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Clarifying mis-scored life safety citations can give your survey a second chance
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August 1, 2010
When a Joint Commission surveyor visits your hospital to check for Life Safety Code® (LSC) compliance, he or she is there to determine how you measure up to 13 standards and 153 elements of performance (EP).
In most cases, not only does the surveyor have just one day to do that job, but in reality, he or she has only about six hours, said Brad Keyes, CHSP, a life safety consultant at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA, and a former Joint Commission LSC surveyor.
The surveyor never gets to review all 153 EPs but picks the ones that are most commonly cited to focus on first, said Keyes, a speaker at the 4th Annual Hospital Safety Center Symposium May 6 in Las Vegas.
Given the tight time frame, mistakes do happen, and it’s important that hospitals are prepared to clarify any “mis-scored” citations, Keyes said.
“You would be surprised how many are clarifiable,” he said, meaning organizations can present evidence to The Joint Commission post-survey to overturn citations.
A high-focus area
The LSC surveyor judges compliance with 10 of the standards in the Life Safety (LS) chapter of the Comprehensive Accreditation Manual for Hospitals, as well as three EC standards, Keyes said.
LS and EC are a high-priority focus area with surveyors and hospitals, Keyes said. In fact, three of the top five problematic standards in hospital surveys in 2009 were from the LS and EC chapters (see related story on p. 1).
Two LS standards are critically important because failure to comply with those requirements could lead to automatic conditional accreditation, Keyes said. So be sure to focus on the following:
- LS.01.01.01 requires hospitals to manage the physical environment to comply with the LSC. EP 3 mandates that the projected completion date on the hospital’s plan for improvement is no more than six months past due.
- LS.01.02.01 requires hospitals to protect occupants when the LSC is not met or during periods of construction. Under EP 3, surveyors can cite a facility for failure to have an interim life safety measures policy for an ongoing life safety deficiency.
Eight of the LS standards and the three EC standards included in the LSC survey are direct impact standards, which carry more weight in your survey.
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