Jack L. Waisblat 1-800-243-8962
Nashville, Houston, Deerfield Beach, Raleigh-Durham, Sarasota, Memphis, Pine Bluff, Phoenix, New Orleans
JCAHO 2002 SURVEYS
MOST COMMONLY CITED
TYPE 1 RECOMMENDATIONS AND SUPPLEMENTALS
AND WHAT TO LOOK FOR IN 2003
Last Update: July 21, 2003
The following represents JCAHO type 1 deficiencies and supplementals that were obtained from actual
2002 Surveys. The data was collected from personal observations in which SSR was present at the
building tour as well as the document review session. Some of the data was collected from facilities
where SSR was called in for remediation work after a survey in which SSR was not involved in pre-
survey preparations. The data represents mostly items in the Environment of Care and other standards and
does not include Life-Safety assessment items, which appear in part III of the statement of conditions,
which could be cited by JCAHO if the items are not identified in the Plan for Improvement.
1. Effective January 1, 2000, if your generator’s test log indicates less than 30% of name plate load,
evidence of no wet stacking must be included in test log (exhaust gas temperature vs. engine mfg
minimum recommendation) or an annual load bank test must be conducted. Generator start and
ATS utilized for engine start must also be included in test log. Generator warm up time of 7-10
minutes and incremental load transfer time must precede the 30-minute load test (don’t cut the
test time down to exactly 30 minutes). Must have evidence that all ATS’S are tested annually.
2. Must have a UPS test log for all level 1 SEPSS, which includes monthly checks and quarterly
Testing under loads for 5 minutes as well as annual checks for 60% rated time duration under full
Load per NFPA 111 if the SEPSS are utilized for life safety circuits.
3. Facilities should have a floor plan identifying locations of all fire and fire/smoke dampers. Each
damper needs to be assigned a unique ID and a test/examination (observation) log must be
maintained in accordance with NFPA 90A.
4. Each of the seven management plans should have a plan review cover sheet/back sheet indicating
manager of the plan, date plan was last reviewed, and dated signatures of plan manager, safety
committee manager and CEO, etc. An annual evaluation of each plan must also be included.
5. Cigarette butts found outside of building entrance doors, on loading docks, on roofs, mechanical
and electrical rooms, stairways may get a Type 1 recommendation. Cigarette ashes (no butt need
to be present) found in stairways and other interior spaces will land a type 1.
6. Electrical panel boards should not be left unlocked in corridors (may get a supplemental)
7. Linen carts on casters left uncovered in clean utility, linen rooms and corridors will get at least a
supplemental. Linen carts also need to have a closed bottom.
8. Cardboard boxes and plastic bags sitting on floors of storage rooms, soil utility rooms, clean linen
rooms and alike, will get at least a supplemental.
9. Untagged or out of date tagged fire extinguishers may get a Type 1 recommendation. Also validly
tagged extinguishers without monthly dated/initialed (during monthly safety checks of
extinguishers) tags will get a supplemental.
10. Medication carts left in corridors unlocked will get a Type 1 recommendation.
11. Storage above the 18” red line below sprinkler heads may get a supplemental if the room has a
red line. Storage directly below the plane of a sprinkler head and within 18” of the head will get
at least a supplemental.
12. Unlabeled, or label out of date, on biomedical equipment and other electrically connected
equipment (TVs, refrigerators, microwave ovens, etc.) as well as patient appliances from home
(hair dryers, radios, etc.), will get at least a supplemental. Note that only Biomedical equipment
needs to tagged (several facilities have done away with tagging biomedical equipment utilizing
predictive maintenance rather then preventive maintenance) but if the facility still tags, or tags
other equipment and the tag has an expiration date or is beyond the inspection due date, these
items may receive a supplemental.
13. Not providing the JCAHO team a hat or hair net when entering the kitchen, as well as employees
not wearing a hat or hair net, may get a supplemental.
14. Security staff and outsourced security staff must have training in effective patient restraint.
15. Regardless of test and balance report (which may indicate proper air changes per hour and
negative relative pressure), if surveyor smells glutaraldehyde in the endoscopy area, it may result
in a supplemental.
16. The tops of fixed Film and Medical records storage bins should not be within 18” directly below
the plane of a sprinkler head.
17. The tops of moveable (Track mounted) Film and Medical records storage bins should not be
within 18” below sprinkler heads anywhere in storage area.
18. Walking in to a sensitive dept. (Medical records, Computer room, etc.) without being challenged
by staff in that dept. could result in type 1.
19. Facility must provide at least one mass casualty (minimum 10 victims recommended) disaster
drill per year, documentation for the drill should be comprehensive, two total drills should be
provided (one mass casualty and another).
20. Medications and supplies in first aid kits particularly those placed in boiler rooms, central energy
plants, plant engineering offices, construction sites, haz-mat areas and other locations, should be
checked for expiration dates on medications and supplies.
21. Areas where chemical solutions are used, mixed or applied particularly in central energy plants at
cooling tower chemical feed drums, boiler rooms, paint shops, carpenter shops, etc., should be
equipped with a permanent or portable eyewash station.
22. The 75’ distance rule to the nearest fire extinguisher in Hospitals also applies to Central energy
plant and storage/maintenance buildings on site that are not attached to the Hospital. Particular
attention should be paid to placing fire extinguisher in Central energy plants near all exterior
doors, at each door in a boiler room, at each door in generator and switchgear rooms and in each
23. Many local fire dept. do not require fire hoses in fire hose cabinets (most prefer a fire dept. valve
in the hose cabinet, check with your fire dept.). If hoses are placed in fire hose cabinet they must
be stamped or tagged with valid hydrostatic test date (five years after initial installation and every
three years thereafter), hoses beyond the expiration date stamped on them will receive a type 1
unless documentation of testing or tags are provided.
24. Facility should have documentation for cooling tower water test (especially if the rim of the
cooling tower cell appears to have algae deposit and is greenish in color).
25. Facility must posses Bio-hazardous waste disposal manifests at time of document review.
26. Decommissioned or unused Trash and Linen chutes must be permanently closed and sealed shut
by means of 2 layer of type x drywall or with tamper proof screws.
27. Trash compactors located outside should be enclosed with a fence surrounding the trash
compactor and the gate must be pad locked at all times. If a trash compactor is not enclosed by a
fence then the compaction activation switch must be a key switch (may not be a push button), and
the compaction prevention micro switches located at each door, must be operational (compactor
will not work with door open).
28. Bio-Hazardous waste dumpsters must be enclosed with a fence surrounding the dumpster and the
gate must be kept locked. If a dumpster is not enclosed by a fence then each door on the dumpster
must be pad locked at all times.
29. A protective gear cabinet must be placed at or near the location of each Bio-Hazardous waste
dumpster. The cabinet must include an impervious apron, heavy protective gloves and a face
shield at minimum. Lack of this equipment, or lack of use of this equipment by the environmental
services staff discarding Bio-Hazardous waste form carts or small containers into the dumpster
will result in a type1 or supplemental.
30. Air transfer grilles in corridor doors are not permitted in any doors except restrooms.
31. A maintenance log must be made available during the document review for all buildings which
utilize emergency battery illumination units, exit lights equipped with a standby battery and
fluorescents lighting fixture equipped with integral emergency battery packs. The maintenance
log must indicate that all these units in each building are tested monthly for 30 seconds, and
annually for 90 minutes. Particular attention should be paid to outpatient services buildings on
and off the campus.
32. Do not use the line “ Back in 1972 when the building was built the code allowed it” during the
building tour. The 1997 NFPA 101 (Life-Safety code) makes it clear that the requirements of
chapter 13 (Existing Healthcare facilities) are applied retroactively.
33. If you elect to keep metal plates on corridor doors above the 48” level from the bottom of the
doors because your contention is that the plate is part of an assembly which includes the door
handle on the back side of the door, make sure you have documentation from the manufacturer of
the assembly indicating that the metal plate is part of the assembly and that the assembly is listed
34. In Behavioral Science/ Psych. Units, showerheads must be of the breakaway type or angle flush
type. Non-breakaway grab bars, rods and doorknobs could result in a supplemental. If breakaway
items are utilized, provide a policy and procedure and test log for testing effectiveness of
35. Acoustical ceiling below 9 feet above beds in a Behavioral Science/ Psych. Unit could result in at
least a supplemental.
36. When presenting PI’s during document review make sure that you include start and finish data
37. Provide fire drill logs for on and off campus outpatient facilities.
38. Lack of infant abduction security system or malfunctioning system or lack of quick reaction to an
alarm will result in a type 1. Documentation for an abduction drill (at least one per year) and
security system testing and maintenance must be on hand during document review session.
39. Don’t place smoking shelters immediately outside of stair discharge areas.
40. Dust, Rust, Gloves and Cardboard: Don’t place cardboard on ac diffusers to block, gloves on
smoke detectors, rust and dust on sprinkler heads and dust on window sills, lockers, refrigerators,
etc. will result in a supplemental.
41. Policies and procedures should include and address: Biological, Chemical and Radiological
terrorist threat, Concealed and exposed weapons, Emergency Management plan needs to spell out
policy of Evacuation or Defend in place in the event of certain types of disasters.
42. Provisions for emergency readiness during disaster (hurricane supplies: batteries, ropes, rations,
paneling, etc.) should be checked for expiration, and conditions.
43. At least one Performance Measure (improvement indicator; graphical, statistical or descriptive)
should be on hand for each of the seven management plans (we recommend that a facility provide
at least 3 PM’S for each of the seven management plans and they should be consistent with stated
objectives in the management plans.
44. Do not use the line; our local fire marshal says that we do not need to comply with NFPA 101
(for having a door closer on a hazardous room door, etc.). Provide letter from fire marshal and be
ready to receive a recommendation or supplemental anyway.
45. In your Emergency Management program make sure to address the phases of the plan: mitigation,
preparedness, response, recovery in the aftermath of a disaster (what will you do immediately
following a hurricane?).
46. Concentration of trash and linen in rooms/areas outside hazardous areas (soil linen and trash
rooms) are limited to 32-gallon single container size and maximum of ½ gallon per sq. ft. in a
room or space and a maximum concentration of containers of 32 gallons within 64 sq. ft.
47. Defibrillators should be tested both plugged into power receptacle and unplugged.
48. Stained ceiling tile (which appear to have been wet at one time) could be evidence of bacterial
growth and should be replaced.
49. Damage in walls (except those walls in a construction area that is isolated from occupied areas by
a dust partition and negative air pressure in the construction area) could raise a flag of the
presence of aspergillus.
50. Missing ceiling tiles not only renders your ceiling to not be smoke resistant, but also leaves the
possibility of air borne contaminants migrating into occupied spaces.
51. Isolated power systems (IPS) and line isolation monitors (which typically serve Operating rooms
and other critical care areas) must be tested every six months utilizing the applied fault method in
accordance with NFPA 99, 3-220.127.116.11 and 3-18.104.22.168. These IPS’s as part of the Utility Management
Plan must be inventoried, tested and documented according to EC.2.14.
52. In Behavioral Health unit’s door hardware must be flush (door knobs at room entrance door and
toilet door could result in a type 1 or supplementals) or swing 180 degrees in a downward
53. The use of IV infusion pumps without free-flow protection of intravenous fluids/medications may
result in a type 1 or supplemental.
54. The inability to decipher between clean and soiled bio-medical equipment parked in corridors
may result in a type 1 or supplemental (i.e.; some hospital put a plastic bag or tag on IV pumps
that are clean, a non covered or untagged IV pump will therefore be assumed to be soiled).
55. A notice must be posted in every building informing occupants of the JCAHO survey date, the
notice must be posted 30 days prior to the survey and should be left up until the survey concludes.
56. Areas where appropriate pressure relationships and air exchange rates are required to be
maintained (operating rooms, special procedure rooms, delivery rooms, isolation rooms, bmtu,
labs, sterile supply rooms, etc.) need to have their doors kept closed.
57. Staff needs to be educated on fire safety and needs to know the answer:
A-Where is the nearest fire extinguisher?
B-How do you operate the fire extinguisher?
C-What is RACE?
D-How do you evacuate?
E-How do you move patients?
F-Where is the nearest pull station?
58. Needles, syringes and meds should not be exposed to view on counters, left on top of medication
Carts parked in corridors, or left at patient’s bedside. Medication room doors should be kept
59. Do not leave key to narcotics cabinet in door.
60. Operating room suite is considered secured while activity is maintained, after hours the suite
is not considered secured thus be sure that all syringes, meds, samples of meds and anesthesia
Agents are secured.
61. Staff and contracted services must wear hospital ID tag.
62. Check your management plans and policies & procedures to make sure you are referencing the
EC reference based on revised numbering in 2001/2002.
63. Facilities being surveyed after July 1, 2001, need to develop a new standard LD5 “Patient Safety
and medical/healthcare errors reduction standards”. The standard will need to apply to all
properties on and off campus.
64. If you received a citation from a regulatory agency (CMS, State or Local Health regulatory
Agency, Fire Marshall, etc.), did you correct them? do you have a plan for correction ?, you’ll
65. If you have washers and dryers, make sure to clean dust and lint behind them.
66. Only keep a small amount (enough for a month’s supply) of formaline in the work area, check
Date on bottle.
67. Staffing levels is a major issue during surveys conducted in the after hours.
68. Recently, JCAHO surveyors have cited NFPA 10 (Standard for portable fire extinguishers) at
several hospitals citing that many fire extinguishers are obscured from view (NFPA 10-1.6.6 and
appendix A). Provide a sign on walls or ceilings “fire extinguisher” that can be seen from any
point in the path of travel.
69. Fire extinguishers located in stairwells and suites are not considered to be located in the “natural
path of travel” and thus will not count toward the 150 ft. spacing unless a sign is placed on door
stating, “fire extinguisher located inside” and door is not locked.
70. Fire extinguisher cabinets may not be locked except for extinguisher cabinets in psychiatric
wards, which must be locked. Make sure each staff member in psych. Wards carry a key for the
fire extinguisher cabinet.
71. Shower curtain rods in psychiatric wards must be a breakaway non-metallic type.
72. In unoccupied areas make sure you flush toilets and sinks on a regular basis.
73. You do not need to include observations of 20% of your smoke compartments for fire drills
unless your policies and procedures still state so.
74. When signs are posted on restrained doors stating “push handle, door will release in 15 seconds”,
then door needs to release within the time noted on sign.
75. Temporary partitions in construction areas may not be plastic sheeting, need to be fire rated.
76. Make sure pictures/paintings located in corridors are secured to wall.
77. In the Utility management plan make sure you state who has the authority for partial and
complete emergency shutdowns of utility systems (water, gas, electric, medical gases, etc).
In the Utility Management program, provide a list of personnel that have specific authority for
78. Provide large identification signs at each major utility shut off point “Hospital main water shut
off valve”, “Normal Power Main Disconnect”, “Oxygen main shut off valve”. When these main
shut off points are located outside and accessible to the public, provide chains, padlocks, etc. to
secure them in the on position.
79. Where exterior walls are part of the building’s rated assembly, doors leading to the outside of the
building are considered fire doors and may not have metal kick-plates above 16” from bottom of
80. Annual evaluation must be included for each of the seven management plans and must state the
effectiveness as to the scope, goals and objectives of the plan.
81. A performance measure must be included for each of the seven management plans, you may not
measure something that the standards require you to do such as fire drill success rate, but you
may measure staff education and knowledge of fire drills. Only one PI for all seven EOC plans
needs to be forwarded to the safety committee for improvement recommendation in the EOC.
82. May not have open wire shelf at bottom of Linen Carts, IC issue.
83. Safety management plan needs to address EC1.1.1 on workers safety and work place violence. A
training log on these subjects will need to be provided.
84. Must have aggregated data indicating 95% completion rate of PM’S listed as Critical
Components of the Utility Management Plan. The Critical Components, number of each
component, pm targets and pm frequency must be indicated in the data aggregation report for PM
85. For construction renovation projects after 1/1/02, make sure you have an ICRA assessment
complying with EC.3.2.1
86. When utility shutoff points are located outside or accessible to the public, provide chains,
padlocks or other means to secure them in the on position.
87. Must conduct a Hazard Vulnerability Analysis for the emergency management plan.
88. Don’t forget to change the title of the life safety management plan to the Fire Prevention
89. You should conduct an environment of care risk assessment and write a report of area specific
risks so you don’t get dinged for: Safety type receptacles in waiting rooms, Nurse call stations in
public toilets, etc.
90. Sprinkler heads in Behavioral health units need to be able to breakaway at 50-pound downward
force and needs to be psych. Type heads.
91. If your fire-plan states “all personnel in all areas of every building” be ready to substantiate that
or change your plan to read, “only personnel who need to be observed and evaluated participate”.
92. Make sure you have EOC policies and procedures for patient safety standards: Mercury
reduction, Restraint use, and Weather related fall prevention.
93. Don’t keep more than a single unit (bottle or can) of Ethyl Chloride in patient areas (highly
94. Make sure your annual evaluations for each of the 7 management plans address: Objectives,
Scope, Performance and Effectiveness.
95. Your Business occupancies need to have one fire drill per year.
96. Certain Antibacterial hand rinses contain 60-70% alcohol and are a class 3 flammable (on a scale
of 4, with 4 being the most flammable). JCAHO considers one dispenser mounted as “For Use”,
more than one in a room is considered storage of flammable substance. Antibacterial hand rinses
should not be mounted in means of egress corridors.
97. Decorations that have no flame spread ratings, or non-flammable or non-combustible labeling
may be cited unless the facility sprayed a fire retardant application on the decoration and affixed a
label indicating date of fire retardant application and type of material applied.
98. Make sure you have an assessment of audible / visual alarm signal levels for clinical equipment
(ventilators, Cardio monitors, IV pumps, Etc.) and have taken measures to assure that clinical
alarms are heard above and beyond ambient noise in the clinical area and with the patient room
door closed (part of JCAHO “national safety goals for 2003”).
99. When contracted services are utilized for clinical services (outsourced Dialysis services
conducted in the hospital, etc.), make sure that the individual conducting the service is licensed
and that your HR department has a credentialing file for the organization and all employees of the
organization that perform the service at your facility.
100. Make sure that water filters casings (ice machines, soda machines, coffee machines, dialysis
units, etc.) have a date of when the filter element was last changed (should not exceed a year).
101. JCAHO Under EC.2.7 may cite electrical panel boards missing directories or having directories
that are not legible.
102. Triage areas must provide for patients privacy or they may be cited under EC.3.3.
103. Staff in kitchens where an automatic hood fire suppression system is provided should possess
basic knowledge on how the automatic fire suppression system works and location of activation
components or risk a supplemental under EC.2.8.
104. If your facility currently has sprinkler heads that are under recall but have not been replaced yet,
make sure you have Interim Life Safety Measures (ILSM) in place for the areas affected by the
105. Stretchers parked in corridors of ED suites, Radiology suites, Operative/ Post-operative suites,
PACU and Endoscopy suites with patients on them may be cited for visual privacy under EC.3.3.
106. Make sure your Emergency Management plan has a reference in it to the Medical Staff standards
(MS.22.214.171.124) regarding granting emergency privileges during a disaster (and make sure you have
an administrative policy for emergency privileges).
107. Make sure you have a written assessment (or data from manufacturer) indicating that your IV
infusion pumps and PCA pumps have free flow prevention.
108. In addition to the annual evaluation required for the emergency management plan.
Make sure your emergency management plans Hazard Vulnerability Analysis (HVA) is evaluated
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