April 06, 2011 | | Comments 0
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Mac’s Safety Space: Greetings From the Survey Zone…

A few items have been popping up in surveys over the last couple of weeks; two require a homework assignment for you, the other I offer as general information. So here goes:

LS.01.02.01 – I thought this one would have gone away forever, but it would seem that there have been a few folks who have lost sight of a very important aspect of the Interim Life Safety Standards and that is the practical application of the risk assessment to determine whether or not the LSC deficiencies you are managing as plan for improvements (PFI’s) (and that’s anything that you are measuring as a PFI) require implementation of any Interim Life Safety Measures (ILSM). Now, every once in a while I get some pushback from folks because this requirement is not necessarily the most explicit in the world; a point with which I do not totally disagree. The key concept here is the phrase “covers situations when Life Safety Code deficiencies cannot be immediately corrected.” I think you’ll agree with me that anything you are managing as a PFI is a deficiency that cannot be immediately corrected, and the surveyors recognize this very clearly. So, homework assignment #1: make sure you have an ILSM assessment for your PFI’s. Pretty simple, so done, done, and on to the next one…

LS.02.01.20 EP #1 – Doors are unlocked in the direction of egress. Now I’m sure you’re all up to snuff on delayed egress doors and the like, but this one is a little, if you’ll excuse the use of the term, funky. Every once in a while, there are exterior doors (and even more rare, interior doors) that have dead bolt locking mechanisms on them. I’ve seen ‘em, you’ve seen ‘em, they are definitely out there. However, if you have dead bolt locking mechanisms on any of the doors in any of your egress paths, you need to make sure that the breakaway features of those doors will still work if the deadbolt is engaged. While this is valuable from a survey standpoint, it makes a great deal of sense to ensure folks can get out in an emergency—and some dead bolt locking arrangements will prevent folks from doing that. So, homework assignment #2: go check all your perimeter doors (and keep an eye out on the interior egress route doors, you don’t want to lock folks in there either).

The information you may very well have figured out—there are more survey days for the LSC surveyors, so they have more time to find stuff and they are finding more stuff. They have more time to look at documents, more time to find penetrations, more time to find corridor clutter, more time to find doors that don’t close and latch, more time to ask to see the ILSM assessments for your PFIs. I do know of at least one survey in which the LSC surveyor arrived a week or so after the rest of the survey team; I don’t know if we should consider that an anomaly or if there are already some scheduling challenges in the mix. Much too early to tell. But if I hear anything more on that point, I’ll be sure to share.

Ok – now get to that homework!

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Filed Under: Life 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 stevemacsafetyspace@gmail.com.

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