Recently, The Joint Commission expanded the scope of LSC Surveyors. In fact, this change will require you to modify your readiness review process. Here are steps to consider.
Scope Of LSC Surveyors Expanded
First, effective immediately, the Joint Commission’s life safety code surveyors will visit the hospitals off-site emergency rooms and all hospital-operated ambulatory surgery settings. Previously, these locations had the physical environment evaluated by the clinical surveyors, not the life safety code surveyors.
This change likely relates to the Federal Register notice on the Joint Commission’s deeming application. As you have seen in recent years, the life safety code specialists review are very thorough. They are much more in depth than a life safety code review performed by a clinician. As a result, the off-site emergency rooms and ambulatory surgery centers may see additional EC or LS findings on your next survey.
In addition, CMS wants a deeper dive of environment of care and life safety deficiencies in business occupancy sites that are under the hospital’s CCN number. While the LSC surveyor will review healthcare and ambulatory care occupancy sites , the TJC clinical surveyors will review the key elements below when they survey a sample of the business occupancies.
List Of Elements
Further, TJC provided this list of elements during a consultant’s forum. It serves as a good punch list for the EOC reviews done. We recommend you incorporate these items into your readiness review or EOC review of clinics.
- Life Safety Code drawings
- Means of egress
- Locked/blocked exits
- Exit access
- Exit discharge illumination
- Battery back-up
- Corridor widths
- Corridor obstructions
- Visible exit signs
- Above ceiling
- Electrical outlets
- Electrical panels
- Safety Data Sheets (SDS)
- Security / access
- Smoke / fire barriers
- Fire extinguishers inspection
- Mounting and visibility of extinguishers
- MRI locations
- Biohazardous and pharmaceutical waste
- Alcohol-based hand rub (ABHR) dispensers
- Eye wash stations
- Storage rooms
- Medical equipment
- High-level disinfection
- Cylinder storage
- Sprinklers / sprinkler systems
- Fire drills
Patton Healthcare Consulting
Patton Healthcare Consulting can help you navigate the new normal. Our new remote consultation “Comprehensive Hybrid Readiness Review” is a hybrid remote/onsite support program. It is designed to assist with assessment and education to meet your needs going forward after this national emergency.
In addition, we understand the need for assistance without disrupting your organization or extensive costs. That’s the specific purpose of this program. Contact us at (888) PHC-INC1 for more information or email us at ExpertAdvice@PattonHC.com.