Jan 30 2014

Clarifications Part 7

Category: BlogBKeyes @ 6:00 am
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Today, I complete my series on clarifications for surveyor findings that I have written for a client.

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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.

 Surveyor finding:

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.

 

Clarification:

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’.

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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:

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Jan 23 2014

Clarifications Part 6

Category: BlogBKeyes @ 6:00 am
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I continue my series on clarifications of surveyor findings that I have written for a client.

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Clarification for LS.02.01.20, EP 30

 LS.02.01.20, EP 30: Signs reading “No Exit” are posted on any door, passage, or stairway that is neither an exit nor an access to an exit but may be mistaken for an exit.

 Surveyor finding:

In the main building first floor Atrium the door needs a “No Exit” sign.

Clarification:

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: Section 7.10.8.1 of the 2000 edition of the Life Safety Code states: “Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows: NO EXIT….”

The door in question that the surveyor refers to is a door to an interior courtyard. It is not at the end of a corridor that would imply a door to an exit; it is not a fire-rated door which would imply a door to a stairwell. It is a door consisting mainly of glass that is only used by maintenance staff when there is a need to be in the interior courtyard. At all other times, the door is locked and unauthorized individuals cannot open the door. There is no other signage that would imply that this door is an exit, or a door to an exit access. Since the door is on the side of the corridor, the door is not at all noticeable unless you were within 10 feet of the door; therefore there is no way it could be mistaken for an exit door.

The Life Safety Code section referenced concerning the need of a “NO EXIT” sign specifically states the sign is only required on doors that are “likely to be mistaken” for an exit, or an access to an exit. Through our Safety Management Plan, which has been in effect for decades, it our observation and determination that this door is not “likely to be mistaken” for an exit or an access to an exit. At no time has anyone inquired to the Facilities Department with concerns that they believe the door is to an exit. Therefore, XYZ Hospital respectfully requests that The Joint Commission vacate this finding under LS.02.01.20, EP 30, and consider this standard to be ‘Compliant’.

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Result? The accreditor accepted this clarification, which just shows you that just because a surveyor says something is deficient, that doesn’t mean it is. In this case, the surveyor’s finding was an opinion, and the clarification successfully pointed out that the ‘NO EXIT’ sign was not required. However, I’ll bet the hospital put a ‘NO EXIT’ sign on the door right away after the survey just to keep future surveyors from thinking about citing it.

If you’re keeping track, the score is:   Accepted 3: Not Accepted 3. Watch for next week’s posting for the seventh and final clarification.

 

 

 

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Jan 16 2014

Clarifications Part 5

Category: BlogBKeyes @ 6:00 am
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I continue my series on clarifications of surveyor findings that I have written for a client.

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Clarification for LS.02.01.10, EP 9

LS.02.01.10, EP 9: The spaces around pipes, conduits, bus ducts, cables, wires, air ducts, or pneumatic tubes that penetrate fire-rated walls and floors are protected with an approved fire-rated material.

Surveyor finding:

In the 6th floor utility room the 4 inch vertical wiring conduit and a one inch wall conduit were not sealed with fireproofing material.

In the Main Building there was a conduit penetration in the hallway by room xxxxx.

In the Main Building there was a conduit penetration by room xxxx.

 Clarification:

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 [is this true?], and through direct conversations with key leaders in the organization.

Why: As an organization that has thousands of feet of fire & smoke rated barriers and corridor walls, we feel that 4 situations of unsealed conduit penetrations 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 fire & smoke rated barriers, and our corridor walls in our facility prior to the survey. The sample size chosen for this audit is 2,954 wall-units for fire & smoke rated barriers, and 2,750 wall-units for corridor walls. This represents 100% of all the fire & smoke rated barriers and 100% of all the corridor walls in the hospital.

A wall-unit is an inspection of the fire & smoke rated barrier, or the corridor wall, whereby the maintenance technician lifts a ceiling panel and examines the wall to the left and to the right for unsealed penetrations. This represents the barrier (or wall) being inspected approximately every six (6) feet.

The audit on the fire & smoke rated barriers was conducted in May, 2013, and the audit on the corridor walls conducted in September, 2013. These audits were conducted as part of our ongoing Building Maintenance Program (BMP), which were no more than 6 months prior to the survey. The walls and barriers were inspected for:

  • Unsealed penetrations
  • Conduit sleeves      penetrating the wall but were not sealed
  • Gaps and holes
  • Completion of construction      to the deck above

The results of these two audits found 2,930 compliant fire & smoke rated wall-units (out of 2,954 total fire & smoke rated wall units), which represents a 99.18% compliance rate, and 2,737 compliant corridor wall-units (out of 2,750 total corridor wall units) which represents a 99.52% 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.02.01.10, EP 9, and consider this standard to be ‘Compliant’.

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Result? The accreditor accepted this clarification. The success of this clarification is based on an audit that the hospital had done prior to the survey, that demonstrated more than 90% compliance. The audit option for clarifications is only allowed to be used on ‘C’ category EPs.

If you’re keeping track, the score is:   Accepted 2: Not Accepted 3

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Jan 09 2014

Clarifications Part 4

Category: BlogBKeyes @ 6:00 am
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I continue my series on clarifications of surveyor findings that I have written for a client.

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Clarification for EC.02.06.01, EP 13

EC.02.06.01, EP 13: The hospital maintains ventilation, temperature, and humidity levels suitable for the care, treatment and services provided.

Surveyor finding:

During a tour of the operating rooms it was noted that the temperature in a recently used operating room was 59 degrees. Nursing and medical staff noted that there were occasions when physicians asked that the temperature in a room be lowered below 68 degrees for personal comfort rather than patient care.

The Soiled Utility room number 6630 has airflow coming out of the room instead of flowing into the room.

Clarification:

Who: The Director of Facilities is responsible for the implementation and compliance of the utility management program at XYZ Hospital.

What: The ventilation requirements for the operating rooms are based on design recommendations from the Guidelines for Design and Construction of Health Care Facilities, as written by The Facilities Guidelines Institute (FGI), and published by the American Society for Healthcare Engineering. These guidelines are not regulatory requirements, as stated in the preface of the FGI document, and as indicated in the Joint Commission standard EC.02.06.05, EP 1. Another Joint Commission standard, EC.02.05.01, EP 1, specifically states: “The hospital designs and installs utility systems that meet patient care and operational needs.”  While the FGI Guidelines were used during the design of the operating rooms, it was fully understood and planned by the hospital with careful input from the medical staff for ventilation settings outside the range that the FGI Guidelines recommended. There are legitimate reasons to have the air temperature lower than the minimum FGI recommendations, such as the operational needs during the surgery. (See “Why” below).

When: Ventilation settings in operating rooms are carefully monitored by Surgery and Plant Operations staff. Normal temperature ranges are adhered to, with the exception when a surgeon makes a request to have the operating room temperature set outside of the recommended range.

How: Operating room staff is educated in the normal ventilation requirements of surgical procedures. New-hires are orientated on all policies and procedures in the Surgery department, and any changes or updates to policies or procedures are communicated to all staff in the Surgery unit.

Why: The request to have the temperature setting in the operating room lower than what is recommend by the FGI Guidelines is not just for surgeon personal comfort, as the surveyor wrote in his finding. This is an operational need for a successful surgical procedure based on the many layers of surgical attire worn by the surgeon and the procedures required during surgery. The layers of attire worn by the surgeon during the procedure include:

  • Undergarments;
  • Surgical scrubs;
  • Sterile surgical gowns;
  • A hooded mask.

The hooded mask is similar to a Hazmat hood and has little air flow. The procedure is performed underneath high wattage intense surgical lights which produce heat, and the procedure requires physical manipulation of the patient’s limbs during prosthetic replacements. The many layers of attire, the heat from the surgical lights, and the physical assertion required during the surgery ultimately requires a lower air temperature in the operating room in order to have a successful surgery, which ultimately is the mission of the organization to provide excellent patient care. Without the lower temperature setting, the surgeon would suffer from physical exhaustion and fatigue, which would jeopardize the success of the surgery and the care provided to the patient.

The decision to set the operating room temperature below a recommended range is not taken lightly, and only done so under the direction of the attending surgeon. Surgery Department policy #12375-2.30 specifically allows for the operating room temperature to be set lower than the 68° to 73°F range at the request of the surgeon for certain surgical procedures.

Therefore, since the 68 degree temperature range is based on guidelines and recommendations and not regulations; since Joint Commission standards permits the operation of utility systems that meets operational needs; and since the air temperature setting that the surveyor observed was permitted in accordance with hospital policy; XYZ Hospital respectfully requests that The Joint Commission vacate this finding under EC.02.06.01, EP 13, and consider this standard to be ‘Compliant’.

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Result? The accreditor did not accept this clarification…. and I think I know why. We made a very good argument that the temperature settings are recommendations only and not regulations, and the hospital had a great reason to have air temperature set lower than recommended. Had that been the only finding the surveyor wrote under this standard I think the accreditor would have accepted the clarification. But there were two findings: the other was improper air pressure relationship for a soiled utility room. We had nothing for that finding. So we decided to argue on the OR temperature setting issue and hope that they would overlook the soiled utility finding.

They didn’t. Oh well… It is what it is.

If you’re keeping track, the score is:   Accepted 1: Not Accepted 3

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Jan 02 2014

Clarifications Part 3

Category: BlogBKeyes @ 6:00 am
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I continue my series on clarifications of surveyor findings that I have written for a client.

clarifywi[1]

Clarification for EC.02.05.01, EP 8

 EC.02.05.01, EP 8: The hospital labels utility system controls to facilitate partial or complete emergency shutdowns.

 Surveyor finding:

In the D-Wing electrical room breaker panel 7HEB did not have breakers labeled and the panel was blocked.

In Surgery operating room 9 the breaker panel 1B/OR9 did not have all breakers labeled.

 Clarification:

Who: The Director of Facilities is responsible for the implementation and compliance of the utility management program at XYZ Hospital.

What: The Utility Management Plan clearly identifies the mission to provide and maintain safe and reliable plant equipment. Plant equipment will be installed, maintained and operated in such a way as to provide a safe, clean, comfortable and efficient environment for our patients, visitors and staff.

When: The Utility Management Plan is reviewed annually and presented to the health system’s Safety Committee for their approval. As recently as November 1, 2013 the Utility Management Plan was reviewed and approved by the Safety Committee along with the annual evaluation of the plan. The annual evaluation of the Utility Management Plan was found to be effective, based on quantitative criteria.

How: The Utility Management Plan 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: The unmarked breakers that the surveyor observed in electrical panel 7HEB, are spares. When the electrical panel was installed by the electrical contractor, it is a requirement for the contractor to provide a full ‘stable’ of breakers, regardless whether all of them are immediately utilized. The remaining unused breakers are considered spares and are available for future use. The breakers that are connected to electrical circuits in panel 7HEB are marked. Only the spare breakers which the surveyor referred to are unmarked.

Contrary to what the surveyor wrote in his finding, all of the breakers in electrical panel 1B/OR9 are marked and were marked at the time of the survey. We are not sure why the surveyor wrote that the breakers were not marked, other than the fact that all of the breakers are two-pole breakers, and perhaps the surveyor did not realize that a description was only needed to be written in one slot on the panel legend for the two-pole breaker.

Therefore, since the unmarked breakers in panel 7HEB are spares, and since we believe these circuit breakers in the electrical panel 1B/OR9 were properly labeled at the time of the survey, XYZ Hospital respectfully requests that The Joint Commission vacate this finding under EC.02.05.01, EP 8, and consider this standard to be ‘Compliant’.

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Result? The accreditor did not accept this clarification. Which just shows that they are serious on having all electrical breakers labeled.

If you are keeping track, the score is:  Accepted 1: Not Accepted 2

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Dec 26 2013

Clarifications Part 2

Category: BlogBKeyes @ 6:00 am
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I continue my series on clarifications of surveyor findings that I recently wrote for a client:

clarify-little-fuzzy[1]

Clarification for EC.02.05.01, EP 4

EC.02.05.01, EP 4: The hospital identifies, in writing, the intervals for inspecting, testing, and maintaining all operating components of the utility systems on the inventory, based on criteria such as manufacturers’ recommendations, risk levels, or hospital experience.

 Surveyor finding: The battery powered lights in the Surgery operating rooms did not have an interval for testing. At Emergency Generator 5 there was no required interval for testing of the battery powered lights.

Clarification:

Who: The Director of Facilities is responsible for the implementation and compliance of the utility management program at XYZ Hospital.

What: The requirement for testing and inspection intervals of the battery powered lights in the hospital is located in the Facilities Department policy #xxxx-x. This policy specifies that battery powered lights will have a functional test at 30-day intervals for at least 30 seconds, and an annual test for 90 minutes.

When: This Facilities Department policy #xxxx-x was written by the Facility Director on July 31, 2006, and approved by the Safety Committee thereafter. This policy has been periodically reviewed by the Facility Director, most recently on January 11, 2013.

How: All new-hires into the Facilities Department are educated on all departmental policies and procedures. All Facilities Department staff is aware of departmental policies and procedures and is provided training and education when changes or updates are made.

Why: The surveyor did not request to see our policy on the intervals for testing the battery powered light, at the time of the survey. It is unknown why the surveyor did not ask to see our policies, but the surveyor did cite us under EC.02.05.01, EP 4 for not having “intervals for testing”, when in fact we did have these “intervals for testing” in written form of the policy for over seven (7) years prior to the survey. Therefore, XYZ Hospital respectfully requests that The Joint Commission vacates this finding under EC.02.05.01, EP 4, and considers this standard to be ‘Compliant’.

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Result? The clarification was accepted by the accreditor. The clarification clearly implies that the surveyor screwed up and scored his finding under the wrong standard. When I write clarifications for findings scored under the wrong standard, I do not point out the obvious, that the surveyor made a mistake. I take the tact that the finding does not fit the standard. Same difference…

If you are keeping track, the score is:   Accepted 1: Not Accepted 1

 

 

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Dec 19 2013

Clarifications Part 1

Category: BlogBKeyes @ 6:00 am
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I’m going to post some clarifications of surveyor findings that I wrote recently for a client. Some were accepted by the accreditor and some were not. I thought you might be interested in the approach and outcome.

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Clarification for EC.02.03.01, EP 1

EC.02.03.01, EP 1: The hospital minimizes the potential for harm from fire, smoke and other products of combustion.

Surveyor finding:

In the Main Building near the utility room+ two open electrical junction boxes did not have covers.

In the Main Building near the elevator located on second floor an electrical junction box did not have a cover.

 Clarification:

Who: The Director of Facilities is responsible for the implementation and compliance of the safety management program at XYZ Hospital.

What: The Safety Management Plan clearly identifies the mission to provide a safe and secure environment for our patients, visitors and staff. 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 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: The element of performance in which the surveyor entered his finding is under the standard that requires the hospital to manage fire risks. The element of performance itself requires the hospital to minimize the potential for harm from fire, smoke and other products of combustion. The fact that a cover was missing from an electrical junction box does not constitute a “potential for harm from fire”. None of the electrical wires or their connections were bare or in any way capable of producing sparks which could lead to a fire situation. All of the wires were properly coated with insulation, and their connections were properly terminated with secure wiring methods. There was no potential for harm due to electrical shock.

All of the junction boxes identified by the surveyor are located above the ceiling and away from any contact with patients, staff and visitors. The wires were neatly tucked into the box and were not protruding out beyond the limitation of the electrical box, which could potentially cause a problem. In his finding the surveyor did not identify a “potential for harm from fire, smoke, and other products of combustion”. It is the position of XYZ Hospital that there was no “potential for harm from fire, smoke or other products of combustion” in regards to the electrical junction boxes observed by the surveyor at the time of the survey. Therefore, XYZ Hospital respectfully requests that The Joint Commission vacate this finding under EC.02.03.01, EP 1, and consider this standard to be ‘Compliant’.

 

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Result?  Clarification was not accepted. [Sometimes you just have to take your shot and hope.]

Keep track of the results with me: Accepted 0: Not Accepted 1

 

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