How to avoid joint commissions top citations
When it comes to life safety problems in the health care physical environment George Mills knows it all. He is the director of the Department of Engineering at The Joint Commission and earlier this year, he outlined the top citations of Joint Commission surveys and also offered tips on compliance at the American Society for Healthcare Engineering (ASHE) Annual Conference.

The third most prevalent citation was related to fire barrier penetrations, fire door issues, and duct issues. Currently The Joint Commission and ASHE are working with the firestop industry and others to set up symposiums to educate facility staff about barrier management.

What can you do to avoid these fire barrier issues? Staying on top of fire barriers and keeping track of your life safety inspections is key. Be aware of any work done in your facility that could cause penetrations in your barriers and follow up with correct firestopping procedures. Using a third party contractor for firestop, who are aware of UL systems and NFPA code, can help you stay organized and ensure that you are covered when it comes to fire barrier compliance.

Mills also stated it is unacceptable to have a contractor inspect life safety systems at a hospital and not provide a timely report. He explained that the fifth top citation on Joint Commission’s list of top citations is fire safety testing, and facilities being unable to provide the proper documentation of their testing in a timely matter. Ensure that the contractor you use is able to provide you with a thorough report of any work completed to keep on hand for your next Joint Commission or AHJ survey.

Also on the list on top citations was means of egress (issues with corridor clutter and life safety drawings), smoke barrier penetration problems, unsafe patient care conditions and more.

What can PREVENT do to help? PREVENT has over 15 years of firestopping experience and can ensure proper UL systems are used. What sets us apart from other service providers is that all our field technicians are certified firestop installers and are familiar with the over 3,000 UL systems in existence. We also offer a unique firestop maintenance program that can help you maintain ongoing compliance with NFPA and life safety codes.

When it comes to fire safety testing we provide many services including fire damper inspection and repair, firestop installation and maintenance programs, and fire door inspection, repair and recertification. With each of these services come detailed reports with comprehensive and easy-to-read inspection reports, annotated floor plans, and in some cases, before and after pictures.

You can purchase Mill’s full presentation with synchronized PowerPoint slides or buy individualized sessions at the ASHE Live Learning Center to find out his other top citations and tips on compliance.
Cookies help us improve your website experience.
By using our website, you agree to our use of cookies.