Clarifications Part 6

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


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.


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 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’.


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.