Life Safety Code

Life Safety and Environment of Care - Document List and Review Tool

Documentation required by the Hospital and Critical Access Hospital accreditation programs for Life Safety (LS) and selected Environment of Care (EC) standards is presented in the following Document List and Review Tool. This tool is provided to accredited organizations for use in their continuous compliance and survey readiness efforts.

Note: In order to provide a thorough and efficient assessment of your facility, it important that your organization have staff available to assist the Life Safety Surveyor in reviewing these documents immediately upon their arrival.

Equivalency Request Information

To accurately respond to your Statement of Conditions (SOC) request, the Standard Interpretation Group (SIG) Engineers require you to follow the submittal process exactly. Any deviation will result in our denying your request and requiring your re-submittal. All references to the Life Safety Code (LSC) are to the NFPA 101-2012 edition.

Acceptable Practices of Using Alcohol-Based Hand Rub

Accredited Organizations are required by the National Patient Safety Goal NPSG.07.01.01 to comply World Health Organization (WHO) hand hygiene guidelines or Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.

According to hand hygiene guidelines, when hands have no visible soil, they may be disinfected with either an alcohol-based hand rub (ABHR) or soap and water; however, when visible soiling is evident, soap and water must be used. Staff is encouraged to use ABHR when no soiling is present and hand hygiene guidelines recommend that all health care organizations make ABHR available for staff.

Categorical Waivers for Certain Life Safety and Environment of Care Requirements

Accredited organizations may choose to comply with alternative provisions for certain requirements in the Life Safety (LS) and Environment of Care (EC) chapters through a categorical waiver process. The document listed below has a full description of these requirements and alternative provisions, as well as how to apply them in the accreditation process. Note: While this document is written for organizations that use Joint Commission for deemed status purposes, all other Joint Commission accredited organizations may choose to use the same categorical waivers.

If an organization decides to make use of any of these waivers for their facilities, the organization is required to do the following:

Document:

  1. The waiver(s) being used
  2. The equipment and location(s) where each waiver is being applied

Present to Joint Commission surveyors at the beginning of a survey, the documentation listed above. This is critical. It is not acceptable for an organization to wait until after a surveyor discovers a non-compliance issue to notify the surveyor that it wishes to use a categorical waiver.