Scope Of LSC Surveyors Expanded

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.

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
Compounding
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.

Scope Of LSC Surveyors Expanded