Today, I complete my series on clarifications for surveyor findings that I have written for a client.
Clarification for LS.02.01.30, EP 11
LS.02.01.30, EP 11: Corridor doors are fitted with positive latching hardware, are arranged to restrict the movement of smoke, and are hinged so they swing. The gap between meeting edges of door pairs is no wider than 1/8 inch, and undercuts are no larger than 1 inch. Roller latches are not acceptable.
The Emergency Department had suite doors that could not latch because hardware is missing.
The storage room number xxxx had doors with vertical gaps exceeding 1/8 inch.
The corridor doors near xxxx in the main building did not completely close. Staff adjusted the door on site permitting closure.
Who: The Director of Facilities is responsible for the implementation and compliance of the life safety management program at XYZ Hospital.
What: Compliance with the NFPA 101 Life Safety Code (2000 edition) is the objective and mission of the Facilities Department. The Safety Management Plan clearly identifies the mission to provide a safe and secure environment, which includes compliance with the Life Safety Code. The Facilities Department conducts routine and non-routine inspections and surveillance throughout the facility, identifying safety and security related issues that need to be resolved. These inspections are documented and reported to the health system’s Safety Committee for their review and consideration.
When: The Safety Management Plan is reviewed annually and presented to the health system’s Safety Committee for their approval. As recently as November 1, 2013 the Safety Management Plan was reviewed and approved by the Safety Committee along with the annual evaluation of the plan. The annual evaluation of the Safety Management Plan was found to be effective, based on quantitative criteria.
How: The Safety Management Plan, and the statement that the facility will be maintained in accordance with the Life Safety Code, is shared with all members of the health system through the intra-net, Safety Manuals and through direct conversations with key leaders in the organization.
Why: As an organization that has hundreds of corridor doors, we feel that three (3) corridor doors that did not fully close, latch or had excessive gaps is not a true reflection of our overall compliance rate. Since this element of performance is designated as a ‘C’ element, we conducted an audit on all of our corridor doors in our facility, prior to the survey. The sample size chosen for this audit is 989 corridor doors, which represents 100% of all the corridor doors in the hospital.
The audit was conducted in June, 2013, as part of our ongoing Building Maintenance Program (BMP), which is 5 months prior to the survey. The 989 corridor doors were inspected for:
- Positive latching
- Ability to fully close
- Excessive gaps around the door
- Ability to resist the passage of smoke
The results of this audit found 981 compliant corridor doors (out of 989 total corridor doors), which represents a 99.19% compliance rate.
Therefore, since our audit of this ‘C’ element demonstrates a compliance rate greater than 90% prior to the survey, XYZ Hospital respectfully requests that The Joint Commission vacate this finding under LS.02.01.30, EP 11, and consider this standard to be ‘Compliant’.
Result? The accreditor accepted this clarification, which is another audit of a ‘C’ category EP.
So, if you’ve been tracking my success, the score ends up being: Accepted 4 : Not Accepted 3, which give me a winning percentage. Not bad for an old consultant.
You’ve been good to follow along with this series, so here is one last sign of a very good clarification: