP 1: Improper system designInability of the mechanical system to

achieve required results EC.02.05.01 EP 4: Lack of written

inspection, testing & maintaining frequenciesContinuous monitoring by a building

automation system (BAS) is acceptable


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SCORING

EC.02.05.01 EP 6: Ventilation system is unable to provide appropriate pressure relationships, air-exchange rates and filtration efficiencies Specific areas lack

negative or positive pressures in relationship to adjacent areas • i.e. Endoscopy Processing Room should

be negative to the egress corridor the correct number of air changes per hour Improper filtration

• MERV = minimum efficiency reporting value


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SCORING Tissue test: only to be used as a pre-screening tool to

evaluate if further investigation needs to occur To perform the flutter test take a tissue and let it hang

just off the floor near the bottom edge of a door If the tissue indicates incorrect air flow, stabilize the

area by closing doors and windows, wait a few minutes and re-screen

If the organization presents a Testing & Balancing report the following questions should be asked

• when was the balancing done (seasonal issues) • are any specific requirements (such as keeping a

door closed) needed to achieve satisfactory results

If non-compliance is determined write a clear and specific finding


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SCORING

EC.02.06.01 EP 13 Maintains ventilation, temperature and humidity

levels suitable for care, treatment and services provided Ventilation:

• i.e. doors held open by air pressure; odors Temperature:

• Hot / Cold calls Humidity

• Primary concern is for areas >60%RH− Mold growth is possible


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SCORING

EC.02.05.05 EP’s 4 & 5 EP 4: Infection Control systems are not

maintained i.e. an isolation room that should be

negative is positive EP 5: non-life support utility system

components are not inspected, tested or maintained Improper number of air changes results in

offensive odors in geriatric unit


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Rated doors must have legible labels on the door and jambsJambs prior to 1966 may not have a rating label

Are ILSM in place where non-compliant door assemblies are found?


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NON FLAMMABLE MEDICAL GAS VOLUME & STORAGE: SCORING

Score EC.02.03.01 EP 1 …fire risk12 ‘E’ cylinders (<300ft³) per smoke compartment

(22,500ft²) may be open to the egress corridor in a rack or appropriate holders

Between 300 and 3000ft³ must be stored in a room that is limited construction with doors that can be locked

“In use” verses “in storage” Properly secured to a gurney is considered “in use” Properly racked is “in storage” Empty are NOT considered part of the 12 in storage Empty and full must be stored (racked) separately


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NON-FLAMMABLE GAS STORAGE: NFPA 99-2005

NFPA 99-2005 edition has additional language regarding O2 storage requirements, specifically:

Storage of nonflammable gases:9.4.1 > 3000 cubic feet9.4.2 300 – 3000 cubic feet 9.4.3 0 - 300 cubic feetOther:5.1.3.3.2 design and construction5.1.3.3.3 ventilation of locations for manifolds5.1.3.3.3.2 ventilation for motor driven equipment5.1.3.3.3.3 ventilation for outdoors

NOTE: CMS also recognizes 9.4.3 reference


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NON-FLAMMABLE MEDICAL GAS UNSAFE CONDITIONS: SCORING

Score EC.02.06.01 …unsafe condition Unsecured cylinders

Laying on top a gurney mattress; leaning against the wall Free standing Comingling of full and empty cylinders

Transfilling liquid oxygen Transfer of any gases from one cylinder to another in patient

care areas of health care facilities is prohibited. Transfilling of liquid oxygen only in an area that is:

• mechanically ventilated• sprinklered• ceramic or concrete flooring• separated with at least 1 hour construction from any patient

care areas


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TANK FARM

EC.02.05.09 EP 1 states the hospital tests, inspects and maintains critical components of the piped medical gas systems. Tank Farm is included in this EP The bulk storage tank(s) and associated systems are

critical components of the piped medical gas system Tanks above ground, not on roofs No electrical service above tanks 10’ Clear from vehicles & sidewalks 50’ from wood frame buildings

• At least 1’-0” from other buildings• At least 10’ form any opening in wall of adjacent

structures• Concrete pads at all spill points (3’ min)

Permanent signage: OXYGEN – NO SMOKING – NO OPEN FLAMES

Access controlled (i.e. locked)


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NFPA 110: EMERGENCY & STANDBY POWER SYSTEMS

Automatic Transfer Switches (ATS) are self-acting devices that have normal electrical power entering and leaving the ATS The power continues on to distribution panels

When a ATS senses a disruption in power it sends a signal to the alternative power source seeking power This start circuit initiates the emergency generator

starter The ATS is also equipped with a test switch to

simulate the power disruption Recommended practice is to rotate which ATS

initiates the start circuit to the emergency generator


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FIRE EXTINGUISHER: DATING

Month, day year and initials of inspector as per NFPA 10-1998 EC.02.03.05 EP 15

4-3.4 Inspection Recordkeeping.4-3.4.1 Personnel making inspections shall keep records of all

fire extinguishers inspected, including those found to require corrective action.

4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.

4-3.4.3 Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record.

DO NOT COUNT DAYS, BUT ENSURE MONTHLY INSPECTION


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Perimeter shelving and sprinkler provision:Are perimeter wall shelving that

extends to the ceiling required to be fastened to the wall?

NO Shelving is not required for storage There is no correlation between

• Shelving• Clearance • The need to secure any shelving


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Firestop: Existing application is acceptable

whenIt was installed in a manner

consistent with original design specifications

It is in acceptable condition currently If the firestop is cracking, etc, then it is to be removed and repaired using current technologies


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Expanding foam used for insulation purposes is NOT an acceptable firestop in any fire or smoke barrier This product does have a UL label: for insulation properties

Easily ignited Toxic gases may occur when burned

NOTE: There are several acceptable fire stop products that expand when installed


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ElectricalUnlocked distribution panels in patient

care areas Based on policy Consider risk assessment Score EC.02.01.06 EP 1

Open junction boxes Score at EC.02.03.01 EP 1

• Risk: arcing resulting in fire or loss of service


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Staff Safety EC.02.02.01

EP 3: Precautions & PPE EP 4: Spill procedures EPs 5 – 10: minimizes risk

EC.04.01.01 EP 1: Monitoring & Reporting EPs 2 – 11: Specifics

Manifests: EP 11DOT training for those signing


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OUTDOOR SAFETY

EC.02.01.01 EP 5The hospital maintains all grounds and

equipment Grounds includes

SidewalksParking lotsPark waysPicnic and patio areasPlay structures


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OUTDOOR SAFETY

EC.02.01.01 EP 5 The hospital maintains all grounds and

equipment Equipment includes

Lawn maintenance equipment Snow removal equipment Maintenance equipment

Paving Road repair

Lighting


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Suite ExitingLS.02.01.20 EP 21 (18/19.2.5.1)

Suites have access to an “exit access corridor”

LS.02.01.20 EP 17(18/19.2.5.3) Suites must have at least two exits

remote from one another A stairwell may be allowed to be

substituted as an “exit access corridor”


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SURGICAL SITE FIRES

>50 million hospital & ASC surgeriesEstimated 100 surgery fires per year

20 Serious 1 – 2 deaths

Fire sites:34% airway28% head/face38% other

74% occurred in oxygen enriched environment


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SURGICAL SITE FIRES

Source: 68% electrosurgical equipment 13% lasers

Recommendations: Fire drills & Staff Education Review alarm procedures Review rescue techniques Review shut off locations

Joint Commission response: Life Safety Code Surveyors gown and survey


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CMS CONDITIONS OF PARTICIPATION

42 CFR 482.41 Hospital must maintain adequate facilities for its

services 42 CFR 482.41(c)(2)

Facilities, supplies and equipment must be maintained to ensure an acceptable level of safety and quality.

The CMS Interpretive Guideline states “the hospital must monitor, test, calibrate and maintain equipment periodically in accordance with the manufacturer’s recommendation and Fed and State law.”


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BACKGROUND

2007 two hospitals cited by state agents based on 42 CFR 482.41(c)(2)

2009 hospital system implemented EQ56 CMS Regional Office stated that any risk or

evidence based program conflicted with 42 CFR 482.41(c)(2)

Other CMS Regional Offices accepted the Joint Commission processes

The hospital system asked CMS why they were inconsistent with 42 CFR 482.41(c)(2)

1/2010 CMS instructed Joint Commission to comply with 42 CFR 482.41(c)(2)


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CMS RESPONSE

I am happy to inform you that the Joint Commission’s approach of utilizing a preventive maintenance schedule has been approved. Thank you for your cooperation and collaboration.

CMS Deputy Director July 26, 2010


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S&C: 12-07-HOSPITAL PUBLISHED 12/11

Allows non-life support to adjust frequencies Restricts non-life support from adjusting

maintenance activities Restricts life support from frequencies and

maintenance activity adjustments Restricts equipment maintenance methods Estimated financial impact to comply:

FTE & other re-occurring costs ($4 – 10 Billion): Clinical Equipment: $2 – 5 Billion Facilities Equipment: $2 – 5 Billion

New capital investment ($2 – 6 Billion): Clinical Equipment: $1 – 3 Billion Facilities Equipment: $1 – 3 Billion


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4/9/2012 DISCUSSION WITH CMS

Ad Hoc team began to meet every Monday to create united response to CMS Provided council and resources

Joint Commission leadership is supportive of discussing the issues with CMS Joint Commission met with CMS to discuss the S&C:

12-07 April 9, 2012

Restriction related to test equipment lifted Saving estimated as $2 – 6 Billion to healthcare

Collaborative discussion with the conclusion research would be of benefit

Research should be specific to reliability of the Joint Commission process in EC.02.04.01


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DISCUSSION, CONTINUED

Research Issues:How many organizations use the Joint

Commission process? What guidance is used to modify

frequency and maintenance activities?Have there been any adverse outcomes

based on solely on this process If so, what?

Self diagnostic equipment: How many devices with this feature?


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ACTION ITEMS

AAMI & ASHE hosted Survey Monkeys 5/18 AAMI, ASHE & JCR hosted free webinars

to review Joint Commission standards and make the field aware of the importance of the surveyAAMI had 526 sitesASHE had 216 sites JCR had 794 sites

Survey responses:AAMI had 1526 ASHE had 790


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QUESTION 1

How many acute care beds is your organization licensed or authorized for?

Range Percentages Responses

<100 27.1 221

100 – 200 15.7 123

201 – 350 23.5 183

351 – 500 12.8 100

>500 20.9 162


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QUESTION 2

How many pieces of equipment are in your inventory?

Range Percentages Responses

<500 20.1 158

500 – 1,000 19.1 150

1,000 – 2,500 22.8 180

2,500 – 5,000 17.4 135

>5,000 20.6 162


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QUESTION 3

Do you use the Joint Commission process identified in EC.02.05.01 EPs 2 – 4 (i.e. have an inventory based on risk and other criteria)?

Percentages Responses

Yes 90.9 714

No 9.1 70


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QUESTION 4

Do you use the Joint Commission process identified in EC.02.05.01 EP 3 to establish maintenance activities (i.e. preventive maintenance procedure)?

Percentage Responses

Yes 92.7 728

No 7.3 57


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QUESTION 5

Do you use the Joint Commission process identified in EC.02.05.01 EP 4 to establish maintenance frequencies?


Yes 90.9 711

No 9.1 71


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QUESTION 6

Have you had any adverse outcomes (i.e. patient injuries or deaths) because you have modified the PM procedures or frequencies from the manufacturer’s recommendations, using the Joint Commission process identified in EC.02.05.01 EPs 2 – 4?


Yes 1.0 8

No 99.0 782


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COMMENTS TO QUESTION 6

None of the 12 that answered YES to question 6 had an adverse event4 are not accredited by the Joint Commission 3 had comments that did not pertain to the topic4 were pro-Joint Commission process comments1 reported a bed brake failed to engage and a patient fell when leaning on the bed


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NEXT STEPS

The Ad Hoc committee has continued to actively help navigate this process

AAMI, ASHE and Joint Commission will be meeting with CMS to review the research results

Goal is to resolve the conflict with sound evidence provided by the research

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QUESTIONS?


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DEPARTMENT OF ENGINEERING630 792 5900

George Mills, MBA, FASHE, CEM, CHFM, CHSP

Director

Michael Chisholm, CPE, CHFM

Engineer

Anne Guglielmo, CFPS, LEED, A.P., CHSP

Engineer

John Maurer, CHFM, CHSP

Engineer

Bruce Boggan, MBA, CHFM

Engineer


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THE JOINT COMMISSION DISCLAIMER

These slides are current as of 6/21/2012. The Joint Commission reserves the right to change the content of the information, as appropriate.

These slides are only meant to be cue points, which were expounded upon verbally by the original presenter and are not meant to be comprehensive statements of standards interpretation or represent all the content of the presentation. Thus, care should be exercised in interpreting Joint Commission requirements based solely on the content of these slides.

These slides are copyrighted and may not be further used, shared or distributed without permission of the original presenter or The Joint Commission.


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EYE WASH STATION FEDERAL REQUIREMENTS: OSHA

Score Eye Wash issues at EC.02.02.01 EP 5 Risk assess location / application based on OSHA

recommendation to reduce the risk of injury from contact with caustic and

corrosive materials in areas such as Power Plant Lab

Placed so that the eyewash is within 10 seconds or 55 feet from where the corrosive chemicals is used

Weekly flush until clear is required Annual inspection to ensure the system is fully functional Mixing valve recommended to achieve tepid

Risk assess potential exposure to determine if cold water only would be acceptable


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EYE WASH STATION: RECOMMENDED LOCATIONS (I.E. OSHA)

Medical services and first aid 1910.151(c) The eyes or body of any person may be exposed to injurious

corrosive materials, suitable facilities for quick drenching or flushing of the eyes and body shall be provided within the work area for immediate emergency use.

Formaldehyde 1910.1048(i)(3) If there is any possibility that an employee's eyes may be

splashed with solutions containing 0.1 percent or greater formaldehyde, the employer shall provide acceptable eyewash facilities within the immediate work area for emergency use.

Battery charging and changing 1917.157(i) Facilities for flushing the eyes, body and work area with

water shall be provided wherever electrolyte is handled, except that this requirement does not apply when employees are only checking battery electrolyte levels or adding water.


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Documents

© Copyright, The Joint Commission 2012 T HE H EALTHCARE E NVIRONMENT U PDATE George Mills, Director Engineering Department The Joint Commission