Clarifications Part 1

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.


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.


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’.



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