Editor’s note: This is the second in a series of articles about how to stay prepared for a Joint Commission life safety survey. It is authored by Brad Keyes, CHSP, safety consultant at The Greeley Company, a division of HCPro, Inc., in Marblehead, MA, and a former life safety specialist for The Joint Commission.
In the last issue, I discussed building tours conducted by Joint Commission life safety specialists. I have a few further highlights from the building tour to pass along.
Corridor clutter is always on the radar for surveyors. Gone is the old myth that you are allowed to leave unattended items in the corridor as long as they are pushed to one side of the hall and they are on wheels. Any unattended item left in the corridor longer than 30 minutes is a violation of the Life Safety Code® (LSC).
The exceptions to this rule are crash carts, as they are considered in use at all times, and isolation supply carts for patients who are actively on isolation precautions. Life safety specialists may actually make mental notes of the time at which they see items left unattended in the corridor, and they will circle back within 30 minutes to see whether the items are still there.
Corridor doors are easy items for a surveyor to inspect because there are so many of them. Doors that open onto an exit access corridor must be able to close and latch (for existing construction, they can be held closed by a device with a minimum of 5 pounds-force). Corridor doors cannot be wedged or propped open.
Tour doesn’t have to be floor by floor
The building tour may not encompass every floor and unit of your hospital. Surveyors may choose random units to inspect as representative of your facility.
They may stop and interview staff members along the way to determine how well trained they are in the hospital’s fire response plan. They may talk to nurses, housekeepers, physicians, students, maintenance technicians, and even contractors.
All staff members must be able to recite the hospital’s plan in case they discover a fire. The plan is typically the RACE acronym (rescue, alarm, confine, and extinguish/evacuate).
When the tour hits the lower floors, life safety specialists will want to inspect rooms that house the generator, fire pump, fire alarm panel, medical gas manifold, and materials storage.
They will look for proper clearances below sprinkler heads, unsealed penetrations in fire-rated walls, and proper ventilation in the manifold room, and they will inspect all doors for proper hardware operation.
Specialists will also visit the kitchen to examine the fire suppression system in the exhaust hoods, along with the food service dry goods storage room.
A hit list of frequent deficiencies
Additionally, life safety specialists commonly watch for the following problems:
- Obstructed electrical panels and medical gas shut-off valves
- Inappropriate construction types for the number of stories in the hospital
- Locked doors in the path of egress that do not comply with LSC provisions
- Poor enforcement of the facility’s no-smoking policy
- Smoke detectors mounted too close to air diffusers
- Areas open to a corridor that don’t have appropriate supervision or smoke detectors
- Unlabeled electric circuits in panels
- Damaged walls or missing ceiling tiles in clean or sterile areas
- Excessive travel distances to exits
- Suites that are too large
- Poor illumination and marking of means of egress