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Top LS issues involve usual suspects: Sprinkler systems, means of egress


December 14, 2019

by A.J. Plunkett (aplunkett@decisionhealth.com)

Cables attached to sprinkler lines, dirty sprinkler heads, obstructions, and problems with escape routes topped the list of Life Safety (LS) violations by The Joint Commission (TJC) during this year’s Chicago session of the commission’s annual Executive Briefings.

A rundown of the problems, and their potential solutions, was offered by Herman A. McKenzie, MBA, CHSP, the new director of TJC’s Department of Engineering. Be aware that TJC is more inclined to put violations in the category of high likelihood for harm, which can threaten your accreditation. LS-related findings of immediate threat to life went up from just 0.01% during all of 2018 to 0.15% of findings in just the first half of 2019.

The rise in findings is likely to only get worse as CMS puts pressure on accrediting organizations (AO) to do a better job of identifying the Life Safety Code® (LSC®) violations that CMS surveyors have found during validation surveys behind the AOs.


The worst problems for LS involved fire extinguishing systems, with the most common problems being damaged or dirty sprinkler heads, he said.

LS.02.01.35, regarding maintenance of those systems, saw the most violations under three elements of performance (EP): EP 4, requiring that automatic sprinkler system piping is not used to support any other item; EP 5, which requires hospitals to ensure fire sprinkler heads are not damaged and are “free from corrosion, foreign materials, and paint,” and have necessary escutcheon plates installed; and EP 14, a catch-all EP that requires hospitals to meet “all other” LSC requirements relating to automatic extinguishing systems.

McKenzie advised instituting an above-ceiling-work permitting process to outline for contractors the restrictions involving sprinkler pipes. (Compliance experts recommend even requiring your own staff to display such a permit.)

“Contractors need to know not to put cables or wires on sprinklers,” as well as the proper route the cables and wires should take, and even any infection control procedures involved.

“Then, after the work is done, audit the work—proper route, proper barriers, not using sprinkler pipe supporting cables,” said McKenzie.

He even suggested a compliance tip: Offer a cafeteria meal ticket to anyone who sees someone working above-ceiling without a permit displayed.

Common problems cited under EP 14 are related to portable fire extinguishers. They need to be tested every month, and those tests must be documented, he said, along with annual maintenance. The portable extinguishers must be installed at the heights specified for the type and size and cannot be blocked. Surveyors too often are finding clutter in front of or around the extinguishers, which impedes quick access.


LS.02.01.30 requires hospitals to maintain building features to “protect individuals from the hazards of fire and smoke.”

Examples of compliance problems involve storage room doors not equipped with a door closer, alcohol-based hand rub dispensers improperly installed over an electrical outlet, and the most common problem: holes in smoke barrier walls.

McKenzie noted that many older hospital buildings have empty patient rooms that are used to store supplies, equipment, or other items to keep them out of the way. But you can’t do that unless the room is constructed as a storage room, said McKenzie.

The LSC depends on compartmentalization to work, McKenzie explained to a room filled mostly with nurses and other compliance managers—an audience more familiar with clinical challenges than facilities issues. Storage rooms must be able to contain a much higher degree of combustible material than what is found in a normal room. Patient rooms are “not designed for it. Don’t do it,” he said.

If you really need the storage space, then commit the resources and work with facilities staff to convert the room to storage. Otherwise, he repeated, “Don’t do it.”

He also warned that staff need to be reminded that storage room doors, for much the same reason, need to remain closed. If a room is fire rated for storage, “no taping over the latch,” he warned.

McKenzie also advised maintaining accurate building drawings that note where storage rooms are located. Anyone doing rounds should check storage rooms against those drawings to ensure there are no surprises.


LS.02.01.20 requires hospitals to “maintain the means of egress.”

EP 13 expressly forbids obstructions to exits, exit accesses, and exit discharges or any other impediments to public, patients, and staff fleeing a fire.

While the LSC allows certain items such as crash carts or isolation carts to be in a corridor, remind staff when some of those items must be removed. For instance, once that patient on standard precautions is discharged, that isolation cart with the necessary personal protective equipment needs to be moved out of the way.

And in all cases of equipment that is allowed to remain in the corridors for when it’s needed (e.g., crash carts and patient lift equipment), it must be movable and all staff must know the fire plan on when, how, and who is supposed to move it out of the way of egress.

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