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Analysis

Joint Commission to Release New SAG, Standard Revisions Effective July 1

By PSQH  
   June 29, 2020

The change will make it easier for hospitals to comply because it requires only that doors only close, not that they must latch.

Editor's note: This article was originally published June 23, 2020 on PSQH by A.J. Plunkett, editor of Inside Accreditation & Quality, a Simplify Compliance publication.

Remember to keep checking for a new Survey Activity Guide (SAG) from The Joint Commission (TJC), which is promised for July and will include new information on surveys as they slowly resume in areas with a slowed rate in COVID-19 cases.

You’ll be able to find the SAG on TJC’s revamped website by going to the Snapshot of Survey Day page, which can be found here. Then look for the “Get your Survey Activity Guide” link under the photo.

Remember also that TJC has updated several of its hospital accreditation standards, primarily related to last year’s long-awaited revisions to the CMS Conditions of Participation (CoP) on burden reduction and discharge planning.

Many of the changes were announced in late February and effective March 15. Then in late May, TJC announced more updates, some related again to the CoP revisions and effective September 13. All of the revisions had to be approved by CMS.

However, there were a few standards updated that were effective as of July 1, and those were the result of the federal review of TJC standards as part of TJC’s February reapplication to be a deeming authority for CMS for hospitals that want to bill Medicare. The changes were required by CMS, said a TJC spokeswoman.

A check of the “What’s New” section of the July 1 hospital accreditation manual also shows some notable revisions, including a requirement under Life Safety standard LS.02.01.50, EP 10, which says that linen and waste discharge service doors should only be self-closing.

The change will make it easier for hospitals to comply because it requires only that doors only close, not that they must latch.

The spring-loaded doors have a fusible link that melts in a fire and fully closes the door when activated, so the risk of smoke passing up through the chute is negligible, says Ernest E. Allen, ARM, CSP, CPHRM, CHFM, a former TJC Life Safety surveyor and now a patient safety executive with The Doctors Company in Columbus, Ohio.

“Sometimes it is difficult to get the door to latch, as the latching mechanism may get dirty or slightly out of alignment with heavy use of hundreds of trash bags falling a great distance out the chute and knocking the latch just slightly to the side,” says Allen.

“Hospitals do need to check soiled-linen and trash chute doors frequently. It is also important to clean out the discharge room of trash and soiled linen on a daily basis,” says Allen. “I have seen some soiled linen rooms that are full and the bags continue up into the chute, thereby preventing the discharge door from closing in the event of a fire.”

The revision does not represent a huge change, notes Brad Keyes, CHSP, founder of Keyes Life Safety Compliance. TJC is just catching up to changes made earlier by the National Fire Protection Association (NFPA) to its standard regarding the chute discharge.

Among the revisions to the standard is a reference to a Tentative Interim Amendment (TIA) by the NFPA.

The revision does not mean the facility needs to remove the positive latching devices, it just means it is no longer required, says Keyes.

A.J. Plunkett is editor of Inside Accreditation & Quality, a Simplify Compliance publication.

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