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Compliance News: Survey Challenges

| David Stymiest

Surveyors often seem to find the violations you did not see before they arrived at your facility.  Why is that?  It may be because they have never seen your facility before, so they see everything with what professionals in the field call “fresh eyes.”  A major contributing factor is also the important fact that surveyors have often found similar problem areas at many other facilities, so they know where to look.

Examples of high-frequency adverse findings often observed during building tours include the PHYSICAL ENVIRONMENT NEVER EVENTS such as obstructed oxygen zone valves, obstructed fire extinguishers, obstructed electrical panelboards, blocked fire alarm system manual (pull) stations, obstructed or wedged-open fire doors, obstructed smoke barrier doors, and obstructed exit signs.  These adverse survey findings are very difficult to avoid because they are often aggravated by repetitive human behaviors.

Corridor clutter continues to be an issue in many facilities despite stringent rules against it.

Surveyor observations during building tours include problems both at the ceiling level and above the ceiling level.

Mechanical and electrical equipment area observations may result in follow-up questions regarding inventories and inspection, testing and maintenance (ITM) processes – areas where CMS drastically expanded the requirements a few years ago.

Another area where surveys may become more challenging is in the utility failure preparation arena.  The CMS Emergency Preparedness Final Rule invokes the requirement for All Hazards preparedness, which also includes internal and external utility system or equipment failures.

NFPA 99-2012 is now a source of adverse survey findings simply because of the changes within that edition.  With CMS publishing 33 K-Tags related to NFPA 99-2012, many which contain detailed requirements and NFPA references, some building tour observations could be related to the NFPA 99 CMS K-Tags.

The short discussion above is from the March 2018 Health Facilities Management Magazine article entitled “How to think like a Compliance Surveyor” available here.

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