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Greeley Reflections

Accreditation Connection, November 16, 2009

Gray matters: Red alert

Part 1 of 5

I will freely admit that things are a little calmer this year on the survey front, at least in terms of survey jeopardy (Preliminary Denial/Conditional Accreditation), but even though the 2010 survey year appears not to represent an increased risk in Environment of Care, there are still two areas (located in the Life Safety chapter) that can run you afoul of those most very adverse accreditation decisions:

• the management of Life Safety Code® (LSC) deficiencies through the Statement of Conditions/Plan For Improvement (SOC/PFI) process
• the management of Interim Life Safety Measures, which are actions that one would take to ensure that an appropriate level of life safety is maintained during various activities like construction and renovation projects

And when you have LSC deficiencies of significant risk/impact or are going to take a while to correct. The most “prominent” application of the latter circumstance is when an organization chooses to manage an LSC issue through the aforementioned SOC/PFI process (see how these two wrap themselves neatly around each other?).

Each of these areas minimally contains the potential for a finding of Conditional Accreditation, and if the deficiency is considered egregious enough, maybe Preliminary Denial. Scary stuff? You bet! But you can do something to avoid such a fate. So huddle up and we’ll talk you through some basic questions to ask.

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