Codes & Standards

New Advocacy & Code Committee:


Chair: Jim Peterkin, Heery Fire Protection, Vice-President, Senior Protection Engineer


Co-Chair: Dan Campbell, Retired - Temple Univeristy Hospital

Co-Chair: Robert N. Roop, P.E., CBIE Criterium Lockatong Engineers

Co-Chair: Jospeh Szymanski, Presbyterian Hospital, Safety Director

Co-Chair: Jeff O'Neill, AIA, ACHA; Director of Engineering Services, Pennsylvania Hospital


If you have any Joint Commission, Fire Code, or Advovacy Issues of any kind , please email:





Useful Twitter Account for Health Care Facility Managers:

ASHE and the American Hospital Association:


American Hospital Association:@AHAhospital

American Hospital Association Advocacy issues:@AHAadvocacy

Regulators & Code Developers:

Centers for Medicare & Medicaid Services:@CMSGov

U.S. Department of Health & Human Services:@HHSGov

The Joint Commission:@TJ Commission

Joint Commission Resources:@JC _Resources

International Code Council:@IntlCode@Council

National Fire Protection Association:@NFPA

NFPA101:Life Safety Code:@NFPA101


Other Organizations:

ECRI Institute:@ECRI_Institute

Association for the Healthcare Environment:@AHEtweets

Association for the Advancement of Medical Instrumentation:@aami_connect

Center for Health Design:@CHD_tweets

America Institute of Architects:@AIAnational


Industry Media:

Health Facility Management magazine:@hfmmagazine

Medical Construction & Design Magazine:@MCDmag

Hospitals & Health Networks magazine:@hhnmag

Infection Control Today magazine:@ICT_magazine


Other Orgnaiuzations:

Center for Medicare & Medicaid Services:@CMSGov

U.S. Department of Health & Human Services:HHSGov

The Joint Commission:@TJCommission

Joint Commission Resources:@JC_Resources


Please see the JCAHO page!


FDA Items

Electronic Statement of Conditions Extension (Click Here)

EPA Standards of Performance for Stationary Compression Ignition Engines (Click Here)

FDA Guidance on Bed Rail Entrapment (click here)


Disaster Preparedness/Safety Items





Meeting Topics

June Meeting Topic

The FDA proposes regulations to prevent injury from medical gas.  FDA proposes to make the contents of medical gas containers more readily identifiable.  In some cases, injury or death has resulted from a medical gas mix-up caused by improper connections, mistaken application of industrial gas to a patient, or contamination of gas.  For further information see QA20060410.htm.

NFPA rejects ASHE proposed amendment to damper testing.  The ASHE proposed amendment sought to extend the damper testing periodicity from 4 to 6 years.  This sought after approval to NFPA 90A was lost when the document was returned to committee for reasons unrelated to this issue.  Damper testing requirements remain at the four year test cycle.

ASHE issued an advisory providing guidance on reducing bed rail entrapment.   The advisory recommends ASHE members pursue a broad approach to develop policy & procedures to fully assess potential patient risk for entrapment & to assure mitigation strategies are in place to reduce identified risks.

On May 31, 2006 JCAHO announced the revision to Standard EC 7.40.  Effective July 1, 2007, facilities are required to test their emergency generators every 36 months for 4 continuous hours.  This extended run test, and other requirements if the test fails, are stated in 3 new elements of performance.  (See for more information.

A new document from NIOSH is now available, namely “Prevention of Airborne Infections in Occupational Settings” RFA-OH-06-002.  On NIOSH web site see:

WMTS Advisory 11-05 final.pdf 4


February Meeting Topics

NFPA 90A approved six (6) year testing of fire dampers but the JCAHO is still in the four (4) year cycle.


USP 797 – JCAHO is backing off enforcement and letting the states approve the standard for compliance.  What you should do until your state approves the standard is use guideline as recommended, perform a gap analysis until state approves.


Updates on NFPA 99 – Two new sections are being added, Re-Engineering and Technology, the other sections are ready for review the deadline for submission is September this year.  The NFPA 99 will not be published until 2010.


Security and Life Safety Code LSC committee is working on protection of patients, including locking methods etc...


House Bill H.R. 378 (attached) if passed directs the Secretary of labor to act through the director of OSHA to establish a Federal safe patient handling Standard no later than on year after enactment of this act.  This standard shall require the elimination of manual lifting of patients by direct-care registered nurses and other health care providers, through the use of mechanical devices, except during a declared state of emergency.


The Standard shall require:

  1. 1.   all health care facilities comply with the standard;
  2. 2.   health care facilities to purchase, use, and maintain safe lift mechanical devices;
  3. 3     input from direct-care registered nurses and organizations representing direct-care registered nurses in implanting the standard;
  4. 4.   a program to identify problems and solutions regarding safe patient handling;
  5. 5.    a system to report, track and analyze trends in injuries, as well as make injury data available to the public;
  6. 6.    training for staff on safe patient handling policies, equipment, and devices at least on an annual basis.  Training will also include hazard identification, assessment, and control of musculoskeletal hazards in patient care areas, which would include interactive classroom-based and hands –on training by a knowledgeable person or staff; and
  7. 7.    annual evaluations of safe patient handling efforts, as well as new technology, handling procedure, and engineering controls.  Documentation of this     process shall include equipment selection and evaluation.


An example of the cost if this standard passes was presented at an Advocacy meeting last week in Albuquerque.  A 32 bed unit cost a Half a million dollars to renovated for compliance with HR 378.  ASHE will be submitting a small questionnaire either through Joe or myself via e-mail.  The results will guide ASHE to take a stance based on the feedback provided by responders.

An addition to the legionella standard includes a statement that “no copper silver anode can be used for drinking water.

ASHRAE 180P HVAC regulations for timeframes when equipment testing and maintenance periods will occur.  It will no longer be up to the facility for non-regulated equipment and items.



Med Gas Letter CMS 07-10

Width of corridorcomp-CMS

March Meeting Topics

HFMADV Code Report

March 2007

Off Site Business Occupancy Fire Exit Drills


LSC:    Chapter 39 Section 39.7 Operating Features

39.7.1  Drills.   In any business occupancy building occupied by more than 500 persons or more than 100 persons above or below street level, employees, and supervisory personnel shall be periodically instructed (determined by EOC committee) in accordance with section 4.7and shall hold drills periodically where practicable (determined by EOC committee).


Phila. Code:      Section F Use B, F, and H – Office, Factory and High – Hazard

F-708.1           Evacuation plan and fire exit drill:           The owners of buildings occupied by use Groups F and H and all buildings three stories or more in height which contain use group B occupancies above the third floor shall prepare and distribute to all employees procedures to follow in the event of an emergency, including an evacuation plan.  These use groups shall conduct fire exit drills two times a year on each work shift.


Corridor Doors and Frames


LSC:           Corridor Doors

  • Door-closing devices shall not be required on doors in corridor wall openings other than those serving required exits, smoke barriers, or enclosures of vertical openings and hazardous areas.  This mean patient room doors do not need door closers.
  • Door frames shall be labeled, shall be of steel construction, or shall be of other materials in compliance with (installed according to NFPA 80)

Exception:        Door frames in smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 9.7 (Installed according to NFPA 13)

  • Fixed fire window assemblies in accordance with (wire glass or other fire rated glazing material in approved metal frames) shall be permitted in corridor doors.

Exception:        There shall be no restrictions in area and fire resistance of glass and frames in smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with (alternate protection measures shall be permitted by AHJ without causing the building to be classified as non-sprinklered.)          A latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions.  The releasing mechanism for any latch shall be located not less than 34 inches and not more than 48 inches above the finished floor.  Doors shall be operable with not more than one releasing operation.


UL Warns of Counterfeit Fire Extinguishers – See paper


January Meeting Topics

Find attached the Power Point Presentation for Potential Revisions to Emergency Plan Standards, FAQ ’ s on the preparation of the eSOC, and the notes I spoke about on the meeting in Chicago.

Notes from “The Joint Commission” Annual Invitational Conference

New Logo and New Name      No more JCAHO or Jayco new name is “The Joint Commission”

CON – 04 Two main reasons:

EC.5.20           EP-5  Not keeping up with part four PFI’s due dates.

EC.5.50           EP-3  not properly implementing ILSM’s per policy, refer to bullets from EP-2

In order to invoke the CON – 04 an RFI must be included in the report.


There are other EP’s that would invoke a CON – 04 such as EC.5.4 where there is an immediate threat to life, i, e, if a fire pump is inoperable and no back up evident, fire alarm system is not working and there is no repair work going on or ILSM’s implemented.

The eSOC input to the “The Joint Commission” has been extended until July 1, 2007.  The Joint Commission hopes to have an interface for the eSOC that will allow information from an Excel spreadsheet would populate the existing Joint Commission’s eSOC form.

eSOC items that are not accepted will be scored under LD.4.50 the leadership standard.  Example of unacceptable eSOC entries are; items included that should be put on a 30 day work order system, and items that have an unrealistic completion date.

The Joint Commission has agreements with many states that they (the states) will not survey your organization if The Joint Commission has deemed your facility accredited for CMS standards.

The Joint Commission is still using the 2000 Life Safety Code, the 2001 AIA guidelines and fire damper inspections on 4 year intervals.  There is a proposal to go to 6 years but is not expected to be approved any time soon.

Surveyors are no longer able to use EC.1.10  EP-4 as a general duty clause.  If findings need a place to be scored the leadership (LD), standards will be used.

Life Safety Code Specialist (LSCS) will have an expanded role beginning January 2008.  Every survey team in 2008 will have a LSCS included no matter the size.  All hospitals with 750,000 square feet or more will the LSCS for 2 days.  All other hospitals will have the LSCS for one day.  Another idea being discussed includes LSCS also surveying the emergency management part of the survey.  This is in the early stages but since it was mentioned in Chicago, I believe that it will become an added responsibility.

Starting in 2007 all hospital surveys will start in the ED.  The reason involves what many surveyors saw in hospitals during 2006 and overcrowding hospital Ed’s. Therefore all 2007 surveys will begin in the Ed and go forth throughout the facility….


Dan Powerpoint

Potential Emergency Plan Standards

Notes From 2007 AIC


April Meeting Topics:

On March 7, 2006, JCAHO issued a clarification on their Alcohol-Based Hand Rub (ABHR) stance.  The document addresses foam and gel stations, their installation requirements, and the safety issues. The full document is available at

JCAHO announced they will not survey for compliance with USP 797 guidelines. Organizations can decide its compliance with USP 797 by performing risk management practices and seeking legal council taking into account state laws and regulations. If permitted by state law, alternatives to USP 797 may be chosen.

On March 22, 2006, an imposter claiming he was a JCAHO official tried to gain access to a CA hospital. JCAHO advises organizations to ask surveyors to show their JCAHO badges when they arrive for security purposes. Also, JCAHO headquarters in Chicago can be contacted to verify the identity of an inspector.

JCAHO has established new thresholds for determining Conditional Accreditation and Preliminary Denial of Accreditation (PDA) decisions.  These decisions are determined by the number of Not Compliant standards that exceed established thresholds at the time of survey.  For more information, including tables outlining the thresholds, see the December issue of Joint Commission Perspectives at

JCAHO & JCR announced the release of a free web-based publication, “Surge Hospitals: Providing Safe Care in Emergencies.”  It can be found at

Life Safety Code 2006 Changes:

Hot Topics:

Alcohol Based Hand Rubs in Corridors will be located in Sections and and the language will be the same as published by ASHE.  A TIA was submitted and approved in April, 2004 to address the 2000 edition of the LSC.

Automatic Sprinklers for Existing Nursing Homes Sections, and have been modified to require automatic sprinkler protection for all existing Nursing Home facilities.  The AHJ will determine the timeframe.

Flammable germicides and Antiseptics changes to Section of NFPA 99 complete drying of these materials and removed of pooled material is outlined in the requirements.

Clinical Need for Locks Sections and allow AHJ’s to make modifications to the code requirements to address certain types of patients.


New definitions for Suite – A series of rooms or spaces separated from the remainder of the building by walls and doors.

Section (1) and (1) New annex note to clarify there are no limits to the number of locked doors in the means of egress for clinical needs.

Section 18.2.5 and 19.2.5 Complete rewrite of the requirements for clarification.  No major technical changes.

Sleeping Suites require direct supervision or smoke detection.  Exiting through adjacent suites will be allowed; travel distance measured to the first suite door.  Suite size can be 7,500 square feet if direct supervision and smoke detection is provided.


Section, and Projections into the corridor width are allowed as follows:

  • Maximum projection – 6 inches
  • Maximum length of projection – 36 inches
  • Minimum height above the floor – 40 inches

Sections and Partitions are allowed to be constructed with fire retardant treated wood enclosed in non-cumbustible materials.


Life Safety Code Specialist Building Tour and Document review

ILSM Matrix

ILSM Daily Checklist Forms

November 2006 Meeting Topics:

Codes & Standards November 2006 Presentation listed below:

HFMADV Codes Stds-Nov 2006

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