New emergency management standards in effect

Effective July 1, new and revised emergency management (EM) chapter standards are now applicable to all Joint Commission–accredited hospitals and critical access hospitals. The Joint Commission undertook a thorough analysis and rewrite of the EM chapter. The current EM chapter standards and elements of performance (EPs) EM.0.01.01 through EM.04.01.01 have been deleted and replaced by new EM chapter standards and EPs, EM.09.01.01 through EM.17.01.01. Other related changes for hospitals and critical access hospitals resulting from the EM project include a new EC.02.05.07, EP 11; a revision of EC.02.06.05, EP 1; a revision of Standard LD.04.01.10; and the deletion of LD.04.01.10, EP 1. 

CMS amends ambulatory surgical center final rules

The Centers for Medicare & Medicaid Services (CMS) published several final rules amending the ambulatory surgical center (ASC) Conditions for Coverage. CMS made revisions to the regulatory tags and interpretive guidelines. It also is making clarifications and technical corrections to other guidance areas based on stakeholder feedback, including minor, non-substantive edits to Exhibit 351. Two of the clarifications are: separation of ASCs when located in a building that is shared with other entities, and applicability of ventilation standards for operating rooms. For additional information, see S&C Letter QSO-22-16-ASC.

Foundation releases findings from door gap study

The Fire Protection Research Foundation, part of the National Fire Protection Association, released its report “Fire door experimental testing to study the influence of door gaps around swinging fire doors.” The report shares results of experimental testing of the effect that door clearances might have on the performance of a fire door assembly. The project was divided into two main sets of experimental testing. The first part included generic full-scale fire door testing with assemblies in compliance with NFPA 80, Standard for Fire Doors and Other Opening Protectives, plus one test with bottom door gap dimensions as specified in NFPA 252, Standard Methods of Fire Tests of Door Assemblies. The second part involved full-scale fire door testing of certain generic fire door assemblies with a door gap dimension larger than NFPA 80 standards. 

CMS guidance on emergency management exercises

The Centers for Medicare & Medicaid Services (CMS) provided expanded guidance on exercise exemption based on a facility’s activation of their emergency plan. The additional guidance clarifies that the exemption only applies to the next required full-scale exercise (not the exercise of choice), based on the facility’s 12-month exercise cycle, which is determined by the facility (e.g., calendar, fiscal or another 12-month time frame). The guidance was provided in response to many of the response activities associated with the COVID-19 public health emergency. For specific examples on the application of the exemption, see CMS S&C Letter QSO-20-41-ALL REVISED 05.26.2022.