Top 3 Compliance Learnings from 2020: Actionable Guide

Thought Leadership: Compliance & Risk

Top 3 Compliance Learnings from 2020: Actionable Guide

ATG’s experts weigh in on learnings from ASHE’s Annual Conference

Whether you took part in ASHE’s annual conference or missed it for any reason, one thing is clear: there was an abundance of information for healthcare facilities and engineering professionals. From infection prevention to life safety risk, pandemic recovery to CMMS solutions, the variety of insights can take your healthcare organization to the next level. But where should you begin?

Our brief guide makes it easy to navigate the key takeaways in healthcare facilities and engineering – and what actionable solutions can help your organization achieve your mission.

  1. Surprisingly, 48% of all acute care hospitals across the U.S. were not compliant with EC 02.05.07 (Emergency Power Supply Systems) in 2019. Here’s where these hospitals fell short:
    • EP 11: Emergency lighting not being present at generator locations and Remote Manual Stop Stations not correctly located or labeled
    • EP 4: Not realizing an Automatic Transfer Switch (ATS) is an “associated component” and needs to have weekly documented inspections
    • EP 4: Maintenance Free Batteries: if the battery has screw-on caps, it must have documented monthly tests
    • EP 4: Separately documenting cool-down time from the run-time

Solution: With the weekly requirement to “inspect the emergency power supply system (EPSS), including all associated components and batteries”, some organizations have under-inspected the “associated components”, which includes the ATS and possibly maintenance-free batteries. To stay ahead of this challenge, implement a technology application to quickly and effectively check emergency power supply systems. ATG’s Utility Equipment Manager has a generator and ATS application which ensures all of these tests and documentation is done correctly.

  1. The Joint Commission (TJC) has emphasized that any space visited by patients or serving patients will be surveyed by Life Safety Code Surveyors (LSCS). This includes:
    • Laundry in the POB next door, even though it is business occupancy it can be surveyed
    • A quick services restaurant like McDonald’s can be surveyed if patients visit the location

Direct quote from Jim Kendig, Field Director at TJC:

“Any space that serves a patient or resident needs to be surveyed by a LSCS. So that means if in your POB (Physician Office Building) or MOB (Medical Office Building), if you have your Lab, your laundry, your kitchen or anything along those lines, we are going into and survey that space because it serves a patient or resident.  Similarly, if you have a McDonalds or Subway in the main lobby and its part of your healthcare occupancy and we see patients or resident receiving services from that, we will survey that space.“

Solution: It’s imperative to review your drawings to determine what serves your patients and update your environment of care (EOC) rounding criteria to address areas serving or visited by patients. If you want to quickly streamline your EOC rounds, click here for ATG’s approach (link to request the ATG EOC insert).

  1. Elevator doors are fire rated doors.

Many hospitals have elevator doors that are wrapped in vinyl to display marketing material, signs or hide marks/blemishes. Since an elevator door is protecting a shaft, and if it is wrapped in vinyl, it must have a proper UL listing that will not compromise the function of the door.

Solution:  Include these elevator doors in your fire door inventory and annual testing.  For information on ATG’s Fire Door inspection service and program, click here.

Bonus Nugget:
TJC Proposed expanding the BBI for January 2021: LS 01.01.01 EP 7 Basic Building Information (BBI). Make sure you’re actively aware of the information on your BBI now and that it is current/accurate.

If you’re interested in learning more or speaking with our team, please contact us.

Compliance & Risk

Hospital Construction and Maintenance

Contact ATG

Contact ATG

Technical Support
Main Support Line: 630.829.8950

Mary E. Schultz
Manager, Training & Technical Support
tel  630.829.8913