Survey Findings

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TJC Survey Findings Seen in 2017

Other Environmental & Safety Risks Scored This Year

Another heavy hitter this year is a potpourri of environmental safety risks that are inadequately managed. These include blanket warmer temperatures, food refrigerator temperatures, breast milk refrigerator temperatures, paraffin temperatures, and hydroculator temperatures (and that you have changed out the hydroculator water every 14 days.)

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TJC Survey Findings Seen in 2017

More Sophistication Mandated in High-level Disinfection & Sterilization

Last year one of the most frequently scored standards was IC.02.02.01, EP 2 dealing with defects in the high-level disinfection or sterilization processes. That is continuing this year, but the sophistication and array of different issues scored against this EP is much more diverse.

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TJC Survey Findings Seen in 2017

Continued Focus on Air Pressure
EC.02.05.01, EP 15 was a heavy hitter last year, and it only appears to be more difficult in 2017. This EP gets scored non-compliant for defects in air pressure relationships or temperature and humidity deviations in critical environments.
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TJC Survey Findings Seen in 2017

Installing Manual Stop Station on Generator

Another new requirement established as a result of adopting the 2012 LSC is in EC.02.05.03, EP 10. This requires installing a manual stop station on the emergency generator to prevent unintentional operation. There was not much time to install this device after publication of the new requirement and prior to the beginning of 2017, but it’s a new “gotcha” in that it has been missed by many organizations.
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Survey Findings Seen in 2017

Longer Reports, More LS/EC Findings, Scoring on the SAFER™ Matrix

Thus far, we are not seeing any surprises come out of the SAFER™ Matrix. Surveyors seem to be judicious in deciding when to place issues in the red zone, with relatively few that we are seeing at this time. However, we do see a very liberal sprinkling of findings in the dark orange/mustard color area, which just like the red zone, requires management intervention in the ESC, and a discussion of preventative analysis.

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