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Try these two ideas to avoid life safety pitfalls during surveys

Hospital Safety Connection, December 2, 2009

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• Verify that employees obey policy nuances. Review your life safety policies’ details and make sure your staff members actually do what a given policy states, said Brad Keyes, CHSP, life safety consultant for The Greeley Company, a division of HCPro, Inc., in Marblehead, MA. A discrepancy between a policy and employee actions is one of the easiest citations to slip into. In some situations, policy wording can override standard requirements. For example, even though The Joint Commission requires quarterly fire drills on all shifts under EC.02.03.03, if your policy states you conduct monthly fire drills, surveyors will hold you to the more frequent schedule.
• Keep ongoing documentation of your building’s current condition. This is an important aspect should a surveyor ever cite you for noncompliance on an item, and you attempt to show a track record of past actions, Keyes said. For example, if a surveyor issues a finding for door latching problems under LS.02.01.30, prior documentation that shows a maintenance program for monitoring fire door latching may help you challenge the citation, he added. Documentation that shows you corrected latching problems after a survey will not be as useful during any citation clarification process.

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