On July 1, 2021, The Joint Commission (TJC) added five new Life Safety (LS) standards for business occupancies. While compliance with the National Fire Protection Association’s NFPA 101®, Life Safety Code®, 2012 edition, hasn’t changed since its adoption by the Centers for Medicare & Medicaid Services in 2016, this demonstrates an increased focus on health care in business occupancies by TJC and other authorities having jurisdiction (AHJs).
Accredited organizations can start to address this by conducting a self-assessment to review their level of compliance, not only with LS standards but with Environment of Care standards as well. Once the assessment is complete, organizations can develop an action plan to address deficiencies.
When reviewing your business occupancy locations, identify whether the location is owned or leased. If leased, look at the agreement to determine ownership of inspection, testing and maintenance (ITM) items. If the property owner is not aware of your AHJ requirements, you should communicate maintenance expectations for items not under your direct control. Are you receiving accurate ITM reports from the property owner, and are they addressing deficiencies promptly? Assigning accountability in leased locations and establishing a process are crucial for maintaining compliance with AHJs.
Another tool to aid compliance is rounding. This will allow organizations to discover potential findings and operational changes — some of which may have ripple effects that impact facilities teams. For example, one department’s workflow may have changed, and they may now need to store sterile supplies in an office adjacent to the storage room. Facilities teams will need to address how to maintain the proper temperature, pressure differential and humidity in the new storage room according to applicable codes and standards.
Whether you are onboarding a new business occupancy or reviewing existing business occupancies, the American Society for Health Care Engineering has produced several tools to help manage the process.