Most Frequently Scored Standards

by Jen Cowel

Most Frequently Scored Standards

by Jen Cowel

by Jen Cowel

What are the most frequently scored standards so far in 2017?

The September Perspectives posts the 2017 most frequently scored standards. Although the specific standards scored aren’t surprising, the scoring frequency is. As a matter of fact, it increased dramatically!

The Most Frequently Scored Standards

So, read on for the top five:

1) The most frequently scored standard is LS.02.01.35.

In 2016 it came in as the 4th most frequently scored standard. In the first half of 2017, 86% of hospital surveys scored this standard! This is the extinguishment standard. To be sure, there are many facets and unique requirements underneath it. This includes the following:

  • Not connecting anything above the ceiling to sprinkler pipes
  • The long standing 18” rule for storage
  • Keeping sprinkler heads clean

Also, a new rule added as a result of changing to the 2012 LSC, requires you to keep:

  • At least 6 spares of each type of sprinkler head in use in the hospital.

Importantly, the need for spares surprise many organizations. Plus, we’ve seen violations for connecting to sprinkler pipe and draping wires, increase for years.

2) The second most frequently scored standard is LS.02.01.30.

We discussed this standard in the July and August Clarifications and Expectations column.

In fact, there are 25 different elements of performance under this standard. And, 74% of hospitals have been scored noncompliant in the first half of 2017.

The issues covered by this standard include:

  • Self-closing doors in hazardous areas
  • Improperly installed alcohol gel dispensers
  • Corridor door latching
  • Smoke barrier doors with minimal gaps
  • Smoke dampers in smoke barrier walls not protected by automatic sprinkler systems

Remember, the 2017 standard requires zero defects. In short, 90% is no longer acceptable. So, what happens if you find defects during regular inspections? Increase the frequency of inspections and preventative maintenance.

3) EC.02.05.01 is the third most frequently scored standard at 73%, up from 57% in 2016

This is a utilities standard with 19 elements of performance.

Clearly, the one highly problematic EP is EP 15. It covers maintaining appropriate air pressure relationships, temperatures and humidity. Too often air pressure or humidity is not where it should be on the day the surveyor is present. Or, documentation is out of range and no one documented any actions to bring it back into range.

But, here’s the key to make this work. Audible and visual alarms that alert staff that temperature, humidity or air pressure are out of range. Too often these parameters are out of range when the surveyor is present and no one has even noticed.

In addition, a second key to success is an automated documentation system. One that mandates documentation of efforts taken to clear the alarm notice. Too often air pressure, temperature or humidity is not where is should be on the day the surveyor is present, or there is documentation that it has been out of range and no one has documented any actions taken to bring it back into range.

4) The fourth most frequently scored standard is IC.02.02.01.

This covers high level disinfection and sterilization.

In previous newsletter editions, we discussed things that can go wrong with this standard. Unfortunately, the frequency of scoring increased to 70% of hospitals from 60% in 2016. Certainly, the surveyors are getting better at evaluating these requirements. In the meantime, hospitals are not keeping up.

5) Surprisingly, EC.02.06.01 is the fifth most frequently scored standard

It’s holding steady at 68% of hospitals surveyed in 2017. But here is the surprise. This standard covers suicide ligature issues. And, the scrutiny on this topic increased in 2017. But as of yet, no scoring improvements.

Of course, it is also somewhat of a potpourri standard. About any defect or hazard in the physical environment can be scored.

Furthermore, you can get regular updates on most frequently scored standards and other compliance topics. Just subscribe to our newsletter or blog.

Patton Healthcare Consulting assists with Joint Commission compliance assistanceCMS survey support and Joint Commission International AccreditationContact us for additional information.


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