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Survey monitor: Surveyors zoom in on testing and a locked egress door

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November 1, 2009

It had been nearly four years since A.O. Fox Hospital’s last Joint Commission visit when surveyors arrived unannounced on August 10 at the facility in Oneonta, NY. The hospital had been expecting The Joint Commission for almost one year.

The later-than-expected survey didn’t faze Carrie Post, RN, BSN, director of employee health and emergency management coordinator at Fox Hospital. Post had established a plan to not only watch the hospital’s Joint Commission extranet site like a hawk—the setup caught the advance warning—but also to strive toward continual compliance.

“We have a Joint Commission team. We meet monthly,” Post says. “I don’t think we did anything special. We were ready.”

After the person assigned to watch the extranet site confirmed it was survey day in the morning, word was sent throughout the facility via an announcement over the public address system: “Fox Hospital welcomes The Joint Commission.”

The physician and nurse surveyors stayed for five days, and the life safety specialist joined them for one day. That was a change from the hospital’s previous experience of three-day surveys.

Glucometer failure receives attention

The life safety surveyor was thorough, but the EC review was a short 90 minutes; more than an hour of it was spent discussing a malfunctioning glucometer uncovered in a tracer, Post says. One potential standard this problem could fall under is EC.02.04.01, element of performance (EP) 6, which requires hospitals to have written procedures dealing with medical equipment failures.

“No one in the EC session was aware of the glucometer issue,” Post says. “[Glucometers] are taken care of by the lab, and it was never reported to safety.”

So the discussion revolved around Fox’s reporting procedures and how that process would be updated to fill the discovered hole in the communication chain.

Surveyors want records of air-handler tests

Although nothing that cropped up in the life safety and EC reviews surprised Post, it was interesting that conditions that had passed in previous surveys became compliance issues this time around, she says. Two such issues included:

  • A lack of a Type K fire extinguisher within 30 ft. of the cafeteria grill. “It was more like 40 ft., and it’s been that way for 40 years,” she says.
  • The reporting of air-handler checks for fire safety. Surveyors wanted written confirmation that the air-handling system was working. However,he vendor the hospital hires to do the checks reports by exception—meaning, it’s noted on the report when an air handler fails to properly shut down during smoke-detector tests, not when the devices operate properly. That problem ended up as a finding for the hospital under EC.02.03.05, EP 19.

During its clarification period, Fox is working with The Joint Commission and the testing contractor to amend its previous reports, as well as to revise its reporting procedures to provide confirmations of air-handler shutdowns in future reports.

Generally, surveyors have been closely checking fire protection equipment records, as related problems constituted one of the top citations in 2008.

Locked door becomes prickly

Another finding involved a locked door in an egress route under LS.02.01.20, EP 1. Currently, the space in question is used by biomedical staff members; the lock was left from its previous incarnation as a behavioral healthcare space.

The door is one of three exits out of the area. The other two are not locked, and both employees who work in the space have keys to the locked door.

However, surveyors determined that the door was locked against egress.

The hospital is attempting to clarify the finding with The Joint Commission, citing an exception in the Life Safety Code® (LSC) that permits a locked door when a space has two employees or less working in it and they have keys.

Note that editors for HCPro could not find a provision in the LSC that would allow key-operated locks as described above, although it is possible the hospital is interpreting a section of the LSC to allow this setup or a state regulation permits the arrangement.

Surveyors issued other citations for the following:

  • Unprotected barrier penetrations, possibly under LS.02.01.30, EP 6
  • Gaps larger than 1/8 inch between fire doors, possibly under LS.02.01.10, EP 5
  • Lack of self- or automatic-closing devices on two storage room doors, likely under LS.02.01.30, EP 2

Emergency management centers on the flu

The emergency management session of the survey only lasted roughly 10 minutes, says Post. The physician surveyor asked how the hospital would react if the local public health department reported there were 30 students out of school with flu-like symptoms.

The hospital would consider that report to be the notification phase of an emergency, Post told surveyors. After that, the surveyor and hospital staff members continued talking for several more minutes about the flu situation, and they moved on to the next part of the survey without discussing the hospital’s 96-hour plan or conducting a tabletop exercise.

“He had seen we had done a 96-hour exercise last November, and he said, ‘Very impressive,’ and that was it,” Post says.

For hospitals with surveys on the horizon

Although Post says her coworkers felt confident on the whole about their survey readiness, if she had one piece of advice to offer the next group of hospitals in line for a survey, it would be this: Recheck what you’ve already checked.

“You do have to go back and check everything you thought was taken care of,” Post says. “We thought that we were okay with all our penetrations. We thought we’d looked at them all. But what happens is that people come behind you and drill more holes.”

Survey at a glance

  • Emergency management highlights: A short session focused on what the hospital would do if it received notice of a spike in flu cases within the community.
  • Life safety highlights: The life safety specialist scrutinized fire protection equipment inspections and maintenance, in particular looking at air handlers. Requirements for locked doors were also a focus.
  • Standards focused on: EC.02.03.05 (inspection, testing, and maintenance of fire protection equipment), EC.02.04.01 (medical equipment risks), LS.02.01.20 (means of egress), and LS.02.01.30 (building features to protect occupants from fire hazards).



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