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Surveyors Sharpen Focus on Kitchen Safety


Editor's Note: Life Safety Code® and Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations® are registered trademarks of the National Fire Protection Association, Quincy, MA.

By Timothy Markijohn, MBA/MHA, CHFM, CHE, field director, Life Safety Code Surveyors

As we enter 2021, The Joint Commission and the Centers for Medicare & Medicaid Services (CMS) will continue to concentrate more and more on the kitchen, the top origin site for fires in health care occupancies.

Both Life Safety Code surveyors and clinical surveyors examine kitchens to ensure compliance with several of The Joint Commission’s Life Safety (LS), Environment of Care (EC), and Infection Prevention and Control (IC) standards and elements of performance (EPs). In addition, Life Safety Code surveyors check for compliance with specific standards in the National Fire Protection Association (NFPA) Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations®* (NFPA 96-2011), which is referenced by The Joint Commission’s “Life Safety” chapter.

Two requirements spelled out in NFPA 96-2011 will receive particular scrutiny next year because they are often scored as noncompliant:

  • There must be at least 16 inches of space between any deep fat fryer and the surface flames of adjacent cooking equipment, unless a steel or tempered glass baffle plate of at least 8 inches in height is installed between the fryer and the surface flames.
  • Because of the precise positioning of designed fire-suppression features in kitchens, organizations must use an approved method to ensure that any cooking equipment temporarily moved (for cleaning or maintenance, for example) will be returned to its exact design location. Though not required, use of caster-positioning chocks is considered a best practice for making sure that wheeled appliances are appropriately returned and positioned.

Scored under LS.02.01.35, EP 11, requirements for improvement (RFIs) involving portable fire extinguishers are also common in kitchens. A Class K-type portable fire extinguisher must be located within 30 feet of any grease-producing appliances that use vegetable or animal oils or fats. By each portable fire extinguisher, a conspicuously placed placard must emphasize the need to activate the kitchen’s automatic fire-suppression system before using the fire extinguisher. Accordingly, the kitchen’s director and staff must be trained on how to use these fire extinguishers as a backup to the main fire suppression system. As is true of any portable fire extinguisher in a health care facility, each Class K-type extinguisher must be unobstructed by equipment or stored items. 

Maintaining the required 18 inches of clearance between sprinkler deflectors on the ceiling and anything beneath them can be especially challenging in kitchens. Surveyors will make sure that storage racks, particularly those perpendicular to walls, do not encroach into the protected space, a deficiency that would be cited under LS.02.01.35, EP 6.

Surveyors also evaluate compliance with a number of EC issues, including but not limited to the following:

  • pest control
  • disposal of garbage
  • functioning of latching mechanisms 
  • dishwater temperatures
  • absence of ice buildup in freezers
  • separate sinks for handwashing and food preparation
  • lack of broken floor tiles, flaking walls, and so on

These issues barely scratch the surface of all the kitchen safety considerations, however. That’s why The Joint Commission and Joint Commission Resources (JCR) have partnered to produce a new tool Checklist for Reducing Fire and Other Risks in Health Care Occupancy Kitchens.

Designed to help facilities comply with wide-ranging kitchen requirements, this checklist is one of 60 helpful tools that are included in JCR’s new book, The Joint Commission Big Book of EC, EM, and LS Checklists. This book will help you tackle the frequently scored EC and LS challenges that persist from year to year. In addition, the book contains checklists that address preparing for high-consequence infectious diseases (HCIDs) such as COVID-19.  

Although Joint Commission surveyors will advise and educate you during surveys, you can also learn a lot about EC, LS, and EM by using the customizable, downloadable tools in The Joint Commission Big Book of EC, EM, and LS Checklists and by reading other JCR books, as well as Environment of Care® News each month. 

Timothy Markijohn, MBA/MHA, CHFM, CHE is field director, Life Safety Code Surveyors. Prior to joining The Joint Commission, he held numerous director-level positions in facilities operations and engineering at major health systems.