Clarifications Part 2

I continue my series on clarifications of surveyor findings that I recently wrote for a client:


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.


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’.


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