Clarifications Part 3

I continue my series on clarifications of surveyor findings that I have written for a client.


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.


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’.


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