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It specifies when surveyors begin reviewing referenced documents during the onsite survey and notes that additional EC/LS materials may be requested as needed. The tool includes compliance tracking legend (C, NC, NA, IOU), revision identification by underlined text, and reminders that some performance elements may not require documentation but should be addressed for survey readiness.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/hospital-life-safety-environment-of-care-document-list-and-review-tool-effective-312024/648166/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/hospital-life-safety-environment-of-care-document-list-and-review-tool-effective-312024/648166.png","ImageObject",300,407,{"name":92,"@type":93},"Mafia Boss","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-11-12","2026-10-23",true,{"@type":102,"interactionType":103,"userInteractionCount":19},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"What is the purpose of this document list and review tool?","Question",{"text":112,"@type":113},"It compiles the documentation required for hospital accreditation under Life Safety (LS) and Environment of Care (EC) standards and supports survey readiness and continuous compliance.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"When will surveyors start reviewing these documents?",{"text":117,"@type":113},"The Life Safety surveyor begins reviewing the documents soon after arrival for the onsite survey.",{"name":119,"@type":110,"acceptedAnswer":120},"How are revisions to the tool identified?",{"text":121,"@type":113},"Revisions are identified by underlined text.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},648166,1792792545,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":19,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":139,"language":140,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":67,"update_tm":129,"read_time":144,"preview_page_count":4},962090760730,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","Hospital Life Safety & Environment of Care Document List and Review Tool  \nEffective: 3/1/2024  \nThe following pages present documentation required by the Hospital Accreditation program Life Safety (LS), and Environment of Care (EC) standards. The Life Safety surveyor will begin review of these documents soon after arrival for the onsite survey.  \nSurveyors may request other EC and LS documents, as needed, throughout the survey.  \nThis list also includes some elements of performance that do not require documentation but appear as reminders to both organizations and surveyors of these expectations.  \nOrganizations may want to consider using this tool in their continuous compliance and survey readiness efforts.  \nRevisions to this document are identified by underlined text.  \nAdditional resources, including a Fire Drill Matrix, are available on The Joint Commission website, Physical Environment Portal which is accessible using the following link: [https://www.jointcommission.org/resources/patient-safety-topics/the-physical-environment/](https://www.jointcommission.org/resources/patient-safety-topics/the-physical-environment/) .  \nLegend: C=Compliant; NC=Not compliant; NA=Not applicable; IOU=Surveyor awaiting documentation  \n\n| STANDARD\u003Cbr>EPs | C | NC | NA | IOU | Document / Requirement | Yes | No |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| LS.01.01.01 |  |  |  |  | Buildings serving patients comply w/ NFPA 101 (2012) |  |  |  |\n| EP 1 |  |  |  |  | Individual assigned to assess Life Safety Code® compliance |  |  |  |\n| EP 2 |  |  |  |  | Building Assessment to determine compliance with Life Safety (LS) chapter (frequency of assessment is defined by the hospital) |  |  |  |\n| EP 3 |  |  |  |  | Current and accurate drawings w/ fire safety features & related square footage\u003Cbr>a. Areas of building fully sprinklered (if building only partially sprinklered)\u003Cbr>b. Locations of all hazardous storage areas\u003Cbr>c. Locations of all fire-rated barriers\u003Cbr>d. Locations of all smoke-rated barriers\u003Cbr>e. Sleeping and non-sleeping suite boundaries, including size of identified suites\u003Cbr>f. Locations of designated smoke compartments\u003Cbr>g. Locations of chutes and shafts\u003Cbr>h. Any approved equivalencies or waivers | ☐\u003Cbr>☐\u003Cbr>☐\u003Cbr>☐\u003Cbr>☐\u003Cbr>☐\u003Cbr>☐\u003Cbr>☐ | ☐\u003Cbr>☐\u003Cbr>☐\u003Cbr>☐\u003Cbr>☐\u003Cbr>☐\u003Cbr>☐\u003Cbr>☐ |  |\n| EP 5 |  |  |  |  | Deemed Hospitals: Documentation of inspections and approvals made by state or local AHJs |  |  |  |\n| EP 7 |  |  |  |  | The hospital maintains current Basic Building Information (BBI) within the Statement of Conditions (SOC) . |  |  |  |\n| COMMENTS: |  |  |  |  |  |  |  |  |\n\n\n| STANDARD\u003Cbr>-EPs | C | NC | NA | IOU | Document / Requirement | Yes | No |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| EC.02.03.01 |  |  |  |  | Hospital Manages Fire Risk – Fire Response Plan |  |  |  |\n| EP 9 |  |  |  |  | The written fire response plan describes the specific roles of staff at and away from fire including:\u003Cbr>• When and how to sound and report fire alarms\u003Cbr>• How to contain smoke and fire\u003Cbr>• How to use a fire extinguisher\u003Cbr>• How to assist and relocate patients\u003Cbr>• How to evacuate to areas of refuge\u003Cbr>• How staff will cooperate with firefighting authorities\u003Cbr>Staff periodically instructed on/kept informed of duties under plan Copy of plan readily available with telephone operator or security | ☐\u003Cbr>☐\u003Cbr>☐\u003Cbr>☐\u003Cbr>☐ | ☐\u003Cbr>☐\u003Cbr>☐\u003Cbr>☐\u003Cbr>☐ |  |\n\n\n|  |  |  |  |  | NFPA 101-2012: 18/19 .7. 1; 7.2 |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- |\n\nCOMMENTS:  \n\n| STANDARD\u003Cbr>-EPs | C | NC | NA | IOU | Document / Requirement | Frequency | Q1\u003Cbr>Semi | Q2 | Q3\u003Cbr>Semi | Q4\u003Cbr>Annual |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| EC.02.03.05 |  |  |  |  | Fire Protection and Suppression Testing and Inspection |  |  |  |  |  |\n| EP 1 |  |  |  |  | Testing for pressure supervisory indicating devices (including both high-and low-air pressure switches), water level sup","cbCaiiXwQzCp0o7R","https://ap.wps.com/l/cbCaiiXwQzCp0o7R","pdf",439390,17,"English","# Document Purpose and Use\n# Legend and Revision Tracking\n# Life Safety (LS) Documentation Items\n## LS.01.01.01 and Related EPs\n# Environment of Care (EC) Documentation Items\n## EC.02.03.01 Fire Risk and Fire Response Plan\n## EC.02.03.05 Fire Protection and Suppression Testing and Inspection","[{\"question\":\"What is the purpose of this document list and review tool?\",\"answer\":\"It compiles the documentation required for hospital accreditation under Life Safety (LS) and Environment of Care (EC) standards and supports survey readiness and continuous compliance.\"},{\"question\":\"When will surveyors start reviewing these documents?\",\"answer\":\"The Life Safety surveyor begins reviewing the documents soon after arrival for the onsite survey.\"},{\"question\":\"How are revisions to the tool identified?\",\"answer\":\"Revisions are identified by underlined text.\"}]","Hospital Life Safety & Environment of Care Document List and Review Tool - Effective 3/1/2024 | PDF",43]