As you know, TJC began surveying to the 2012 edition of the National Fire Protection Life Safety Code in November 2016. Resulting changes to the Environment of Care and Life Safety standards went into effect January 2017. (See the November 2016 issue of TJC Perspectives for the full listing of revised standards and elements of performance.) One of the changes that went into effect for both the Hospital and Behavioral Health programs is a new requirement for inspection of EXIT signs. We are now seeing this issue arising on surveys so let’s clarify the requirement. The relevant standard is EC.02.05.07 in both the Hospital and Behavioral Health manuals. EP # 1 requires a monthly test of battery powered egress lights for 30 seconds and has been around for a long time. What was added to this EP in 2017 is the requirement for “a visual inspection of the EXIT signs.” So, what should this visual inspection include? The standard does not define that but we recommend that the following elements be included in your monthly inspection based on best practice guidelines:

  • Is the EXIT sign mounted correctly?
  • Are the bulbs intact?
  • Is there any dust buildup inside the light or the sign that could lead to an electronic shortage?

As with all inspections, this activity must be documented. So, if your existing forms for the monthly inspection of egress lights are limited to documenting the 30 second test and do not include the visual inspection, make sure to revise the forms to include this new requirement.

In regard to fire drills, we are seeing more and more organizations cited for not varying the times of their fire drills. The relevant standard is EC.02.03.03 EP 3 in both the Hospital and Behavioral Health manuals. It requires fire drills to be “held at unexpected times and under varying conditions.” The purpose, of course, is to avoid predictability. What we are seeing cited on surveys is that organizations hold their fire drills at the same time each quarter. For example, one organization was cited for holding all of their third shift fire drills between 6:20 A.M. and 6:44 A.M. Surveyors have specifically cited organizations for conducting drills within an hour of the same time of day each quarter. While the requirement to vary times by at least one hour is not part of the standard, it is considered best practice. So, make sure that you develop a schedule for your fire drills that includes various times for the drills so that staff and patients can learn how to respond no matter what time of day it is – just like they would need to do in a real fire.


The Foundry Treatment Center Achieves Gold Standard of Joint Commission Accreditation Psychiatric Hospitals: Top Ten Compliance Issues on the SAFER Matrix