Archive August 2014 XV, No. 8

Surveyor Says ... Dings that Might Surprise You

Our annual look at accreditors' odd and unusual dings.

Jim Burger, Associate Editor

accreditation surveyors GOTCHA! You might be surprised at the things that accreditation surveyors can cite you for.

A cigarette butt on a rooftop. (Really?) Expired hand sanitizer. (Who knew?) Waste receptacles 1 inch too close to each other. (Yes, they pulled out a tape measure.) Not having a policy on warming up Danish in the microwave. (Wait, what?) These infractions top of the list of the zany things accreditation surveyors cited facilities for in Outpatient Surgery’s annual look at odd and unusual dings. These kinds of hard-to-fathom dings may not be typical — about 65% of your colleagues say their surveyors were just about the right amount of picky during their last accreditation surveys — but a hefty minority (about 31%) say their surveyors were more persnickety than warranted, and they have the stories to prove it.

fire alarm FALSE ALARM Surveyors might want you to actually pull the fire alarm — even if you share your building with other practices.

1. The fire alarm. Stephanie Reed, MSN, RN, CNOR, nurse manager at Ophthalmology Associates in Lutherville, Md., and her staff assumed it wouldn’t be necessary to disrupt and frighten the numerous other medical practices that share her building. They assumed wrong.

“We were cited for a tabletop drill because we didn’t physically pull the fire alarm, even though the staff had correctly identified the need to pull the alarm in a real emergency,” she says. “When I explained to the surveyor that we’re in a multi-use building and that it wasn’t feasible, he said it didn’t matter. He cited the EP (Elements of Performance), which was in the hospital book. I showed him the ambulatory book, which didn’t have that and he said he’d have to check with headquarters. I knew it was sticking when we got the final report back.”

2. 7 feet, 11 inches apart. Technically, of course, surveyors aren’t supposed to be in the business of cutting people slack, but does that mean there can be no gray areas at all? “Would you believe we got cited for having our waste receptacles off by 1 inch?” asks one facility administrator. “According to the fire code, garbage receptacles and dirty laundry receptacles have to be 8 feet away from each other. They literally pulled out a tape measure, and we got cited!”

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