Q: We recently had a survey which resulted in multiple Life Safety findings. We want to clarify away some of these findings, and were told we can only clarify the ‘C’ category findings. Is this true?
A: No, I would not say that statement is true. Any finding may be clarified after the survey as long as the organization provides sufficient evidence that they were in compliance with the standard at the time of the survey. All ‘A’ and ‘C’ listed elements of performance that received a finding from the surveyor may be appealed to the accreditor with an explanation as to why the hospital believes they were compliant. This is called the clarification process, and organizations have ten (10) days to submit their clarifications once the survey report has been posted.
However, standards with ‘C’ elements of performance do have the additional advantage of clarification if the organization can prove they were compliant with at least 90% of the items covered under the standard prior to the survey. Take the example that corridor doors are required to latch (LS.02.01.30, EP 11); If the hospital regularly examines their corridor doors and has documentation that demonstrates at least 90% of the corridor doors did latch, then that information may be used in a written clarification and any finding of a corridor door not latching would eventually be vacated if the accreditor accepts the clarification.
In order to take advantage of this additional ‘C’ EP clarification process, the documented evidence of compliance must be gathered prior to the survey. This would require the organization to have a monitoring program in place that evaluates various features of life safety on a routine basis. That is why the old Building Maintenance Program (BMP), which is optional, is so important as it provides a documented history of compliance at any given time. Many hospitals choose not to implement a BMP because it no longer provides any direct relief of a finding during the survey, but the program still provides the historical evidence needed for a clarification. And, it is a very good self-assessment program of your features of life safety.
The clarification process seems to be hit and miss, at times. It is dependent on a well-crafted written response with the evidence needed to vacate the finding. The staff in the Standards Interpretation Group at the accreditation organization does not always approve the clarifications the same way. It may depend on who is actually reviewing the clarification.