Life Safety & Environment of Care Reviews
Are you aware that survey findings related to Life Safety Code compliance and ligature risks rank very high in the Top 10 findings on TJC and CMS surveys of psychiatric hospitals? Current data shows these are high risk areas for Condition level findings and follow-up surveys. So, being prepared for your survey is more critical than ever!
Our Life Safety & Environment of Care Reviews are designed for psychiatric hospitals and psychiatric units within acute care hospitals that are Joint Commission accredited and/or CMS certified. These facilities are required to comply with the National Fire Protection Association (NFPA) Life Safety Code, Joint Commission standards, and CMS Conditions of Participation (CoPs.) Currently, survey findings related to Life Safety and ligature risks rank high in the Top 10 findings on TJC surveys of psychiatric hospitals.
Our Life Safety & Environment of Care Reviews are conducted as a mock survey and cover the following areas:
- NFPA Life Safety Code requirements applicable to your facility
- Joint Commission Life Safety, Environment of Care, and Emergency Management standards
- CMS CoPs for Physical Environment and Patient Rights
The review replicates all the activities conducted by the Joint Commission engineer who will survey your facility.
Agenda for Life Safety & Environment of Care Reviews
Our expert Life Safety consultants work with you to plan a detailed agenda for the review. You know exactly what to prepare and what their onsite activities will be. The agenda includes the following components:
Document Review Session
- Building Assessment
- Life Safety drawings
- Interim Life Safety Measures
- Fire Response Plan
- Fire drills
- Fire protection/suppression testing and inspection
- Medical equipment inspection, testing, and maintenance
- Utilities systems risk management
- Emergency power systems maintenance and testing
- Medical gas and vacuum systems maintenance and testing
- Data on monitoring of environmental conditions
- Emergency Operations Plan
- Environment of Care Plans
All of the components we include in our service are designed to help your organization be prepared for your next Joint Commission survey.
Life Safety Building Tour
Our Life Safety consultants will conduct a comprehensive building tour side by side with your Facilities Management Team to evaluate:
- Fire and smoke separations
- Hazardous areas (soiled linen rooms, trash collection rooms, oxygen storage rooms)
- Conduct an “above the ceiling” survey at each location identified above by observing the space above the ceiling to identify:
- Penetrations of smoke, fire, or corridor walls
- Smoke or fire walls not continuous from slab to slab and outside wall to outside wall
- Penetrations or discontinuities of rated enclosures including hazardous areas, stairwells, chutes, shafts, and floor or roof slabs
- Corridor walls not slab to slab or do not terminate at a monolithic ceiling
- Presence or absence of required smoke detectors or fire dampers
- Presence or absence of required fireproofing on structural members such as columns, beams, and trusses
- Verify fire exits per building and verify they are continuous from the highest level they serve to the outside of the building
- Assess any kitchen grease producing cooking devices
- Assess any laundry and trash chutes (including bottoms of any laundry and trash chutes)
- Assess the condition of all emergency power systems and equipment
Environment of Care Session
In the EOC session, our Life Safety review specialists will simulate for your team how the surveyor will evaluate your EOC program. This will include review and discussion of your EOC Plans, Safety Committee minutes, and your process for identifying and managing environmental risks. Your Facilities Management Team will get the opportunity to practice presenting their EOC program and answering the surveyor’s questions.
Emergency Management Session
In the EM session, our LIfe Safety Specialist will review your process for disaster planning, disaster mitigation, and disaster response. He’ll evaluate your disaster drills and whether they meet all TJC requirements. Your Facilities Management Team will hear the types of questions they’ll be asked during the TJC survey and prepare for how best to respond.
Evaluation of Ligature Risks
Compliance with the current TJC and CMS requirements for ligature resistant environments is a significant challenge for psychiatric hospitals. Our Life Safety review consultants are experts in how these requirements are applied during surveys. We have an environmental risk assessment tool you can use to meet the TJC requirement for this type of risk assessment. We help you prioritize the most significant ligature risks and how you will resolve or mitigate those to achieve full compliance.
Why Choose Barrins & Associates for your Life Safety & Environment of Care Review?
Our Life Safety review specialists are trained in the most current TJC and CMS standards and survey process. They specialize in facility regulatory compliance for psychiatric hospitals. They also have facility management leadership experience in large, acute care hospital systems. Barrins & Associates is focused on helping your behavioral healthcare organization achieve successful outcomes.