Nov 07 2013

Changes to Joint Commission Standards for 2014: Part 2

Category: BlogBKeyes @ 5:00 am
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As mentioned in last week’s posting, The Joint Commission announced changes to their standards that takes affect January 1, 2014. We discussed already the change they are making with time defined which will have a significant impact on scheduling fire drills, and other quarterly activities. This week we will look at the other change that the accreditor announced: Monthly generator load testing.

During a recent webinar which was sponsored by ASHE, George Mills, the Director of Engineering for The Joint Commission, announced starting in 2014, monthly generator load testing will be permitted to be accomplished anytime during the month, rather than the current requirement of no less than 20 days and no more than 40 days from the previous monthly load test. Why this change? George did not explain why, but perhaps it is Joint Commission’s attempt to make it easier on the facility manager.

But if that is the case, then I’m not sure it is a favor, as this latest move by the accreditor is not consistent with the Life Safety Code (LSC) for new construction, nor is it consistent with the Centers for Medicare & Medicaid Services (CMS) Conditions of Participation.

But why did The Joint Commission have the 20 day/40 day requirement for generator monthly load test in the first place? Because it is a requirement of NFPA 99 Health Care Facilities (1999 edition), section 3-4.4.1.1(b), and the LSC (2000 edition) section 18.5.1.2 requires compliance with NFPA 99. Now, chapter 18 is for new healthcare occupancy construction, and chapter 19, which regulates existing healthcare conditions, does not have the same requirement. So, you might think the 20 day/40 day window for monthly testing only applies to new construction (since March 1, 2003) and not existing. Well, I wouldn’t bet on that.

Enter the CMS Conditions of Participation, paragraph 482.41(a)(1) interpretive guidelines says: “The hospital must comply with the applicable provisions of the Life Safety Code…and applicable references such as NFPA 99…for emergency lighting and emergency power.” This CoP standard applies to all healthcare occupancies, regardless whether they are new or existing and is required to be assessed by the LSC Survey Report Form CMS-2786, also known as the K-Tags. Tag K-144 says the following: “Generators inspected weekly and exercised under load for 30 minutes per month and shall be in accordance with NFPA 99, 3-4.4.1, NFPA 110,8-4.2.” This means CMS requires the generator monthly load tests to be conducted within the 20 day/40 day window of opportunity.

As a deeming authority who has been approved by CMS, Joint Commission is required to have standards that are at least equal to or greater than CMS’s CoP. This new change announced by Joint Commission appears to establish their standards less than what CMS’s CoP requires. Will CMS hold them accountable to this difference? If history is an indication of future events, I suspect they won’t.

As a side-note, during the Q&A session of the ASHE sponsored webinar, my good friend George Rivas of TSIG Consulting asked George Mills if Joint Commission surveyors will allow monthly generator load tests conducted on the 30th of one month, and then next on the 1st of the following month, essentially just 1 day apart. Mills kind of hesitated and said he wouldn’t know why a facility manager would want to do that, but he agreed it would be permissible.

So… What does all this mean? Joint Commission can do what they want, and they often do. But this change to their standards will only provide temporary relief for the healthcare facility managers. On this issue, CMS has more restrictive requirements, so it would be wise for facility managers to continue to conduct their generator monthly load tests within the 20 day/40 day window, so they are ready if the CMS approved state agency inspectors show up to do a validation survey.

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