Every surveyor has his/her own specialty that they like to look for during a survey. I know of one surveyor that writes up every hospital he surveys if the fire alarm panel is not marked with the electrical panel number and circuit that feeds the power to the fire alarm system. It’s a requirement, but he’s the only surveyor that I know who is writing it.
Another surveyor that I know is very astute on construction type to the point where he wrote up a hospital for having combustible siding on the exterior of the building. The hospital was 20 years old and the plywood siding was original. They were upset because for two decades the siding was never an issue, then all of a sudden ‘Boom’; it’s a problem. The hospital contacted the architect who originally designed the hospital, and he wrote a thundering letter of protest. That one I checked with NFPA and it turns out the surveyor was correct. The hospital will have to remove the combustible siding or submit an equivalency or a waiver request.
When I surveyed for The Joint Commission, I remember paying special attention to how fire dampers were installed at the hospitals I surveyed. I did this because the hospital where I worked got cited for improperly installed fire dampers by the state agency conducting a validation survey on behalf of CMS. I learned the hard way on the proper method of installing fire dampers, and used that newly gained knowledge when I surveyed.
Which leads me to the issue concerning tamper resistant electrical outlets. I don’t think you will see any specific standard in a Joint Commission, HFAP or DNV, manual (or in a CMS CoP for that matter) on tamper resistant electrical outlets, but this issue is being observed on more and more survey reports. Apparently, some surveyors have a strong background in the National Electric Code (NFPA 70) and uses that knowledge during surveys.
If you are not already doing so, please be checking the electrical receptacles in pediatric areas to be sure they are the tamper resistant type. Section 19.5.1 of the 2000 Life Safety Code requires compliance with section 9.1, and section 9.1.2 requires compliance with NFPA 70 National Electric Code (1999 edition). Article 517-18(c) of NFPA 70 says the receptacles rated for 15 or 20 amps, 125 volts, intended to supply patient care areas of pediatric wards, rooms, or areas in healthcare facilities, shall be listed tamper resistant or shall employ a listed tamper resistant cover.
The areas where tamper resistant receptacles are required are areas where children are likely to found; which include areas outside of a pediatric unit such as the cafeteria, main lobby, waiting rooms, and play areas. The tamper resistant receptacles would not be required in adult patient rooms, corridors, physician consultation rooms, etc., as these areas, even if children are present, would have supervising adults present.
It is not wrong, or unethical for a surveyor to cite an organization on an issue just because he/she has special knowledge about that issue. After all; the hospital is required to comply with that issue, right? What’s frustrating is there usually is no warning that some surveyors are looking for a particular issue and it surprises facility managers when it happens. No one likes those kinds of surprises.