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Keyes Life Safety

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Avoidable Deficiencies in ASCs

by Brad Keyes, CHSP, on Jan 30, 2020 12:00:15 AM

I have often been told by ambulatory surgery center staff during surveys that the Life Safety Code surveyor is the person that they fear the most.

Keeping up with the requirements can be a daunting task, but I have found that it isn’t the deep-down obscure requirements that trip up facilities; it is often the easy stuff that is missed by the staff and easily found by a surveyor. These are the deficiencies that start popping up over time and are ignored - soon they become commonplace. Sometimes they are even on a routine environment of care (EOC) check form, but those forms can become time-consuming and things may get marked as being compliant but actually were not even checked.

Here are a few of the deficiencies that I often find that are easily avoidable:

Medical gas cylinders that are not secured from falling. We all know they have to be secured, but this is still a common deficiency. This is often blamed on the medical gas delivery person. Probably the best time to check the cylinders in the medical gas room is right after a gas delivery.

Fire-rated doors that are being propped open with just about anything other than a proper hold-open device that is connected to the fire alarm system. If the door needs to be open on a regular basis, then it is probably best to install a hold-open device instead of being cited by a surveyor or the fire marshal.

Fire-rated doors that do not latch because someone has put tape or other items over the latching system so the door can just be pushed open.  

Access to manual fire alarm pull stations that are visually and/or physically blocked. For some reason, potted plants like to grow in front of pull stations. Chairs also like to grow there. Keep in mind that access to these pull stations needs to be unobstructed.

Access to fire extinguishers that are visually and/or physically blocked. This is the same as the manual pull stations. Occupants need to know that it is there and need to be able to get to it.

Equipment and other items blocking clear access in ASC corridors or reducing the clear width to less than 44 inches. As ASCs get busy, it is easy for clutter to build up in the corridors and egress paths. Staff should be educated on the importance of keeping the paths clear.

Electrical circuit breaker panels that are blocked and do not have a clear working area of at least 36 inches in front of them. This is usually seen inside the electrical rooms, but it does happen throughout some facilities.

This list is just a small sampling of the simple things that fall through the cracks and results in citations for ASCs. Education is often the first step to combat this on-going issue; however, if the issues persist, persistent on-going surveillance may be needed. There is nothing more irritating than being cited for simple deficiencies that are easy to prevent.

Topics:Life Safety Code

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