Spotlight on Beating the Clock

By Douglas S. Erickson, FASHE, CHFM and James P. Stahl Jr., CFPS, CDT

Effective August 1, 2016, The Joint Commission changed the Statement of Conditions® (SOC) process related to Life Safety (LS) requirements. Previously, deficiencies discovered during mock surveys or scheduled inspections could be added to a Plan for Improvement (PFI) and corrected in an organized approach . With the new SOC requirements, this is no longer the case, as the new SOC process requires any LS deficiency to be addressed by corrective action within 60 days of it being cited on a TJC or CMS survey.

According to presentations by TJC, one of the top 20 most commonly cited deficiencies relates to unsealed or improperly sealed “fire barrier penetrations” (LS.02.01.10, EP9). With the massive amount of data and communication cabling being installed to support ever-growing technology needs of a modern healthcare facility, low voltage cable penetrations are one of the most single common culprits in mez-path-complete-solution1aintaining barriers. To accommodate new technologies, openings in barriers are created to run new services or new cable is added to existing sleeves or pass-through devices. As we all know, cable penetrations are being made daily and are typically not sealed in accordance with UL requirements. A recent study performed by Global Fire Protection, a third-party inspection firm with extensive inspection experience within healthcare organizations, confirmed that frequently these conditions are found unsealed when standard sleeves or non-self-sealing pass-through devices are used. They went on to confirm that their study indicated that self-sealing devices such as EZ-Path remain compliant because no further intervention is required after installation.

To eliminate getting cited, self-sealing fire-rated pathways, such as STI’s EZ-Path® Fire Rated Pathway, are the logical solution. They are maintenance-free, since they do not require an action to activate the sealing function, and that means they are always sealed for fire and smoke 100% of the time. With the changes enacted by CMS and TJC as it relates to the SOC, healthcare organizations should be taking a proactive approach on how penetrations through smoke and fire barriers are being addressed. Selecting the wrong type of system that requires a manual manipulation of the device and thereby leaves the pass-through device non-compliant can trigger maintenance projects that have to be addressed in a much more immediate fashion then in the past.

An Evaluation Report recently issued by Underwriters Laboratories Inc. (UL), the global leader in testing and certification of fire protection products and systems, confirmed that EZ-Path® Fire Rated Pathways are maintenance-free and proven to comply with all the requirements imposed by the NFPA 101, “Life Safety Code” (LSC) as they relate to firestopping and smoke sealing in fire and smoke barrier construction. Thus, a healthcare organization that standardizes with products like EZ-Path will avoid the possibility of fire and smoke barrier deficiencies and the running clock forcing them to perform corrective action within 60 days.

Doug is STI’s Senior Advisor for Healthcare. James is STI’s Vice President of Engineering. Specified Technologies Inc. is the leading manufacturer of firestopping products and systems for the built environment. Visit to learn more about these and other exciting STI products.


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