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Survey monitor: Emergency management de-emphasized in Texas survey

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December 1, 2009

The Joint Commission’s survey at East Texas Medical Center (ETMC) in Tyler continued what appears to be a trend, anecdotally at least, of little interest in emergency management tabletop exercises.

The five-day survey began August 17 at the 49-bed rehabilitation hospital. Surveyors gave a few minutes’ discussion about emergency management, but no tabletop disaster drill occurred despite the hospital’s anticipation of an exercise, says William Deitenbeck, director of plant services.

“That’s what we were expecting,” Deitenbeck says. “But we didn’t try to push it and ask for a tabletop or anything.”

In our past two “Survey monitors,” safety and quality professionals have also noted a lack of tabletop drills during their Joint Commission visits.

Magnetic lock tests bring a citation

The life safety specialist came on the first day of the survey and handed down three indirect findings:

  • Although magnetic locks on egress doors had been tested by the hospital alarm vendor, there was no inventory of the mag locks. The alarm company stated that it had tested “all,” but without an inventory, the life safety specialist felt the hospital could not ensure that the alarm company had checked all the locks on egress doors. Generally, this problem can be cited under leadership standard LD.04.01.05, element of performance (EP) 4 (see “Keep your vendor maintenance logs on-site for surveyors” below for more details).
  • The specialist also found four unprotected penetrations in fire barrier walls bordering a gymnasium, which Deitenbeck and his colleagues didn’t think were fire walls. Three of the penetrations were due to holes from cable runs. This was likely cited under LS.02.01.10, EP 9, which requires cables and other penetrating items to be sealed with an approved fire-rated material.
  • At a clinic in a separate building covered under the hospital’s license, a fire extinguisher fell out when the surveyor opened the door to its housing. The citation may have come from EC.02.03.05, EP 15, which requires monthly checks of extinguishers.

On a related note, ETMC has addressed recent reports of fire damper testing scrutiny through the following actions:

  • Documenting damper inspections by having the inspection company representative sign and date reports
  • Attaching repair tickets to the report to demonstrate how and when the hospital acted upon a report of a faulty damper

E-SOC credentials questioned

Surveyors determined that the facility lacked a written document assigning an individual to maintain the electronic Statement of Conditions (SOC) under LS.01.01.01, EP 1. The hospital addressed the issue quickly, creating a memo assigning that job during lunch and getting it signed by the CEO.

This is a somewhat controversial aspect of the e-SOC, as there is no mandate to have such paperwork. In fact, the EP in question isn’t even marked with a D icon to formally indicate documentation is required. The surveyor at ETMC was aware there was no D icon, too.

All that said, it is unwise to assign someone responsibility for the e-SOC without documentation noting this duty to hospital leaders and outlining the individual’s credentials, says Peter Leszczak, Network 3 fire protection engineer at the U.S. Department of Veterans Affairs in West Haven, CT.

“How do you prove someone is qualified if they don’t have any documentation?” Leszczak tells our sister publication, Healthcare Life Safety Compliance.

Surveyor asks for alarm company monitoring

In other life safety tidbits, one of the surveyors suggested that, on occasion, the hospital should notify the fire department—not the alarm company—about its fire drills. Then, after setting off an alarm, the hospital should log how long it takes the alarm company to notify the fire department.

The inspection of door self-closing and latching features caught Deitenbeck’s eye. The life safety specialist would open a door a little, let go, and if the door didn’t latch upon closing, he’d do it again, opening it wider. If it didn’t latch the second time, he’d give it a third try, opening it much wider.

“He gave us the benefit of the doubt,” Deitenbeck says. “That was interesting.”

Also, surveyors were pleased with ETMC’s organization of its documents, such as fire and generator testing, which were referenced by the EP under which they fell, Deitenbeck says.

BMP yields positive results

Although The Joint Commission ended any scoring benefits for hospitals participating in the optional building maintenance program (BMP) at the start of 2009, some hospitals continue to use it, including ETMC.

That dedication paid off with this visit because surveyors found few problems related to common Life Safety Code® deficiencies addressed in the BMP, Deitenbeck says.

One note he passes along to fellow facilities folks at hospitals coming up for a survey: In a recent state association meeting, Joint Commission senior engineer George Mills, FASHE, CHFM, CEM, emphasized that surveyors would take a zero-tolerance stance on cables run along fire sprinkler pipes.

In ETMC’s 60-year-old main hospital building, which wasn’t surveyed this time out, there are bundles of cables running off sprinkler pipes, Deitenbeck says.

In a Joint Commission response to a query from him about the matter, Deitenbeck was advised to put the deficiency on a plan for improvement (PFI) with a six-year time frame. The problem didn’t come up in the rehab hospital survey that’s the subject of this article, although some cables do run along sprinkler pipes there, too.

He also passes on a final procedural hint: ETMC conducts an interim life safety measure assessment for every PFI entered into the e-SOC.

Keep your vendor maintenance logs on-site for surveyors

The Joint Commission’s life safety specialist may apply leadership standards to fire protection deficiencies in certain cases.

For example, LD.04.01.05, element of performance 4, requires hospital leaders to hold their staff members accountable for their responsibilities. This provision can be invoked if a surveyor requests fire protection inspection documentation and the paperwork is not immediately available, but instead arrives late from an off-site vendor, George Mills, FASHE, CHFM, CEM, senior engineer at The Joint Commission, said during the American Society for Healthcare Engineering’s annual conference in Anaheim, CA, in August.

Letting a vendor hold on to your maintenance logs for weeks at a time is not a good practice and probably isn’t a solid career move either, Mills said.

When surveyors cite this problem, “You’re going to have to explain to your boss why you think it’s okay to [not have the logs] for six or eight weeks,” Mills said. “Good luck.”

Survey at a glance

  • Emergency management highlights: Surveyors only conducted a short emergency management review and did not request a tabletop drill.
  • Life safety highlights: Surveyors looked at fire protection requirements for doors, scrutinized barrier penetrations, and requested documentation proving a qualified person was completing the electronic Statement of Conditions (SOC).
  • Standards focused on: EC.02.03.05 (inspection, testing, and maintenance of fire protection equipment), LS.01.01.01 (Life Safety Code® and e-SOC compliance), and LS.02.01.10 (building and fire protection features).



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