Life Safety & Environment of Care Document List and Review Tool

Copyright: 2022 The Joint Commission Hospital and Critical Access Hospital Life Safety and Environment of Care Document List and Review Tool Page 1 of 16

Effective: 1/1/2022

The following pages present documentation required by the Critical Access Hospital and Hospital Accreditation programs Life Safety (LS), and selected

Environment of Care (EC) standards. The Life Safety surveyor will begin review of these documents soon after arrival for the onsite survey.

Surveyors may request other EC and LS documents, as needed, throughout the survey.

This list also includes some elements of performance that do not require documentation but appear as reminders to both organizations and surveyors of these

expectations.

Organizations may want to consider using this tool in their continuous compliance and survey readiness efforts.

Revisions to this document are identified by underlined text.

Additional resources, including a Fire Drill Matrix, are available on The Joint Commission website, Physical Environment Portal which is accessible using the

following link: https://www.jointcommission.org/resources/patient-safety-topics/the-physical-environment/.

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Legend: C=Compliant; NC=Not compliant; NA=Not applicable; IOU=Surveyor awaiting documentation

STANDARD -

EPs

See Legend

Document / Requirement

Yes No

IOU

LS.01.01.01

Buildings serving patients comply w/ NFPA 101 (2012)

EP 1

Individual assigned to assess Life Safety Code

compliance

EP 2

Building Assessment to determine compliance with Life Safety (LS) chapter

(frequency of assessment is defined by the hospital)

EP 3

Current and accurate drawings w/ fire safety features & related square

footage

a. Areas of building fully sprinklered (if building only partially

sprinklered)

b. Locations of all hazardous storage areas

c. Locations of all fire-rated barriers

d. Locations of all smoke-rated barriers

e. Sleeping and non-sleeping suite boundaries, including size of

identified suites

f. Locations of designated smoke compartments

g. Locations of chutes and shafts

h. Any approved equivalencies or waivers

☐

EP 5

Deemed Hospitals: Documentation of inspections and approvals made by

state or local AHJs

EP 7

The hospital maintains current Basic Building Information (BBI) within the

Statement of Conditions (SOC).

COMMENTS:

STANDARD

- EPs

See Legend

Document / Requirement Frequency Yes No / Missing Date

IOU

EC.02.01.01

The hospital manages safety and security risks.

EP 17

The hospital conducts an annual worksite analysis related to its workplace

violence prevention program. The hospital takes actions to mitigate or resolve the

workplace violence safety and security risks based upon findings from the

analysis.

Note: A worksite analysis includes a proactive analysis of the worksite, an

investigation of the hospital’s workplace violence incidents, and an analysis of

how the program’s policies and procedures, training, education, and

environmental design reflect best practices and conform to applicable laws and

regulations.

COMMENTS:

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STANDARD

- EPs

See Legend

Document / Requirement Yes No

IOU

EC.02.03.01

Hospital Manages Fire Risk – Fire Response Plan

EP 9

The written fire response plan describes the specific roles of staff and LIPs at

and away from fire 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

• How to evacuate to areas of refuge

Staff and LIPs periodically instructed on/kept informed of duties under plan

Copy of plan readily available with telephone operator or security

NFPA 101-2012: 18/19.7.1; 7.2

☐

COMMENTS:

STANDARD

- EPs

See Legend

Document / Requirement Frequency

Semi

Annual

IOU

EC.02.03.05

Fire Protection and

Suppression Testing and

Inspection

EP 1

Supervisory Signals-including:

Control valves; pressure

supervisory; pressure tank,

pressure supervisory for a dry

pipe (both high and low

conditions), steam pressure;

water level supervisory signal

initiating device; water

temperature supervisory; and

room temperature supervisory.

NFPA 72-2010: Table 14.4.5

Quarterly

EP 2

Water flow devices

NFPA 72-2010: Table 14.4.5

NFPA 25-2011: Table 5.1.1.2

Semiannual

Tamper switches

NFPA 72-2010: Table 14.4.5

Semiannual

EP 3

Duct, heat, smoke detectors,

and manual fire alarm boxes

NFPA 72-2010: Table 14.4.5;

17.14

Annually

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STANDARD

- EPs

See Legend

Document / Requirement Frequency

Semi

Annual

IOU

EC.02.03.05

Fire Protection and

Suppression Testing and

Inspection

EP 4

Notification devices (audible &

visual), and door-releasing

devices

NFPA 72-2010: Table 14.4.5

Annually

EP 5

Emergency services notification

transmission equipment

NFPA 72-2010: Table 14.4.5

Annually

EP 6

Electric motor-driven fire pumps

tested under no-flow conditions

NFPA 25-2011: 8.3.1; 8.3.2

Monthly

Diesel-engine-driven fire pumps

tested under no-flow conditions

NFPA 25-2011: 8.3.1; 8.3.2

Weekly

EP 7

Water storage tank high and

low level alarms

NFPA 25-2011: 9.3; Table

9.1.1.2

Semiannual

EP 8

Water storage tank low water

temp alarms (cold weather only)

NFPA 25-2011: 9.2.4; Table

9.1.1.2

Monthly

EP 9

Sprinkler systems main drain

tests on all risers

NFPA 25-2011: 13.2.5;

13.3.3.4; Table 13.1.1.2; Table

13.8.1

Annually

EP 10

Fire department connections

inspected (Fire hose

connections N/A)

NFPA 25-2011: 13.7; Table

13.1.1.2

Quarterly

EP 11

Fire pump(s) tested – under

flow

NFPA 25-2011: 8.3.3

Annually

EP 12

Standpipe flow test every 5

years

NFPA 25-2011: 6.3.1; 6.3.2;

Table 6.1.1.2

5 years

EP 13

Kitchen suppression semi-

annual testing

NFPA 96-2011: 11.2

Semiannual

EP 14

Gaseous extinguishing systems

inspected (no discharge req.)

NFPA 12-2011: 4.8.3 and NFPA

12A-2009: Chapter 6

Annually

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STANDARD

- EPs

See Legend

Document / Requirement Frequency

Semi

Annual

IOU

EC.02.03.05

Fire Protection and

Suppression Testing and

Inspection

EP 15

Portable fire extinguishers

inspected monthly

NFPA 10-2010: 7.2.2; 7.2.4

Monthly

EP 16

Portable fire extinguishers

maintained annually

NFPA 10-2010: 7.1.2; 7.2.2;

7.2.4; 7.3.1

Annually

EP 17

Fire hoses hydro tested 5 years

after install; every 3 years

thereafter

NFPA 1962-2008: Chapter 7

and NFPA 25-2011: Chapter 6

5 years /

3 years

EP 18

Smoke and fire dampers tested

to verify full closure

NFPA 90A-2012: 5.4.8; NFPA

80-2010: 19.4; NFPA 105-2010:

6.5

1 year after install

At least every 6 years thereafter

EP 19

Smoke detection shutdown

devices for HVAC tested

NFPA 90A-2012: 6.4.1

Annually

EP 20

All horizontal and vertical roller

and slider doors tested

NFPA 80-2010: 5.2.14.3; NFPA

105-2010: 5.2.1; 5.2.2

Annually

EP 25

Inspection and testing of door

assemblies by qualified person.

Does not include nonrated

doors, including corridor doors

to patient care rooms and

smoke barrier doors.

NFPA101-2012: 7.2.1.5.10.1;

7.2.1.5.11; 7.2.1.15; NFPA 80-

2010: 4.8.4; 5.2.1; 5.2.3; 5.2.4;

5.2.6; 5.2.7; 6.3.1.7; NFPA 105-

2010: 5.2.1

Annually

EP 27

Elevators with firefighters’

emergency operations

NFPA 101-2012: 9.4.3; 9.4.6

Monthly

EP 28

Documentation of maintenance

testing and inspection activities

for EPs 1-20 and 25 includes:

activity name; date; inventory of

devices, equipment or other

items; frequency; contact info

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STANDARD

- EPs

See Legend

Document / Requirement Frequency

Semi

Annual

IOU

EC.02.03.05

Fire Protection and

Suppression Testing and

Inspection

for person performing activity;

NFPA standard; activity results

NFPA 25-2011: 4.3; 4.4; NFPA

72-2010: 14.2.1; 14.2.2; 14.2.3;

14.2.4

COMMENTS:

STANDARD -

EPs

See Legend Document / Requirement Frequency Yes No / Missing Date

IOU

EC.02.05.07

Emergency Power Systems are Maintained

and Tested

EP 1

At least monthly performs 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

NFPA 101-2012: 7.9.3; 7.10.9; NFPA 99-2012:

6.3.2.2.11.5

Monthly

EP 2

Every 12 months performs functional test of

battery powered lights on the inventory

required for egress and exit signs for a

duration of 1 ½ 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 with test results and completion

dates documented

NFPA 101-2012: 7.9.3; 7.10.9; NFPA 99-2012:

6.3.2.2.11.5

Annually

EP 3

Functional test of Level 1 SEPSS, monthly;

Level 2 SEPSS, quarterly, for 5 minutes or as

specified for its class

Annual test at full load for 60% of full duration

of its class

NFPA 111-2010: 8.4

Monthly

Quarterly

Annually

Note 1: Non-SEPSS tested per

manufacturer’s specifications

Per Mfr.

Note 2: Level 1 SEPSS defined for critical

areas and equipment

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STANDARD -

EPs

See Legend Document / Requirement Frequency Yes No / Missing Date

IOU

EC.02.05.07

Emergency Power Systems are Maintained

and Tested

Note 3: Class defines minimum time which

SEPSS is designed to operate at rated load

without recharging

EP 4

Emergency power supply system (EPSS)

inspected weekly, including all associated

components and batteries

NFPA 110-2010: 8.3.1; 8.3.3; 8.3.4; 8.4.1

Weekly

EP 5

Emergency generators tested monthly for 30

continuous minutes under load (plus cool-

down)

NFPA 99-2012: 6.4.4.1

Monthly

EP 6

Monthly load test for diesel-powered

emergency generators conducted with

dynamic load at least 30% of nameplate rating

or meets mfr. recommended prime movers’

exhaust gas temperature; OR

Monthly

Emergency generators tested once every 12

months using supplemental loads of 50% of

nameplate rating for 30 minutes, followed by

75% of nameplate rating for 60 minutes for

total of 1 ½ continuous hours

NFPA 99-2012: 6.4.4.1

Annually

EP 7

All automatic and manual transfer switches

monthly/12 times per year with results and

completion dates documented

NFPA 99-2012: 6.4.4.1

Monthly

EP 8

Fuel quality test to ASTM standards

NFPA 110-2010: 8.3.8

Annually

EP 9

Generator load test once every 36 months for

4 hours

NFPA 110-2010, Chapter 8

36 Months

EP 10

Generator 4-hour test performed at, at least

30% nameplate

NFPA 110-2010, Chapter 8

36 Months

COMMENTS:

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STANDARD

- EPs

See Legend

Document / Requirement

THIS MAY BE SCORED AS

CONDITIONAL OR STANDARD

Testing Dates

IOU

Yes

EC.02.05.09

Medical Gas and Vacuum Systems are

Inspected and Tested

EP 7

Test, inspect and maintain critical

components of piped medical gas and

vacuum systems, waste anesthetic gas

disposal (WAGD), and support gas systems

on the inventory.

Inventory of critical components includes at

least all source subsystems, control valves,

alarms, manufactured assemblies containing

patient gases, and inlets and outlets with

activities, dates and results documented

No prescribed frequency; recommend risk

assessment if < annual

NFPA 99-2012: 5.1.14.2; 5.1.15; 5.2.14;

5.3.13

Per policy

EP 8

Location of and signage for bulk oxygen

systems

NFPA 99-2012: 5.1.3.5.12

On Bldg. Tour

EP 9

Emergency oxygen supply connection

NFPA 99-2012: 5.1.3.5.13

On Bldg. Tour

EP 10

Review medical gas

installation/modification/breech certification

results for cross connection, purity, correct

gas, and pressure

NFPA 99-2012: 5.1.2; 5.1.4; 5.1.14.4.1;

5.1.14.4.6; 5.2.13

As applicable

EP 11

Medical gas supply and zone valves are

accessible and clearly labeled

NFPA 99-2012: Table 5.1.11

NFPA 99-2012: 5.1.4; 5.1.11.1; 5.1.11.2;

5.1.14.3; 5.2.11; 5.3.13.3; 5.3.11

On Bldg. Tour

EP 12

Handling, transfer, storage, labeling,

transfilling of cylinders

NFPA 99-2012: 11.5.3.1; 11.6.1; 11.6.2;

11.6.5; 11.7.3

Per policy

COMMENTS:

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STANDARD

- EPs

See Legend

Document / Requirement Frequency Q1 Q2 Q3

Annual

IOU

EC.02.03.03

Fire Drills

EP 1

Fire drills once per shift per quarter in

health care occupancies; Quarterly in

each building defined as ambulatory

health care occupancy (If available,

please provide five quarters of fire drill

data)

Quarterly

EP 2

Fire drills every 12 months from date of

last drill: Business Occupancies

Annually

EP 3

When quarterly fire drills are required,

ALL are unannounced

• Drills held at unexpected times and

under varying conditions – greater

than one hour apart

• Drills include transmission of fire

alarm signal and simulation of

emergency fire conditions

NFPA 101-2012: 18/19: 7.1.7; 7.1; 7.2;

7.3

Quarterly

(See fire drill

matrix)

EP 4

Staff participate in the drills according to

the hospital's fire response plan

YES NO

EP 5

Critiques include fire safety equipment

and building features, and staff

response

YES NO

COMMENTS:

STANDARD

- EPs

See Legend

Document / Requirement Frequency Yes No / Missing Date

IOU

EC.02.05.01

Manages risks associated with utility systems

EP 15

In critical care areas designed to control airborne contaminants (such as

biological agents, gases, fumes, dust), the ventilation system provides

appropriate pressure relationships, air-exchange rates, filtration efficiencies,

temperature and humidity.

(form of and frequency of assessment per hospital policy)

Note: For more information about areas designed for control of airborne

contaminants, the basis for design compliance is the Guidelines for Design and

Construction of Health Care Facilities, based on the edition used at the time of

design (if available).

COMMENTS:

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STANDARD

- EPs

See Legend

Document / Requirement Yes No

IOU

EC.02.05.02

Manages risks associated with utility systems

– Water Management Program

EP 1

Verify individual or team responsible for oversight and implementation of the

water management program

EP 2

Review water management program to verify the following components are

included:

• Diagram of water supply sources, treatment systems, processing

steps, control measures, and end-use points

• Water risk management plan identifies areas where potentially

hazardous conditions may occur

• Plan for addressing the use of water in areas of buildings where water

may have been stagnant for a period of time

• Evaluation of immunocompromised patients

• Monitoring protocols and acceptable ranges for control measures

EP 3

Verify that the water management program includes documentation of the

following:

• Results of all monitoring activities

• Corrective actions and procedures to follow if test results are outside of

acceptable limits

• Corrective actions taken when control limits are not maintained

EP 4

Verify water management program reviewed annually and when changes have

been made to the water system that add risk, new equipment or at-risk systems

have been added that could generate aerosols or be source for Legionella

COMMENTS:

STANDARD

- EPs

See Legend

Document / Requirement Yes No

IOU

EC.02.04.01 Management of Medical Equipment Risks

EP 2

Non-deemed status requirement: Maintains either a written inventory of all

medical equipment or a written inventory of selected equipment categorized by

physical risk associated with use (including all life-support equipment) and

equipment incident history.

Evaluates new types of equipment before initial use to determine whether they

should be included in the inventory.

Deemed status requirement: Maintains a written inventory of all medical

equipment.

EP 3

High-risk medical equipment identified on the inventory

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STANDARD

- EPs

See Legend

Document / Requirement Yes No

IOU

EC.02.04.01

Management of Medical Equipment Risks

EP 4

Inventory includes activities and associated frequencies for maintaining,

inspecting, and testing all medical equipment on the inventory.

Activities and associated frequencies are in accordance with manufacturers’

recommendations or with strategies of an alternative equipment maintenance

(AEM) program.

COMMENTS:

STANDARD

- EPs

See Legend

Document / Requirement Frequency Yes No / Missing Date

IOU

EC.02.04.03

Medical equipment inspection, testing and maintenance

EP 2

All high-risk equipment.

Note 1: High-risk equipment includes medical equipment for which there is a

risk of serious injury or even death to a patient or staff member should it fail,

which includes life-support equipment.

Note 2: Required activities and associated frequencies for maintaining,

inspecting, and testing of medical equipment completed in accordance with

manufacturers’ recommendations must have a 100% completion rate.

Note 3: Scheduled maintenance activities for high-risk medical equipment in an

alternative equipment maintenance (AEM) program inventory must have a

100% completion rate. AEM frequency is determined by the hospital's AEM

program.

EP 3

Non-high-risk equipment identified on the medical equipment inventory

Note: Scheduled maintenance activities for non-high-risk medical equipment in

an alternative equipment maintenance (AEM) program inventory must have a

100% completion rate. AEM frequency is determined by the hospital’s AEM

program.

EP 4

Conducts performance testing of and maintains all sterilizers

EP 10

All occupancies containing hyperbaric facilities comply with construction,

equipment, administration, and maintenance requirements of NFPA 99-2012:

Chapter 14.

COMMENTS:

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STANDARD

- EPs

See Legend

Document / Requirement Frequency Yes No / Missing Date

IOU

EC.02.05.05

Utility system Inspection, testing and maintenance

EP 4

High-risk utility system components on the inventory with completion date and

results of activities documented

Note 1: A high-risk utility system includes components for which there is a risk

of serious injury or even death to a patient or staff member should it fail, which

includes life-support equipment.

Note 2: Required activities and associated frequencies for maintaining,

inspecting, and testing of utility systems components completed in accordance

with manufacturers’ recommendations must have a 100% completion rate.

Note 3: Scheduled maintenance activities for high-risk utility systems

components in an alternative equipment maintenance (AEM) program inventory

must have a 100% completion rate.

EP 5

Infection control utility system components on the inventory with completion

date and results of activities documented

Note 1: Required activities and associated frequencies for maintaining,

inspecting, and testing of utility systems components completed in accordance

with manufacturers’ recommendations must have a 100% completion rate.

Note 2: Scheduled maintenance activities for infection control utility systems

components in an alternative equipment maintenance (AEM) program inventory

must have a 100% completion rate.

EP 6

Non-high-risk utility system components on the inventory with completion date

and results of activities documented

Note: Scheduled maintenance activities for non-high-risk utility systems

components in an alternative equipment maintenance (AEM) program inventory

must have a 100% completion rate. AEM frequency is determined by the

hospital AEM program.

EP 7

Line isolation monitors (LIM), if installed, are tested at least monthly by

actuating the LIM test switch. For LIM circuits with automated self-testing, a

manual test is performance at least annually.

NFPA 99-2012: 6.3.2; 6.3.3; 6.3.3.3.2; 6.3.4

COMMENTS:

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Legend: C=Compliant; NC=Not compliant; NA=Not applicable; IOU=Surveyor awaiting documentation

STANDARD

- EPs

See Legend

Document / Requirement Frequency Yes No / Missing Date

IOU

EC.02.01.01

The hospital manages safety and security risks.

EP 1

The hospital implements its process to identify safety and security risks

associated with the environment of care that could affect patients, staff, and other

people coming to the hospital’s facilities.

Note: Risks are identified from internal sources such as ongoing monitoring of the

environment, results of root cause analyses, results of proactive risk

assessments of high-risk processes, and from credible external sources such as

Sentinel Event Alerts.

EP 3

The hospital takes action to minimize or eliminate identified safety and security

risks in the physical environment.

COMMENTS:

STANDARD

– EPs

See Legend

Document / Requirement Frequency Yes No / Missing Date

IOU

EC.01.01.01 The hospital plans activities to minimize risks in the environment of care.

EPs 1-9

The hospital has a written plan for managing the following;

EP-4 Environmental Safety

EP-5 Security

EP-6 Haz Materials

EP-7 Fire Safety

EP-8 Medical Equipment

EP-9 Utility Systems

Note 1: One or more persons can be assigned to manage risks associated with

the management plans described in this standard.

Note 2: For hospitals that use Joint Commission accreditation for deemed status

purposes: The hospital complies with the 2012 edition of NFPA 99: Health Care

Facilities Code. Chapters 7, 8, 12, and 13 of the Health Care Facilities Code do

not apply.

Note 3: For further information on waiver and equivalency requests, see

https://www.jointcommission.org/resources/patient-safety-topics/the-physical-

environment/life-safety-code-information-and-resources/ and NFPA 99-2012: 1.4.

COMMENTS:

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STANDARD

- EPs

See Legend

Document / Requirement Frequency Yes No / Missing Date

IOU

EC.04.01.01

The hospital collects information to monitor conditions in the environment.

EP 15

Every 12 months, the hospital evaluates each environment of care management

plan, including a review of the plan’s objectives, scope, performance, and

effectiveness.

STANDARD

- EPs

See Legend

Document / Requirement Frequency Yes No / Missing Date

IOU

EC.04.01.03

The hospital plans activities to minimize risks in the environment of care.

EP 2

The hospital uses the results of data analysis to identify opportunities to resolve

environmental safety issues.

STANDARD

- EPs

See Legend

Document / Requirement Frequency Yes No / Missing Date

IOU

EC.04.01.05

The hospital improves its environment of care.

EP 1

The hospital takes action on the identified opportunities to resolve environmental

safety issues.

STANDARD

- EPs

See Legend

Document / Requirement

Addressed in policy?

Implemented as required?

IOU

Yes

LS.01.02.01 Interim Life Safety Measures (ILSM)

EP 1

ILSM policy identifying when and to what extent

ILSM implemented

EP 2

Alarms out of service 4 or more hours in 24

hours or sprinklers out of service more than 10

hours in 24 hours in an occupied building - Fire

watch / Fire Dept. notification

NFPA 101-2012: 9.6.1.6; 9.7.6; NFPA 25-2011:

15.5.2

EP 3

Signs for alternate exits posted

EP 4

Daily inspection of routes of egress (See also

19.7.9.2 RE: daily inspections)

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STANDARD

- EPs

See Legend

Document / Requirement

Addressed in policy?

Implemented as required?

IOU

Yes

LS.01.02.01

Interim Life Safety Measures (ILSM)

EP 5

Temporary but equivalent systems while system

is impaired

EP 6

Additional firefighting equipment provided

EP 7

Smoke tight non-combustible temporary barriers

EP 8

Increased surveillance implemented

EP 9

Storage and debris removal

EP 10

Additional training on firefighting equipment

EP 11

Additional fire drill per shift per quarter

EP 12

Temporary systems tested and inspected

monthly

EP 13

Additional training on building deficiencies,

construction hazards, temp measures

EP 14

Training for impaired structural or impaired

compartment fire safety features

EP 15

Other ILSM's

COMMENTS:

NOTE: The following evaluation will be completed during the building tour.

STANDARD

- EPs

See Legend

Document / Requirement Frequency Yes No / Missing Date

IOU

EC.02.02.01 The hospital manages risks related to hazardous materials and waste.

EP 1

The hospital maintains a written, current inventory of hazardous materials and

waste that it uses, stores, or generates. The only materials that need to be

included on the inventory are those whose handling, use, and storage are

addressed by law and regulation. (See also IC.02.01.01, EP 6; MM.01.01.03,

EPs 1 and 2)

EP 3

The hospital has written procedures, including the use of precautions and

personal protective equipment, to follow in response to hazardous material and

waste spills or exposures.

EP 11

For managing hazardous materials and waste, the hospital has the permits,

licenses, manifests, and safety data sheets required by law and regulation.

COMMENTS:

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STANDARD

- EPs

See Legend

Document / Requirement Frequency Yes No / Missing Date

IOU

EC.02.01.01 The hospital manages safety and security risks.

EP 1

The hospital implements its process to identify safety and security risks

associated with the environment of care that could affect patients, staff, and

other people coming to the hospital's facilities.

Note: Risks are identified from internal sources such as ongoing monitoring of

the environment, results of root cause analyses, results of proactive risk

assessments of high-risk processes, and from credible external sources such as

Sentinel Event Alerts.

EP 3

The hospital takes action to minimize or eliminate identified safety and security

risks in the physical environment.

EP 9

The hospital has written procedures to follow in the event of a security incident,

including an infant or pediatric abduction.

EP 10

When a security incident occurs, the hospital follows its identified procedures.

COMMENTS: