Pending Survey

Hello Patient Safety,

May I ask a question please?

We are due for a Joint Commission survey any day now. As part of the preparation I am trying to address any last minute hot button issues and/or going through all of the Joint Commission checklists to make sure I have everything covered for Environment of Care, Life Safety and Emergency Management chapters.

Anyone have a recent survey and could share quickly the hot topics for these three chapters?


Charlie McCardle
Safety Officer
(319) 334 5277


  • edited July 2016
    Oxygen tank storage is huge- they want to see storage as full, partial and
    empty. Full=still sealed

    Judy R. Effler, RN MSN
    Patient Safety Officer
    Blount Memorial Hospital
    907 E. Lamar Alexander Pkwy
    Maryville, TN 37803
    (865) 980-4903 office
    (865) 749- 5910 pager

    In the midst of winter, I finally learned that there was in me an
    invincible summer. - Albert Camus

  • edited July 2016
    Agree with the O2 tank management.......I would add staff ability to talk about the temperature and humidity management in procedural areas, eyewash station management, minimizing hallway clutter, and no blocking of fire pulls/extinguishers.
    Let us know if you need anything further........I' certain your hard work will pay off during survey!!

    LeAnn Springman RN, BSN, MSA
    Manager of Accreditation
    5215 Holy Cross Parkway
    Mishawaka, Indiana 46545
    Office 574-335-2463
    Fax 574-335-1449
    From: []
    Sent: Wednesday, February 17, 2016 4:05 PM
    To: Patient Safety Talk
    Subject: Re: [patientsafety_talk] Pending Survey

  • edited July 2016
    Just had a survey in Oct.

    We are a psych facility so they were big on assessments for ligature points
    & potential barricade situations

    Also as a previous response - access to fire extinguishers. Along with
    properly labeled breakers and utility systems.

    And of course = penetrations.

    Donna McGraw

  • edited July 2016
    Donna, may we chat please. We are psych also.

    319 334 5277

  • edited July 2016
    I would agree on the oxygen tanks. We have worked hard on that this past 3
    years getting everything labeled, getting plenty of carriers etc.

    We were surveyed last week. On the last day the surveyor was doing one
    more tracer and was in a patient room. Over in the corner, kind of behind
    the bed, she found that someone had left a tank propped against the bed.

    It is a never ending scavenger hunt.

    Most of our issues were with Life Safety and Environment of Care.

    *making sure that smoke and fire walls have not been penetrated and then
    not sealed properly
    *we had some wiring that had been zip tied to a sprinkler pipe
    *making sure the documents had been completed correctly for the fire drills
    etc that had been done.

    They indicated that LS / EOC and IC were the biggest issues when they
    surveyed. We only had one IC issue, which was the correct dilution of some
    cleaning solution.

    The surveyor team was wonderful, collaborative, did a lot of teaching.
    Overall it really was a good experience, even though we have several RFIs
    to complete.

    Peggy Tuxhorn RN, MSM, CPHQ
    Vice President of Quality
    Hutchinson Regional Medical Center
    1701 E. 23rd, Hutchinson, KS 67502
    O - 620-665-2147 C - 620-899-4969
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