August 19, 2010 | | Comments 1
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The song remains the same – will it ever stop?

In the August 18, 2010 edition of Joint Commission Online (if you don’t subscribe already, click here to see the whole wretched mess), The Joint Commission lists requirements that were most frequently identified as “not compliant” in each healthcare setting, and if there is any surprise at all, it’s that EC/LS didn’t manage to sweep the top compliance headaches among hospitals (maintenance of complete and accurate medical records for patients took the #1 spot).

One particularly disheartening piece of information is that we (and I mean that in the most inclusive sense possible) haven’t quite gotten our arms around the documentation requirements for EC.02.03.05. Unfortunately, there’s no way to know at this point whether there is a particular EP(s) that is causing this breakdown or whether it is indeed spread over the continuum. (If anyone out there was cited under this standard during 2010, please share your story about what got you into hot water during survey).

I personally don’t like being able to pinpoint the vulnerabilities on this one. Is it something as simple as that ever-funky question of whether or not you need to have an inventory, by location, of your fire alarm devices? Or is it something else – a couple of missed monthly fire extinguisher checks perhaps? Inquiring minds want to know.

For the other three  in the top five (this is for hospitals, by the way – EC/LS made it a clean sweep in the critical access hospital category) we have:

  • LS.02.01.20 (#2) – Integrity of egress (will there ever be the day when we don’t have “stuff” in the corridors?)
  • LS.02.01.10 (#3) – Building and fire protection features designed to minimize the effects of fire, smoke & heat (most likely fire wall penetrations)
  • LS.02.01.30 (#5) – Building features (I’m gonna guess we’re looking at a combo of penetrations in smoke barriers and issues with hazardous areas on this one)

I don’t think these will ever go away, particularly as the survey team only needs to find two instances of non-compliance to generate an Requirement for Improvement (RFI), until we can successfully integrate the ongoing (and I’m talking a certain level of constancy here folks) management of the Statement of Conditions process (including the work order process as the “front end” of the process), and proactively identify LSC deficiencies. (Just between you and me, we know they’re out there. Even as we speak those adorable creatures that I fondly refer to as the cable monkeys are taking screwdrivers out of their pockets and jabbing your walls for another data drop – if you listen closely, you can hear them scurrying overhead…)

For all intents and purposes, penetrations are a fact of life in hospitals. In my opinion, there will never be a moment in the history of your building when you are completely penetration-free; it’s just not going to happen – trust me on this.

But, in that recognition we can start to manage the processes that will result in those penetrations. Do you have an above-the-ceiling permitting process? No – well maybe it’s time to look at it. Then you can use the permit to identify cable runs, get the follow up work in queue through your work order system, and maybe just maybe, we can make it tough for the surveyors to find penetrations that are not in the process (by TJC rules, if there’s a work order or if we’re managing it through the Plan for Improvement (PFI) process, we are in compliance with the standard).

You may have noticed that I’ve somewhat skirted the issue of #2, integrity of egress – I think we’ll save that for another day. But if someone has some cool stuff to share on that count, I’m all ears (actually, I’m mostly torso, but all the same…).

Entry Information

Filed Under: Environment of careLife Safety Code

Steve MacArthur About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Briefings on Hospital Safety. Contact Steve at

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  1. Steve,

    With your comment regarding LS.02.02.10 one of the issues I have encountered on a number of occassions, especially in older buildings, is the sprinkler systems installed under older building codes are in the hallways only. Whether or not it was the original design or if rooms/offices have been created after the fact through the renovation process I am not sure. Also, many of these rooms are used as storage, with no/inadequate fire suppression. My firse encounter with this was while responding to a stench eminating from a “storage room” that had file boxes stacked floor to ceiling,I uncovered a bathtub, sink, and toilet. Of course the traps had long dried out and of course the stench was sewer gas. It surprised me then that the sprinkler system was only in the hallways, however, I have come across it a number of times since.

    Keep on writing. I enjoy your articles and your sense of humor.

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