There’s one in every crowd…

I suspect that this is going to be a rather brief entry (but, if I’m honest, I usually think that and then…) as it is (yet another!) entry in the “the goal of the survey process is to generate as many findings as possible” series.

In recognition that the amount of truly useful information that shows up in the monthly issues of Perspectives can be somewhat varied, the February 2022 edition does have a couple of items worth a look-see. First up is the Consistent Interpretations column, which, in this case deals exclusively with the management of ceiling tiles (damaged, missing, stained, etc.) as a function of the physical environment requirements that do not specifically relate to Life Safety.

I guess the only thing that I found puzzling was that the non-compliance rate for the indicated standard/performance element combination was only 60% in 2020. I can’t think of the last time I couldn’t find a damaged, stained, or missing ceiling tile, unless it was a fairly new facility or a fairly small facility. Much as is the case with sprinkler heads, circuit breakers, etc., if your place is “big enough,” it is almost impossible not to find an instance of non-compliance. I’m still not even sure if you could produce a work order for the condition—to indicate that the issue was being addressed—that would be enough to stave off a survey finding (maybe that’s the other 40% of the hospitals surveyed).

If anything, it speaks to the continued importance of point of care/point of service folks being actively involved in the identification of deficiencies in the environment (though I suspect that time and inclination for that participation is probably flagging). At any rate, I think we can safely say that ceiling tiles are going to be in the mix for the foreseeable future.

The other item of interest is an article outlining some Frequently Asked Questions regarding the post-survey clarification process; one item of particular note is that, if you have an issue relating to the Life Safety/physical environment finding(s), your greatest potential for success is while the LS surveyor is still on site. I’ve seen a number of instances in which post-survey clarifications were not approved because the information upon which the clarification is based was not shared with the surveyor at the time of survey.

I know it can be difficult to figure out what’s actually in play while the survey is occurring and even more difficult to try and schedule some time for trying to convince the surveyor that “whatever” is not truly an instance of non-compliance. It does seem like rolling a stone up the hillside…

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 also a contributing editor for Healthcare Safety Leader. Contact Steve at stevemacsafetyspace@gmail.com.