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Survey time is always a period of anxiety for facility directors no matter how prepared they think they are. New regulations or what accrediting agencies focus on during the survey process are always areas of concern for directors. No one wants to feel unprepared. Below is an area of primary focus and a few tips from my experience as a former Joint Commission surveyor to help you feel more prepared for your upcoming survey.
Area: Physical Environment
- Rope packing on your fire pump. Although rope packing is not required by the NFPA, it is utilized because it's less prone to failure then mechanical seals. The area you want to check is ensuring that your rope packing is dripping at a consistent rate. Make sure it’s not completely dry/not dripping at all or make sure that the water is not continuously pouring out from the packing.
- Monthly conductance tests on your generator battery system. If you truly have sealed/maintenance-free batteries, you should be doing a monthly conductance test to analyze the state of your generator batteries. If your batteries are not sealed and you must check the water level, remember you also need to have an eyewash station present (installed in uninterrupted travel distance of 10 seconds or maximum of 55 feet).
- Weekly checks of your emergency power supply system include your automatic transfer switches. This is a general inspection of the cabinet. You are checking it for leaks, water stains and debris. Ensure it’s in normal power and the incoming power source is labeled. The last thing to check is to make sure your informational lights or panels are operable.
Tips For Your Survey
- Make sure your documentation is organized. I cannot stress this enough. If your documentation is not organized and easily presented, it’s going to give your surveyor the impression that you are not following the standards correctly. Additionally, it gives the surveyor more time to review documents and identify problems with your report. Surveyors look to complete document review within 90 minutes. If that is dragged along, you are going to allow your surveyor to have more time to review your IOU’s and find issues with documentation. If more than 3 findings are found within EC 02.03.05, you will also be scored for a leadership finding as well.
- Do not be vague in your answers or intentionally trying to distract or create a diversion. Remember your surveyor has been to multiple facilities and seen all approaches. I was able to quickly identify if an individual or team was trying to misalign my focus during a survey. In fact, all it did was make me focus more because I knew they were using distraction techniques. If you’re using distraction techniques, you’re going to lose the ability to have open, honest conversations throughout your entire survey. If you do not know the answer, say so and ask for clarification. Your surveyor is more apt to help then you realize.
- Ask questions and for clarification. If you feel a finding is incorrect or you are not familiar with the regulation, take that opportunity to ask questions and educate your staff or team if you are not familiar with the regulation. I was more then happy to clarify a finding and at times take away an observation due to the open dialogue that occurred. Clarifying and contesting everything is something I would not suggest either or your communication is going to eventually break down. Make the effort to keep your conversations as open, honest, and educational as possible. Also, do not be afraid to ask the surveyor what they are looking for to educate yourself. I was always more than happy to educate the team.
Hopefully, the information and examples in this article will help you on future surveys. If you are interested in a mock survey prior to your accrediting agency's survey, feel free to check out Soleran's process here. As a former Joint Commission surveyor, I personally conduct your facility's mock survey. I would love to help get your ready!
About the author
Director of Life Safety Compliance
Former Joint Commission Life Safety Code Surveyor with over 17 years of experience in healthcare.