Try these two ideas to avoid life safety pitfalls during surveys

Hospital Safety Insider, December 2, 2009

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Compliance with The Joint Commission’s life safety and related EC standards often centers on code distinctions.
With that in mind, consider the following compliance tips culled from HCPro’s “Life Safety Code Solutions for Hospitals” seminar, which took place in September in Boston:
  • 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.
For seven more tips about life safety compliance, including thoughts about eliminating smoke barrier walls and who not to show your Joint Commission plans for improvement to, check out the December 2009 issue of Healthcare Life Safety Compliance, the only monthly resource exclusively dedicated to fire protection in healthcare facilities.

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