Here are the January 2018 Joint Commission Environment of Care Code Updates. The text marked in Red are the new updates/additions to the code.
EC.01.01.01 EP-3 (NEW)
The hospital has a library of information regarding inspection, testing, and maintenance of its equipment and systems.
Note: This library includes manuals, procedures provided by manufacturers, technical bulletins, and other information.
EC.02.03.01 EP-9 (MODIFIED)
The written fire response plan describes the specific roles of staff and licensed independent practitioners at and away from a fire’s point of origin, including when and how to sound and report fire alarms, how to contain smoke and fire, how to use a fire extinguisher, how to assist and relocate patients, and how to evacuate to areas of refuge. Staff and licensed independent practitioners are periodically instructed on and kept informed of their duties under the plan. A copy of the plan is readily available with the telephone operator or security.
Note: For full text, refer to NFPA 101-2012: 18/19.7.1; 7.2.
EC.02.03.01 EP-11 (NEW)
Periodic evaluations, as determined by the hospital, are made of potential fire hazards that could be encountered during surgical procedures. Written fire prevention and response procedures, including safety precautions related to the use of flammable germicides or antiseptics, are established.
EC.02.03.01 EP-12 (NEW)
When flammable germicides or antiseptics are used during surgeries utilizing electrosurgery, cautery, or lasers, the following are required:
- Nonflammable packaging
- Unit-dose applicators
- Preoperative “time-out” prior to the initiation of any surgical procedure to verify the following:
- Application site is dry prior to draping and use of surgical equipment
- Pooling of solution has not occurred or has been corrected
- Solution-soaked materials have been removed from the operating room prior to draping and use of surgical devices
(For full text, refer to NFPA 99-2012: 15.13)
EC.02.03.01 EP-13 (NEW)
The hospital meets all other Health Care Facilities Code fire protection requirements, as related to NFPA 99-2012: Chapter 15.
EC.02.03.03 EP-3 (MODIFIED)
When quarterly fire drills are required, they are unannounced and held at unexpected times and under varying conditions. Fire drills include transmission of fire alarm signal and simulation of emergency fire conditions.
Note 1: When drills are conducted between 9:00 P.M. and 6:00 A.M., the hospital may use alternative methods to notify staff instead of activating audible alarms.
Note 2: For full text, refer to NFPA 101-2012: 18/19: 7.1.7; 7.1; 7.2; 7.3.
EC.02.03.05 EP-27 (NEW)
Elevators with firefighters’ emergency operations are tested monthly. The test completion dates and results are documented. (For full text, refer to NFPA 101-2012: 9.4.3; 9.4.6)
EC.02.04.03 EP-10 (NEW)
All occupancies containing hyperbaric facilities comply with construction, equipment, administration, and maintenance requirements of NFPA 99-2012: Chapter 14.
EC.02.05.01 EP-1 (MODIFIED)
The hospital designs and installs utility systems according to National Fire Protection Association codes to meet patient care and operational needs.
EC.02.05.01 EP-2 (NEW)
Building systems are designed to meet the National Fire Protection Association’s Categories 1–4 requirements. (For full text, refer to NFPA 99-2012: Chapter 4 for descriptions of the four categories related to gas, vacuum, electrical, and electrical equipment.)
EC.02.05.01 EP-19 (MODIFIED)
The emergency power supply system’s equipment and environment are maintained per manufacturers’ recommendations, including ambient temperature not less than 40°F; ventilation supply and exhaust; and water jacket temperature (when required). (For full text, refer to NFPA 99-2012: 9.3.10)
EC.02.05.01 EP-20 (NEW)
Operating rooms are considered wet procedure locations, unless otherwise determined by a risk assessment authorized by the facility governing body. Operating rooms defined as wet locations are protected by either isolated power or ground-fault circuit interrupters. A written record of the risk assessment is maintained and available for inspection. (For full text, refer to NFPA 99-2012: 18.104.22.168.8.4; 22.214.171.124.8.7; 126.96.36.199)
EC.02.05.01 EP-21 (NEW)
Electrical distribution in the hospital is based on the following categories:
- Category 1: Critical care rooms served by a Type 1 essential electrical system (EES) in which electrical system failure is likely to cause major injury or death to patients, including all rooms where electric life support equipment is required.
- Category 2: General care rooms served by a Type 1 or Type 2 EES in which electrical system failure is likely to cause minor injury to patients.
- Category 3: Basic care rooms in which electrical system failure is not likely to cause injury to patients. Patient care rooms are required to have a Type 3 EES where the life safety branch has an alternate source of power that will be effective for 1 1/2 hours.
(For full text, refer to NFPA 99-2012: 3.3.138; 188.8.131.52.10; 184.108.40.206.2; 220.127.116.11.1)
EC.02.05.01 EP-22 (NEW)
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered are tested after initial installation, replacement, or servicing. In pediatric locations, receptacles in patient rooms (other than nurseries), bathrooms, play rooms, and activity rooms are listed tamper-resistant or have a listed cover. Electrical receptacles or cover plates supplied from the life safety and critical branches have a distinctive color or marking. (For full text, refer to NFPA 99-2012: 6.3.2; 6.3.3; 6.3.4; 18.104.22.168.6; 22.214.171.124.4.2; 126.96.36.199.3.2)
EC.02.05.01 EP-23 (NEW)
Power strips in a patient care vicinity are only used for components of movable electrical equipment used for patient care that have been assembled by qualified personnel. These power strips meet UL 1363A or UL 60601-1. Power strips used outside of a patient care vicinity, but within the patient care room, meet UL 1363. In non–patient care rooms, power strips meet other UL standards. (For full text, refer to NFPA 99-2012: 10.2.3.6; 10.2.4; NFPA 70-2011: 400-8; 590.3(D); Tentative Interim Amendment (TIA) 12-5)
EC.02.05.01 EP-24 (NEW)
Extension cords are not used as a substitute for fixed wiring in a building. Extension cords used temporarily are removed immediately upon completion of the intended purpose. (For full text, refer to NFPA 99-2012: 10.2.3.6; 10.2.4; NFPA 70-2011: 400-8; 590.3(D); Tentative Interim Amendment (TIA) 12-5)
EC.02.05.01 EP-25 (NEW)
Areas designated for administration of general anesthesia (specifically, inhaled anesthetics) using medical gases or vacuum are in accordance with NFPA 101-2012: 8.7 and NFPA 99-2012 as follows:
- Zone valves are located immediately outside each anesthetizing location for medical gas or vacuum, readily accessible in an emergency, and arranged so shutting off any one anesthetizing location will not affect others.
- Area alarm panels are installed to monitor all medical gas, medical-surgical vacuum, and piped waste anesthetic gas disposal (WAGD) systems. Alarm panels include visual and audible sensors and are in locations that provide for surveillance, including medical gas pressure decreases of 20% and vacuum decreases of 12-inch gauge HgV (mercury vacuum).
- Alarm sensors are installed either on the source side of individual room zone valve box assemblies or on the patient/use side of each of the individual zone valve box assemblies.
(For full text, refer to NFPA 101-2012: 18/188.8.131.52; NFPA 99-2012: 184.108.40.206.7; 220.127.116.11)
EC.02.05.01 EP-26 (NEW)
Areas designated for administration of general anesthesia (specifically, inhaled anesthetics) using medical gases or vacuum are in accordance with NFPA 101-2012: 8.7 and NFPA 99-2012 as follows: The essential electrical system’s (EES) critical branch supplies power for task illumination, fixed equipment, select receptacles, and select power circuits. The EES equipment system supplies power to the ventilation system. (For full text, refer to NFPA 101-2012: 18/18.104.22.168; NFPA 99-2012: 22.214.171.124.4.2)
EC.02.05.03 EP-4 (NEW)
New buildings equipped with or requiring the use of life support systems (electro-mechanical or inhalation anesthetics) have illumination of means of egress, emergency lighting equipment, exit, and directional signs supplied by the life safety branch of the electrical system described in NFPA 99. (For full text, refer to NFPA 101-2012: 126.96.36.199; 188.8.131.52; NFPA 99-2012: 184.108.40.206)
EC.02.05.05 EP-7 (NEW)
Line isolation monitors (LIM), if installed, are tested at least monthly by actuating the LIM test switch per NFPA 99-2012: 220.127.116.11.3.6, which activates both visual and audible alarms. For LIM circuits with automated self-testing, a manual test is performed at least annually. LIM circuits are tested per NFPA 99-2012: 18.104.22.168.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. (For full text, refer to NFPA 99-2012: 6.3.2; 6.3.3; 6.3.4)
EC.02.05.07 EP-1 (MODIFIED)
At least monthly, the hospital performs a functional test of emergency lighting systems and exit signs required for egress and task lighting for a minimum duration of 30 seconds, along with a visual inspection of other exit signs. The test results and completion dates are documented. (For full text, refer to NFPA 101-2012: 7.9.3; 7.10.9; NFPA 99-2012: 22.214.171.124.11.5)
EC.02.05.07 EP-2 (MODIFIED)
Every 12 months, the hospital performs a functional test of battery-powered lights on the inventory required for egress and exit signs for a duration of 1 1/2 hours. For new construction, renovation, or modernization, battery-powered lighting in locations where deep sedation and general anesthesia are administered is tested annually for 30 minutes. The test results and completion dates are documented. (See also LS.02.01.20, EP 39) (For full text, refer to NFPA 101-2012: 7.9.3; 7.10.9; NFPA 99-2012: 126.96.36.199.11.5)
EC.02.05.07 EP-5 (MODIFIED)
At least monthly, the hospital tests each emergency generator beginning with a cold start under load for at least 30 continuous minutes. The cooldown period is not part of the 30 continuous minutes. The test results and completion dates are documented. (For full text, refer to NFPA 99-2012: 188.8.131.52)
EC.02.05.09 EP-1 (NEW)
Medical gas, medical air, surgical vacuum, waste anesthetic gas disposal (WAGD), and air supply systems in which failure is likely to cause major injury or death are designated as follows:
- Category 1: Systems in which failure is likely to cause minor injury to patients
- Category 2: Systems in which failure is not likely to cause injury, but can cause discomfort to patients
- Category 3: Deep sedation and general anesthesia are not administered when using Category 3 medical gas system
(For full text, refer to NFPA 99-2012: 184.108.40.206; 5.2.1; 220.127.116.11; 18.104.22.168; 22.214.171.124)
EC.02.05.09 EP-2 (NEW)
All master, area, and local alarm systems used for medical gas and vacuum systems comply with the category 1–3 warning system requirements. (For full text, refer to NFPA 99-2012: 5.1.9; 5.2.9; 126.96.36.199.2)
EC.02.05.09 EP-3 (NEW)
Containers, cylinders, and tanks are designed, fabricated, tested, and marked in accordance with NFPA 99-2012: 188.8.131.52.1–184.108.40.206.7.
EC.02.05.09 EP-4 (NEW)
Locations containing only oxygen or medical air have doors labeled “Medical Gases: NO Smoking or Open Flame.” Locations containing other gases have doors labeled “Positive Pressure Gases: NO Smoking or Open Flame. Room May Have Insufficient Oxygen. Open Door and Allow Room to Ventilate Before Opening.”
EC.02.05.09 EP-5 (NEW)
A precautionary sign readable from 5 feet away is on each door or gate of a cylinder storage room, where the sign, at a minimum, includes the wording “CAUTION: OXIDIZING GAS(ES) STORED WITHIN. NO SMOKING.” Storage is planned so cylinders are used in the order they are received from the supplier. Only gas cylinders and reusable shipping containers and their accessories are permitted to be stored in rooms containing central supply systems or gas cylinders.
EC.02.05.09 EP-6 (NEW)
When the hospital uses cylinders with an integral pressure gauge, a threshold pressure considered empty is established when the volume of stored gases is as follows:
- When more than 300 but less than 3,000 cubic feet, the storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited-combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2-hour fire protection rating.
- When less than 301 cubic feet in a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in NFPA 99-2012: 11.6.2.
(For full text, refer to NFPA 99-2012: 220.127.116.11; 18.104.22.168.3; 22.214.171.124; 5.3.10; 11.3; 126.96.36.199.1)
EC.02.05.09 EP-11 (MODIFIED)
The hospital makes main supply valves and area shutoff valves for piped medical gas and vacuum systems accessible and clearly identifies what the valves control. Piping is labeled by stencil or adhesive markers identifying the gas or vacuum system, including the name of system or chemical symbol, color code (see NFPA 99-2012: Table 5.1.11), and operating pressure if other than standard. Labels are at intervals of 20 feet or less and are in every room, at both sides of wall penetrations, and on every story traversed by riser. Piping is not painted. Shutoff valves are identified with the name or chemical symbol of the gas or vacuum system, room or area served, and caution to not use the valve except in emergency. (For full text, refer to NFPA 99-2012: 5.1.4; 188.8.131.52; 184.108.40.206; 220.127.116.11; 5.2.11; 18.104.22.168; 5.3.11)
EC.02.05.09 EP-12 (MODIFIED)
The hospital implements a policy on all cylinders within the hospital that includes the following:
- Labeling, handling, and transporting (for example, in carts, attached to equipment, on racks) in accordance with NFPA 99-2012: 22.214.171.124 and 11.6.2
- Physically segregating full and empty cylinders from each other in order to assist staff in selecting the proper cylinder
- Adaptors or conversion fittings are prohibited
- Oxygen cylinders, containers, and associated equipment are protected from contamination, damage, and contact with oil and grease
- Cylinders are kept away from heat and flammable materials and do not exceed a temperature of 130°F
- Nitrous oxide and carbon dioxide cylinders do not reach temperatures lower than manufacturer recommendations or -20°F
- Valve protection caps (if supplied) are secured in place when cylinder is not in use
- Labeling empty cylinders
- Prohibiting transfilling in any compartment with patient care
(For full text, refer to NFPA 99-2012: 11.6.1; 11.6.2; 11.6.5; 11.7.3)
EC.02.06.05 EP-3 (MODIFIED)
The hospital takes action based on its assessment to minimize risks during demolition, construction, renovation, or general maintenance.
EC.03.01.01 EP-1 (NEW)
Staff responsible for the maintenance, inspection, testing, and use of medical equipment, utility systems and equipment, fire safety systems and equipment, and safe handling of hazardous materials and waste are competent and receive continuing education and training.