You show up to work like it’s any other day except today is anything but ordinary, the Joint Commission is there to greet you. Is there cause for panic or are you completely confident that your healthcare facility will ace the Joint Commission Review? For most facilities, this may be an unnerving moment if they didn’t prepare for the Joint Commission’s top life safety and environment of care code citations. Fortunately, once you’re aware of these fire safety code violations you can prepare and mitigate the risk of receiving these citations. Then you’ll be one step closer to acing your Joint Commission Review.

1. LS.02.01.20: The hospital maintains the integrity of the means of egress

This is one of the biggest problems in hospitals since all types of items pass through and sometimes linger in aisles, corridors, and ramps. These areas must maintain an unobstructed width of 8ft., in certain conditions the width can be reduced to 6ft. When the designated area is for anything other than housing, treatment, or inpatient use then maintain an unobstructed width of 44in. Make sure the staff understands these regulations and make it a regular routine to check the clearance area.

2. LS.02.01.10: The building and fire protection features are designed and maintained to minimize the efforts of fire, smoke, and heat

A lot of traffic moves through hospital doors and bangs them up quite a bit. All of the dings and dents can affect fire doors ability to close properly.  Additionally missing, improperly installed, or incorrect fireproofing material affects the fire rating in various areas. The best way to avoid this problem is to hire a contractor that has ample experience in fireproofing and has a thorough understanding of the life safety code requirements.

3. LS.02.01.30: The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke

Common Joint Commission citations include improper fire-stopping in openings hidden from sight. These are areas where air flows such as ductwork, elevator shafts, etc. Unfortunately, people forget about the areas they don’t see every day. So make a note to check up on them periodically because construction and changing space’s original use affect fire protection systems.

4. EC. 02.03.05: The hospital maintains fire safety equipment and fire safety building features

Even when health care facilities perform fire safety services at the right intervals, without documentation there’s no evidence of the work.  Another issue is improper fire protection system service documentation. The best way to avoid this issue is to keep all the information in a binder that contains every fire protection service, deficiency, repair, and work order. Create tabs and organize the information so that anyone could easily find any particular item. In order to ensure you have the properly documented information select a fire protection contractor who has a proven track record working in health care. Ask for their references and find out whether there were any issues in the Joint Commission Review related to fire protection systems.

5. LS.02.01.35: The hospital provides and maintains systems for extinguishing fires

Healthcare facilities have the required fire sprinklers they need but not the appropriate clearance for sprinkler heads. This commonly occurs in storage rooms because stacked items are too close to fire sprinklers. Make sure there’s 18in. clearance below the sprinkler head to the top of storage. Items can be stacked to the ceiling along perimeter walls as long as no fire sprinkler is located directly above. Since there are some exceptions it’s best to err on the side of caution and maintain the 18in. rule.

Why receive a fire code violation for something that you knew was a problem? Start taking preventative action and be one step closer to acing your Joint Commission Review.

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