Life Safety Changes EFFECTIVE March 11, 2018
Effective March 11, 2018, Hospitals accredited through the Hospital Accreditation Program of The Joint Commission must be in compliance with the following:
EC 02.05.01 EP 27:
Areas designated for administration of general anesthesia (specifically, inhaled anesthetics) using medical gases or vacuum are as follows: – Heating, cooling, and ventilation are in accordance with ASHRAE 170. Medical supply and equipment manufacturers’ instructions are considered before reducing humidity levels to those allowed by ASHRAE. – Existing smoke control systems automatically vent smoke, prevent the recirculation of smoke originating within the surgical suite, and prevent the circulation of smoke entering the system intake, without interfering with exhaust function. New occupancies have no smoke control requirement. – For hospitals that use Joint Commission accreditation for deemed status purposes: Existing smoke control systems are maintained according to the edition of NFPA 101 adopted by The Centers for Medicare & Medicaid Services at the time of installation. (For full text, refer to NFPA 101-2012: 20/18.104.22.168; NFPA 99-2012: 9.3.1)
LS.02.01.30 EP 13:
In existing buildings, all corridor doors are constructed of 1 3/4-inch or thicker solid bonded wood core or constructed to resist fire for not less than 20 minutes, and the doors do not have ventilating louvers or transfer grills (with the exception of bathrooms, toilets, and sink closets that do not contain flammable or combustible materials). Roller latches are prohibited. PLEASE NOTE THE EXCEPTION FOR ROLLER LATCHES THAT RESIST 5 POUNDS OF PRESSURE HAS BEEN REMOVED.
EC.02.03.05 EP 25
The requirement for written documentation of the annual inspection and testing of the fire door assemblies has been removed. Documentation of the PROCESS is still required, please review the notes for non-rated doors as noted in the CMS S&C letter 17-38-LSC effective 1-1-18. A copy can be found at here.