March 30, 2011 | | Comments 1
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Mac’s Safety Space: A visit to the infusion center

Q: Our Chief Operating Officer (COO) is concerned that The Joint Commission may go to our infusion center. We understand that the life safety surveyor will focus his survey on healthcare occupancies, in our case the main hospital and ambulatory surgery center. Should we be concerned that the survey will include a visit to the infusion center?

Steve MacArthur: Generally speaking (and this would need to be validated, though I’m pretty sure), if the infusion center is not designated as a healthcare occupancy, then the Life Safety Code (LSC) surveyor will not need to visit that location. If we have designated it as ambulatory healthcare (sometimes this is something the state would determine), then it is likely that they will, considering they’ll have two days to fill.

I would check on the e-Statement of Conditions to see how we’ve identified the occupancy type and if it’s a business occupancy (and I suspect that it is), then the LSC surveyor will in all likelihood confine themselves to the main hospital and the Ambulatory Surgical Center. That said, it is also more than likely that at least one member of the survey team will pay a visit to that location, so we want to make sure that we’re appropriately managing general safety stuff, as well as the basics of life safety—no corridor obstructions, fire extinguisher checks in order, nothing stored in front of fire extinguishers, fire alarm pull stations, etc.

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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. Considering the recent letter from CMS “clarifying” what constitutes a healthcare facility, I wonder if that clarification will result in the need to re-visit the above response?

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