Which standards caught the eye of surveyors so far this year? EC News recently published a list of the EC LS frequently scored standards. It includes a table that also lists the most frequently cited EP within each of those standards. Here are the details:
Top 10 EC LS Frequently Scored Standards
- EC.02.06.01, EP 1: ligature issues
- EC.02.05.05, EP 6: inspection, testing and maintaining non high-risk utility system components
- EC.02.05.01, EP 9: utility system controls and labeling
- EC.02.02.01, EP 5: minimizing risks when handling hazardous chemicals, often eyewash issues
- EC.02.05.01, EP 15: ventilation in critical areas, usually incorrect air pressures, temperature or humidity issues
- EC.02.03.03, EP 3: quarterly fire drills unannounced and varied times, often sequential fire drills not separated by at least an hour
- EC.02.05.09, EP 11: piped medical gas shut off valves, usually blocking or mislabeling issues
- EC.02.05.09, EP 12: medical gas cylinder policy, usually commingling full and empty cylinders or improper storage without support by a rack or carrier
- EC.02.05.01, EP 16: ventilation in noncritical areas, usually incorrect air pressure, temperature or humidity
- EC.02.04.03, EP 3: high-risk medical equipment inspection and testing, usually a failure to check or find this high-risk equipment
Most Problematic EC LS Standards
In addition, the article highlights one problematic LS standard, LS.02.01.35 and its two commonly scored EPs, 4 and 5. This standard deals with fire extinguishment system maintenance.
EP 4 addresses the need to not clamp or rest any wires, supports or duct work on sprinkler pipe above the ceiling. Since it is impossible to check unless you go above the suspended ceiling to look, this is especially difficult to evaluate. The second very frequently scored is EP 5 which covers sprinkler heads. In fact, they need to be free from corrosion, dust or any foreign material. Again, this is difficult to detect. Plus, it’s not the type of device you can clean by swinging a dust mop at.
Because these standards plague hospitals throughout the nation, we suggest vigilance and frequent monitoring. That is especially important if you were scored for one of these issues previously. You don’t want to obtain repeat findings. Too often TJC finds a problem and hospitals choose to fix that problem but only in the specific area where TJC cited it. We encourage readers to look for that same problem throughout the hospital, not just in the one location.
Patton Healthcare Consulting
Patton Healthcare Consulting provides Joint Commission and CMS Compliance Assistance and a full range of pre-survey and post survey services.
We serve more than 200 hospitals, behavioral health care organizations, ambulatory clinics and home care companies nationwide—hospitals ranging from critical access hospitals to the largest health systems. Contact us at (888) PHC-INC1 for more information.