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The Joint Commission, Fire Protection & YOU: Everything You Need to Know about Fire Protection in your Healthcare Facility

Conner Wolff-Torres · Feb 7, 2023 ·

Keeping your healthcare facility in constant preparedness for Fire and Life Safety surveys can be a challenge. It’s important that you be ready, but it can be easy to get overwhelmed.

The Joint Commission accreditation is the gold standard in healthcare certification, and as a facility professional, the responsibility for Fire and Life Safety Code compliance falls to you. That means that you’re on the spot when The Joint Commission surveyors, including a Life Safety Code surveyor, arrive unannounced.

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February 7, 2023

It’s important for hospitals to demonstrate their dedication to safe, effective, and comprehensive patient care. While they can display this in their day-to-day operations, most choose to take things a step further by earning accreditation from The Joint Commission (JCAHO) or another accrediting organization. 

Accrediting organizations have applied for and received “deeming authority” from the Centers for Medicaid and Medicare Services (CMS). This means they can determine which healthcare facilities meet Medicare and Medicaid certification requirements. However, each of them goes about determining that in their own way, with a different set of standards. 

In the United States, nearly 23,000 health care organizations are evaluated and accredited through the Joint Commission, one of the few accreditation organizations accepted by the Centers for Medicare and Medicaid Services (CMS).

At A P Fire we will help you understand and tackle JCAHO and the standards it uses to determine fire safety in hospitals – large and small.

What Is the Joint Commission?

The Joint Commission is an accreditation body that focuses on quality care for the American public through a voluntary and independent evaluation process. It is governed by a 21-member Board of Commissioners that includes physicians, administrators, nurses, employers, quality experts, a consumer advocate and educators. They also employ approximately 1,000 people in its surveyor force.

All of these people work together to influence national healthcare policy, funding priorities, performance measurement, and future legislation. In addition, they establish standards for safe, effective, and comprehensive patient care. 

What Are jcaho Standards?

The Joint Commission performs on-site surveys once every three years, but hospitals must also perform annual self-assessments.  These standards are all focused on setting hospital performance expectations that are reasonable, achievable, and surveyable. Together they are aimed at holding healthcare facilities responsible for high-quality care.

Over the years, JCAHO has established hundreds of standards, with categories, or chapters, ranging from Document and Process Control (DC), to Infection Prevention and Control (IC), to Medication Management (MM), and many more. When it comes to fire safety in hospitals, these standards are found in The Joint Commission’s Life Safety (LS) Chapter. 

GENERAL BUILDING REQUIREMENTS – LS.02.01.10 (HOSPITALS) AND LS.03.01.10 (AMBULATORY CARE FACILITIES)

The elements of performance:

Unprotected openings in fire rated walls and floors
Fire doors hardware and gaps
Openings in 2-hour fire rated walls for 1½ hours

MEANS OF EGRESS REQUIREMENTS – LS.02.01.20 (HOSPITALS)

The elements of performance:

Corridor clutter
Doors unlocked in the direction of egress

PROTECTION – LS.02.01.30 (HOSPITALS)

The elements of performance:

Hazardous storage area issues
Corridor doors
Smoke barriers do not have unsealed penetrations

FIRE PROTECTION – EC.02.03.05 (HOSPITALS)

The elements of performance:

Lack of documentation related to the maintaining, inspecting, and testing
Annual testing of smoke detectors, duct detectors, etc.
Automatic air handling unit shutdown
Annual testing of visual and audible fire alarms
Water flow device testing
Quarterly testing of fire alarm notification to off-site fire responders

How The Joint Commission Evaluates Facilities for Fire Safety

JCAHO standards provide the basis for an evaluation process to measure, assess, and improve hospital performance. They conduct surveys for a given facility every three years to determine if they are in compliance with CMS requirements.

Between surveys, health care facilities are required to conduct ongoing self-assessments and make improvements based on their results. This requirement encourages continuous improvement, which – where fire and life safety are concerned – directly contributes to improved occupant safety.

There are two groups of The Joint Commission Standards that pertain specifically to fire and life safety:

The Joint Commission Environment of Care (EC) Standards

These standards address a number of safety and security risks within the facility’s building or space, including fire safety.

The Joint Commission Life Safety (LS) Standards

These standards address all of The Joint Commission requirements in the National Fire Protection Association (NFPA) 101 Life Safety Code for construction and operational conditions to minimize fire hazards and provide safe fire protection systems.

How Joint Commission Standards relate to the National Fire Protection Association Standards

The Joint Commission standards related to fire safety are based on National Fire Protection Association (NFPA) codes. Most of the codes specific to hospitals and ambulatory care facilities come from NFPA 101 Life Safety Code. Furthermore, there are a number of different NFPA codes that are applicable to all health care occupancies. The table below provides a comparison between The Joint Commission Standards and their corresponding NFPA Codes.

If you work in a hospital or healthcare setting that’s accredited by The Joint Commission, it’s important to know what these standard updates mean for your facility. In order to pass your annual self-assessment or triennial survey from The Joint Commission, you need to ensure full compliance with protocol. 

The Joint Commission helps hospitals become reliable organizations for delivering safe and effective care. A large component of that is adhering to their standards on effective fire protection.

Maintaining accreditation is critically important for any facility that provides services to Medicare and/or Medicaid patients. And, any facility found to have critical violations can find itself on a 90-day termination track toward losing CMS reimbursement.

Fire safety continues to be a significant challenge for health care facilities in their Joint Commission surveys. According to the results of The Joint Commission surveys in 2018, almost half of the top compliance issues for hospitals and ambulatory facilities were related to fire safety.

Top Fire Safety-Related Compliance Challenges

Here are the top fire safety-related deficiencies that The Joint Commission identified in 2018 with the applicable standard noted in parentheses:

  • Only 35 percent of hospitals were adequately maintaining their fire safety equipment and the fire safety features of their buildings (EC.02.03.05).
  • The building and fire protection features of more than 55 percent of the ambulatory care facilities (LS.03.01.10) and 68 percent of hospitals (LS.02.01.10) evaluated did not adequately protect occupants from the effects of fire, smoke, and heat.
  • In fewer than 28 percent of the hospitals (LS.02.01.30) evaluated, the buildings either did not provide the necessary features to protect occupants from the hazards of fire and smoke, or they had the necessary features but were not being properly maintained.
  • Almost 89 percent of rural hospitals designated as critical access hospitals were lacking the required equipment for extinguishing fires. And, in the other hospitals evaluated, that number jumped to 90 percent. More than 55 percent of outpatient facilities did not meet these standards (LS.03.01.35).
  • Another common area of non-compliance was in the Means of Egress provided by hospitals (LS.02.01.20) with half of those evaluated failing to meet The Joint Commission standards.

APFP Can Help You Meet The JCAHO and NFPA Standards

A P Fire Protection is one of the few fire protection companies in Arizona that can provide total protection from one source. If your facility is accredited by The Joint Commission, our team of NICET-certified and factory-trained engineers and technicians can provide the knowledge and expertise you need to ensure that your employees and patients are safe – and your facility is compliant with both The JCAHO and NFPA standards.

Fire protection Services for Healthcare Accreditation

Keeping your healthcare facility in constant preparedness for Fire and Life Safety surveys can be a challenge. It’s important that you be ready, but it can be easy to get overwhelmed.

The Joint Commission accreditation is the gold standard in healthcare certification, and as a facility professional, the responsibility for Fire and Life Safety Code compliance falls to you. That means that you’re on the spot when The Joint Commission surveyors, including a Life Safety Code surveyor, arrive unannounced.

With the overwhelming number of operating challenges you face on any given day, it’s unlikely you have time to continually think about Fire and Life Safety documentation. APFP services for The Joint Commission accreditation are designed to give you the peace of mind knowing that a sudden visit is never a cause for alarm.

Leave the documentation management to us

The Joint Commission’s accreditation program requires that you maintain an extensive set of Fire and Life Safety documentation, properly completed, appropriately organized and easily accessible. Missing paperwork or incomplete entries are more than embarrassing; they can trigger non-compliance requiring corrective action.

 A P Fire Protection Fire Services for The JCAHO Accreditation ensure proper documentation of all inspection and test reports related to Fire and Life Safety systems in your buildings and are designed to simplify and streamline the survey process. The program provides you with an annual delivery schedule to ensure no test is overlooked. Regular review meetings will be included to familiarize your staff members with all related documentation and paperwork as well as prepare them to speak knowledgeably with surveyors during a survey.

Our goal is to help you avoid unpleasant surprises, and free you up to devote more of your resources to daily operations.

Our highly trained professionals speak “The Joint Commission” language.

You can depend on A P Fire Protection testing, inspection and documentation to mirror the very latest requirements including The Joint Commission Environment of Care and Life Safety requirements. The APFP team maintains in-depth knowledge of The Joint Commission standards, as well as National Fire Protection Association codes as it relates to healthcare.

Make A P Fire Protection your single source for Fire and Life Safety

When A P Fire Protection partners with your facility, you can end the hassle of managing multiple life-safety vendors. With one service agreement, you can consolidate testing and maintenance processes, scheduling and documentation for all your Fire and Life Safety systems.

Testing and maintenance services can include fire alarm systems, sprinklers, kitchen hoods, portable extinguishers, fire pumps, fire suppression systems and more. Learn more about A P Fire Protection Fire Services.

A P Fire Protection services for The Joint Commission Accreditation Program can be tailored to your exact needs:

• Testing of Fire and Life Safety systems to The Joint Commission and other regulatory standards

• Easy-to-read, customized test reports, created per each applicable Element of Performance standard established by The Joint Commission

• Comprehensive inspection management in the form of a detailed inspection schedule, structured around The Joint Commission Elements of Performance standards

• Deficiencies tracking and repairs in full accordance with applicable standards and deadlines of The Joint Commission

• Account management services including frequent review meetings to discuss present and future needs

• Assistance with interpretation of The Joint Commission standards and requirements

If you’d like to know more about The Joint Commission’s Standards, check out these publications: Joint Commission resources2023 Environment of Care® Essentials for Health Care,  Life Safety Made Easy: Your Key to Understanding Fire Safety in Health Care Facilities and The Joint Commission Big Book of EC, EM, and LS Checklists

At A P Fire Protection, we’re experts on The Joint Commission’s standards. We can help you ensure you’re always in compliance. Contact us to learn more.

Schedule Now!
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AASBO 2022: Racing Towards Excellence

Conner Wolff-Torres · Jul 29, 2022 ·

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Racing to excellence

AASBO 2022

Last week we attended the 69th Annual AASBO Conference and Expo in Tucson, AZ. This year’s theme, Racing to Excellence, was a NASCAR super-fan dream. It was another great year at AASBO 2022! Our booth was decked out with all things racing including: balloons, blow up tires, checkered flags and racing themed photo props! We weren’t the only ones embracing the event’s spirit, there were so many awesome booths this year.

Happily, we saw a few familiar faces in the crowd. We love that you keep coming back and letting us educate you on the importance of fire protection and fire safety in your facilities.

AASBO 2021
AASBO 2022
AASBO 2021
AASBO 2022

Safety in schools is a top priority, and we are excited to keep growing and helping to build a fire safe community in Arizona.

Giveaways

As always, we had some pretty amazing giveaways to entice a pit stop or two to our booth. This year we brought notepads, stickers, back scratchers, koozies, ice packs and rulers!

In addition, our Grand Prize this year consisted of Two Arizona Cardinals Club Level Game Tickets and a few tailgating necessities like snacks, drinks (the fun kind), Cardinals merch and a cooler!

Our Grand Prize Winner, Shaina with The Arizona School for the Deaf and Blind

What is AASBO

The Arizona Association of School Business Officials (AASBO) is a professional organization; providing support and professional development opportunities for individuals in the field of education who provide management and services. AASBO is recognized by the educational community as the primary source of accurate, objective business and operations information, educating its diverse membership and constituency in professional best practices, and promoting the highest standards in school business administration. AASBO is dedicated to improving the skills of its members to ensure that the educational needs of Arizona’s school children are best served.

Why are we members

Many of AASBO’s programs, presentations are made by individuals with expertise in areas of school business and support service operations. The association’s programs feature keynote speakers from various fields and high elective offices, as well as technical sessions in the areas of business operations.

Furthermore, as a vendor interested in doing business with Arizona public schools and a registered member of AASBO, we are in a great position to best serve you and your school. If you are looking for a reliable, customer focused fire protection company to service your facilities for the 2022-23 school year, we are here for you! Let us help you get your fire protection equipment race ready and your school year preparation to the finish line.

Schedule Now!

WE had a great time, See you next year!

AASBO 2022
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Why Does My Bid Have a Compliance Engine Fee?

Conner Wolff-Torres · May 24, 2022 ·

Why Does My Bid Have a Compliance Engine Fee?

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May 24, 2022

WHAT IS THE COMPLIANCE ENGINE

The Compliance Engine is a simple, internet-based tool for Fire Prevention Bureaus, Water Departments, and Building Departments and depending on where your business is located, it may be a required tool to help keep your business and your city up to date.

The Compliance Engine provides a secure environment for third-party contractors, like A P Fire Protection, who inspect, test, and maintain fire protection systems and backflows to submit their reports via BRYCER’s Web Portal directly to the Authority Having Jurisdiction (AHJ) in local municipalities. This facilitates a more efficient review, tracking, and follow-up process with occupants to correct deficiencies and maintain systems and allows AHJs to track and drive inspection and testing code compliance which ultimately reduces false alarm activity, ensures clean drinking water and provides a safer community.

While it may seem like this is just a way to generate revenue for contractors and the local AHJ, the single biggest reason we are starting to see the shift to a compliance engine is to make it safer for the people who occupy these buildings. Utilizing the compliance engine can play a considerable role in reducing the likelihood of a fire event and the damage it could cause if the fire protection systems are not being maintained properly. 

The compliance engine process

THE PROCESS

Property owners will receive timely, proactive notifications of their testing requirements by mail. If we have not already contacted you to get you on the schedule, please call our office. Once testing has been completed, we will provide you with our testing reports and suggested repairs for your systems. We are then required to submit all testing information and noted deficiencies to the AHJ via the compliance engine. If repairs have not been completed for required deficiencies and been reported back to the compliance engine within 30 days, the property owner will then receive an additional notice of deficiency giving them and additional 30 days from receipt of the letter to complete the needed repairs. Property owners do not need to submit any reports to the compliance engine. As the testing company, we do this for you!

Pressure gauge reading on fire hydrant

REPORTING & CORRECTING DEFICIENCIES

In the last few years, AHJs who have put more of an emphasis on the proper inspection, testing and maintenance of fire protection systems have frequently found deficiencies that could impact the performance of fire systems that go un-repaired. We understand as property owners you may not want to pay for the correction of the deficiencies immediately because there is a lack of budgetary funding and there may not seem to be any urgency in doing so, but it is our job to communicate the impact of the deficiency in the event of an emergency can be devastating.

Now, with the utilization of compliance engines and having to submit the inspection reports along with the list of deficiencies, there is a priority to have these deficiencies corrected immediately in order to properly maintain fire protection systems and prevent major property loss. While the upfront cost may seem sizeable, the long-term savings is priceless.

RESULTS WE ARE SEEING FROM COMPLIANCE ENGINES

Having a compliance engine to keep track of code compliance aids the Fire Marshal and Fire Prevention Bureaus by providing accurate data of which buildings have fire protection systems, when they were last tested, and if there are any open deficiencies that could hinder the successful deployment of their fire protection teams in the event of an incident.

As a service provider offering quarterly, semi-annual, and annual inspections and testing to our customers, we are seeing more and more local municipalities we serve adopting the compliance engine in an effort to track and drive responsible inspection and testing code compliance. Thanks to the database the compliance engines are building, we know that over 50% of all fire protection systems go untested and maintained annually, and together we are working to change that.

While this is generating more revenue for us, it is also giving us an opportunity to interact with our customers more than usual, ultimately building a much stronger relationship with you, and that is our ultimate goal.

SYSTEMS TRACKED THROUGH THE COMPLIANCE ENGINE IN OUR AREA:

  • Fire Alarm Systems
  • Automatic Fire Sprinkler Systems
  • Fire Pumps
  • Kitchen Hood Suppression Systems
  • Fire Hydrants
  • CO2 Detection Systems
  • Spray Booths
  • Standpipe Systems
  • Backflow Preventers

CITIES & MUNICIPALITIES CURRENTLY UTILIZING COMPLIANCE ENGINES

Arizona Municipalities Requiring Compliance Engine Reporting

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  • The Joint Commission, Fire Protection & YOU: Everything You Need to Know about Fire Protection in your Healthcare Facility
  • ASBA 2022: Another Great Year
  • Food Trucks: Fire and Life Safety
  • Food Trucks: 10 Quick Tips for Enhancing Fire Safety
  • Fire Won’t Wait, Plan Your Escape

Kitchen Safety: Dealing with Fires this Holiday

Molly Smith · Nov 13, 2020 ·

Keeping fire safety a priority during the merry, yet manic holidays is very important. Thanksgiving is the peak day for cooking fires, followed by Christmas Day. Distractions are at an all time high with all of the people around and activities going on.

According to a Fire Estimate Summary presented by FEMA, in 2018 there were 103,600 reported fires in nonresidential buildings. Of those fires, 31,700 were from cooking. That is three times higher than any other fire causes. Cooking fires alone made up 31% of all nonresidential fires in 2018. 🤯

Understanding how a fire works will give you the tools and knowledge to extinguish it.

The Fire Tetrahedron is a pyramid to help understand the necessary ingredients for most fires. Each of the four sides illustrates an element that must be present in order for a fire to occur: oxygen, heat, fuel and a chain reaction.

The Fire Tetrahedron

Ways to put out a grease fire:

  1. Turn off the heat. DO NOT try and move the pan. You could burn yourself or spill the burning grease in the kitchen, causing the fire to spread.
  2. Cover the pot. This will eliminate the oxygen that is needed to sustain the fire. The lid needs to be metal because the heat will shatter a glass lid. If you don’t have a metal lid then a cookie sheet will suffice.
  3. Pour baking soda or salt on a grease fire. Baking soda releases carbon dioxide which smothers the flames. However, this will only work with small grease fires because it will take a large amount to get the job done. Salt works well because it helps absorb the heat and you will only need a moderate amount, about one cup, to put a decent size grease fire out.
  4. Use a Class B Dry Chemical Fire Extinguisher. The mess a fire extinguisher leaves behind might be as bad as the destruction of the fire, not to mention it will contaminate your kitchen. With that being said, this should be a last resort if the first 3 options do not work.

Whatever you do, DO NOT pour water on a grease fire! Oil and water do not mix. Adding water to a grease fire can cause the oil to splash and spread throughout your kitchen and other appliances. In most cases adding water will generate an even larger fire, creating a small explosion. This happens because oils burns at a much higher temperature then water boils, so when it is added to the oil it instantly sinks below it.

Slow motion video of what happens when water is added to a grease fire.

Do You Include Fire Protection Into Your Annual Budget?

Molly Smith · Oct 13, 2020 ·

The need for buildings to be safe and the systems within them to be operational is and will continue to be critical to public and fire responder safety.”

– Jim Pauley, CEO & President of NFPA

Something very important to consider when developing your annual budget is Fire Protection for your business. This allows foresight into any issues that may arise throughout the year. To elaborate, this does not only include annual and semi-annual inspections, but also any maintenance and/or repairs needed throughout the year. In addition, if you are planning any tenant improvement projects, a detailed budget is essential for the success of the project.

Your budget is basically an educated guess based on your past revenue and expenditures that will help you see what the future of your business finances will look like. With that being said, the more detailed and accurate you can be, the more efficient your budget will be.

Conducting your own visual inspection will allow you to anticipate and account for possible repairs. A checklist is attached of some common items to look for when conducting your own visual inspection. Taking into account all of the annual inspections, semi-annual inspections and possible repairs will help you create a more precise budget. This will allow you to actually proceed with all of the necessary inspections and/or repairs through an A P Fire Protection licensed contractor. Failure to consider all the above will have a negative impact on your planned success and overall profitability. Trying to save a buck, because you didn’t plan for certain repairs, could have devastating consequences!

click here to download checklist

By taking the time to factor Fire Protection into your budget, you will be giving yourself the greatest chance of achieving your budgetary goals. Which in turn will make your business more successful. If you are unaware of how much it costs to get your systems inspected or which repairs could be needed, schedule a free walkthrough and A P Fire Protection will be happy to provide you with a free estimate.

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Fire Protection Budget Checklist

A P Fire Protection
7612 N 71st Ave
Glendale, AZ 85303

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