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Clarifying mis-scored life safety citations can give your survey a second chance


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.


Noncompliance can derail your survey

Depending on the number of surveyor days, failure to comply with a certain number of direct impact standards will result in a review by the Joint Commission central office, which could lead to various decisions for your survey, including an adverse accreditation decision, Keyes said. 

With 11 direct impact standards that can lead to a requirement for improvement (RFI), there is a lot of potential in the LSC survey to trigger a review. The Joint Commission dropped the original thresholds for RFIs to trigger an automatic conditional accreditation decision or preliminary denial of accreditation. As of January 2009, the accreditor now uses so-called bands and screens based on surveyor days.

“While The Joint Commission prefers to call this decision process ‘bands and screens,’ it sure looks like floating thresholds to me,” Keyes said.


You can fight surveyor perception

Joint Commission surveyors will cite you when they believe your hospital has not complied with a particular standard. 

“It’s their observation, their perception,” Keyes said. That opinion is usually based on surveyors observing your staff members or reviewing your documents. Although their opinion may be factual and true, that does not necessarily mean you cannot clarify the finding, he explained.

There are many reasons why a surveyor can cite a particular standard for noncompliance, including the following:

  • Visual observation of staff not complying with your own policies
  • Lack of written evidence, which may indicate noncompliance with an EP
  • One or more findings for an “A” category EP
  • Two or more findings for a “C” category EP 

It’s important to consider each citation in the following ways to determine if you can clarify the finding and  overturn the citation.

• Do the math. For instance, if a surveyor cites you for noncompliance on an EP with a “C” designation (two or more findings), you need to do the math. If you comply with at least 90% of the EP’s sample size, even with the findings, you can clarify it as being compliant, Keyes explained.

For example, EC.02.03.05, EP 6 (a C category) requires hospitals to test the fire pump each week under no-flow conditions. This means for each week, you would need to conduct 52 tests in a 12-month period. If you missed two weeks, that means two findings, and the surveyor will cite you for noncompliance.

However, for the 50 tests you actually conducted, divide that by the 52 tests required, and you have a 96% completion rate. The evidence of survey compliance (ESC) process allows 90%–100% compliance for a score of satisfactory compliance, Keyes said.

In this example of weekly fire pump testing, a hospital could miss up to five weeks and still be in compliance with this EP, Keyes noted. But the surveyor is required to cite you for noncompliance when two or more findings are observed.

Therefore, a written clarification after the survey as part of your ESC explaining your position will result in removal of the RFI.

• Check to see whether written documentation is required. The Joint Commission indicates when documentation is required with a letter “D” next to the standard in the Comprehensive Accreditation Manual for Hospitals.

Take, for example, LS.01.01.01, EP 1 (an A category), which requires the hospital to assign an individual to assess compliance with the LSC and complete the electronic Statement of Conditions. This is usually accomplished by the hospital in a letter, memo, or management plan.

A surveyor can cite a hospital if there is no written evidence that the facility assigned an individual to this role. However, a hospital could make the clarification that the assignment for this role was accomplished verbally, since there is no requirement for written documentation.

• Watch for citations under the wrong EP. LS.02.01.10, EP 5, requires fire-rated doors to have functioning hardware, including positive latching devices and self-closing or automatic-closing devices. Keyes cited an example in which the surveyor’s actual finding states, “The entrance door to the third floor soiled utility room does not have a self-closing device.” 

The standards require hospitals to designate soiled utility rooms as hazardous rooms. All hazardous rooms must have self-closing doors. However, if the soiled utility room is in an existing occupancy, there is no requirement for the entrance door to be fire-rated.

The surveyor was correct that the soiled utility room failed to have a self-closing device; however, he or she wrote the finding under the wrong EP and standard. The surveyor should have written the finding under LS.02.01.03, EP 2.

The solution for the hospital is to submit a written clarification through the ESC process stating that its fire doors did actually comply with self-closing devices and the surveyor incorrectly identified the third floor soiled utility room entrance as a fire door, Keyes said. 

Be careful how you word your clarifications. You don’t want to state the obvious—that the third floor soiled utility room door did not have a closure, he added.


Reasons for the mistakes

Why do surveyors write their findings incorrectly? Time is of the essence, and surveyors can find themselves under the gun, Keyes said. LSC surveyors are usually on-site for only one day and need to enter their findings into the computer before leaving the hospital at the end of the day. Pressure leads to mistakes.

This is especially true for new LSC surveyors, who at times make mistakes due to inexperience, Keyes said. For instance, in a hurry to enter their findings, surveyors who are not as familiar with the standards can cite the wrong EP under a standard.

Although hospital officials may feel that surveyors operate under a quota and must increase the number of findings, Keyes said this is not true. The Joint Commission does track surveyors and their findings. If someone is an ineffective surveyor, the accreditor will hold him or her accountable. However, The Joint Commission does not require surveyors to find a certain number of citations. Keyes said he averaged about five citations per survey when he worked as a surveyor.

And with all those standards and EPs, mistakes do happen, he said.


Steps to take when a surveyor makes a mistake

Joint Commission surveyors are human, and they do make mistakes. So the important question for hospitals is: What do you do when you think a surveyor cites you incorrectly?

First, try to clarify the citation before your survey is over, said Brad Keyes, CHCP, a life safety consultant at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA, and a former Joint Commission Life Safety Code® surveyor. Take the following steps:

  • Discuss the issue with the surveyor—but be sure to do so respectfully, Keyes said. Don’t be argumentative. 
  • Provide documentation, such as code references, to support your position.
  • If a surveyor will not change his or her opinion, ask to discuss the situation with the survey team leader. Continue to provide supporting documentation.
  • Ask to have a conference call with The Joint Commission’s Standards Interpretation Group. Again, continue to provide documentation that supports your position.


There are times, however, when you cannot change a surveyor’s opinion when it comes to compliance with a particular standard and element of performance (EP), Keyes said. If the citation makes it to the final survey report, you may want to consider submitting a clarification. Seven to 10 days after the end of your survey, your final report will appear on the extranet site.


What you need to know about clarifications

An organization has the opportunity to submit clarifying evidence of survey compliance (ESC) if it believes the facility was in compliance with a particular standard at the time of the survey. The clarification is part of the ESC process, and hospitals must submit this within 10 days following the posting of the official survey report on the extranet site. If you anticipate submitting a clarification, begin preparing your paperwork immediately after your survey is over so you can meet that deadline, Keyes said.

Remember, the submission of a clarification does not negate the requirement for submission of a corrective ESC within 45 days if the citation is for a direct impact standard or 60 days if the citation is for an indirect impact standard, Keyes said.

 A clarification does not provide the organization with additional time to submit an ESC. Therefore, a hospital still needs to submit a corrective ESC within 45 or 60 days unless The Joint Commission accepts the clarification and removes the requirement for improvement (RFI), Keyes said.

The written clarification must explain why you believe your organization was in compliance at the time of the survey. Address the EP and the surveyor’s actual finding. For those EPs that are designated as a “C,” you must submit an audit (not evidence) that addresses the sample sizes prior to the start of the survey. Include all information regarding how you determined the sample size, how you randomized it, who conducted the audit, and the date range of the audit. 

The written formation should follow a specific format and include the following:

  • Who: Title of the person who approved the action, policy, or procedure
  • What: A description of the action taken
  • When: Date when you completed each action
  • How: A description of how you implemented the process
  • Why: An explanation of why you did not review this information during the survey 


The Joint Commission wants you to submit clarifications if you believe you were in compliance with the standards during the time of the survey, Keyes said. Why should an organization accept an RFI if it believes it was in compliance? 

Keep the following points in mind:

  • If the EP has an “M” designation, a written measure of success is required, which includes a quantifiable measure, such as an audit, that proves you are back in compliance. 
  • If The Joint Commission accepts a clarification, it may conduct a follow-up survey to examine the evidence of clarification. “The Joint Commission reserves the right to come back,” Keyes said. Make sure you have the evidence to back up your clarifications.
  • Always take a second look at the official survey report with an eye for clarification. “This is very critical,” Keyes said. In fact, you may want to have someone outside the organization, such as a consultant, look at the report as well, with an eye toward mis-scored citations.


The Joint Commission does not accept all clarifications. Even though you think you have documentation to overturn a citation, you may not always be successful, Keyes said.

Will The Joint Commission explain why it does not accept your clarification? “If you ask them, yes,” said Joseph L. Cappiello, MA, BSN, chair of Cappiello & Associates in Elmhurst, IL, and the former vice president for accreditation field operations at The Joint Commission.

You can call The Joint Commission’s Standards Interpretation Group and ask them the reason. “Make sure you have a clear read on why they didn’t accept it. Further discussion may allow you to get it explained away,” Cappiello added.

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