FOCUS on LS.02.01.20

LS.02.01.20 – The hospital maintains the integrity of the means of egress


The following elements of performance are the most common reasons why hospitals are cited for LS.02.01.20.

ASHE is providing resources to help hospitals address each of these elements of performance. Additional resources will be added throughout October and November 2015.


In addition to providing resources for health care facility professionals, the Focus on Compliance project with the Joint Commission provides resources for hospital leaders in an effort to promote organizational-level compliance. Leadership resources will be provided later in October and November 2015.

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The hospital manages risks associated with its utility systems.
(August/September 2015)

The hospital maintains the integrity of the means of egress.
(October/November 2015)

The hospital establishes and maintains a safe, functional environment.
(December/January 2016)

The hospital maintains fire safety equipment and fire safety building features.
(February/March 2016)

Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.
(April/May 2016)

The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.
(June/July 2016)

The hospital provides and maintains equipment for extinguishing fires.
(August/September 2016)

The hospital manages risks related to hazardous materials and waste.
(October/November 2016)

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