Did you know that most life safety code deficiencies that contribute to Centers for Medicare and Medicaid Services (CMS) condition-level deficiencies are “low-hanging fruit”?

What does that mean? I’m glad you asked.

Low-hanging fruit are “the obvious or easy things that can be most readily done or dealt with in achieving success or making progress toward an objective” (Merriam Webster Dictionary, 2018). This means that many findings could be prevented if you would simply deal with the easy-to-address deficiencies on a routine basis.

For the sake of this article, I’m going to pinpoint places where the life safety code low-hanging fruit are most commonly found in hospitals and offer simple practices for quick remediation.  

Corridors:

  • Reduce projections into the corridor that protrude more than 6 inches from the wall.
  • Eliminate placement of two soiled linen hampers stored side by side.
  • Clean dirty sprinkler heads and replace soiled ceiling tiles.
  • Repair bent sprinkler head deflectors.
  • Label all medical gas shut-off valves.
  • Ensure that the medical gas shut-off valves are not blocked by carts, stretchers, or wheelchairs.

 Above the ceiling: 

  • Remove cables draped over sprinkler pipes.
  • Replace missing cover plates on electrical junction boxes.
  • Increase the frequency with which you inspect barrier penetrations.
  • Implement an “above-ceiling” policy and enforce it.

Mechanical spaces:

  • Replace missing cover plates on electrical junction boxes. (This is not a typo. Check for this deficiency in both above-ceiling areas and mechanical spaces.)
  • Reposition cables and wiring so they are not attached to sprinkler pipes.
  • Eliminate storage of items within 3 feet of electrical panels or in electrical storage closets.
  • Eliminate storage of items in front of HVAC unit access doors.
  • Label all circuit breakers that are in the “On” position.

Kitchens:

  • Clean dirty sprinkler heads.
  • Place the deep fryer at least 16 inches away from an open flame or mount an 8-inch metal splash guard between cooking appliances.
  • Mount K-extinguishers within 30 feet of cooking surfaces. Ensure that staff know how and when to use these types of extinguishers.

Generator rooms: 

  • Provide eyewash station if measuring the battery-specific gravity.
  • Mount a remote manual stop outside of generator room.

Operating Rooms:

  • Maintain an unobstructed path to medical gas shut-off valves.
  • Eliminate blocked line-isolation panels.
  • Increase the frequency with which you inspect barrier penetration above the ceiling.
  • Label medical gas shut-off valves.
  • Eliminate corridor clutter.

Main fire alarm control panel:

  • Check the panel cover for the circuit breaker label.
  • Check the sub-electrical panel to ensure the main fire alarm control panel breaker is marked in red.
  • Provide your security department or hospital operators with a written copy of the fire response plan.

In the words of Confucius, “Life is really simple, but we insist on making it complicated.”

There’s no need to complicate the way you manage your facility. Keep the simple things simple. Identify and address your low-hanging fruit. Your healthcare facility will be a safer place for your staff, patients, and visitors.


About Ken Blackwell, LCSC, CHSP

Ken Blackwell, LCSC, CHSP, is a Senior Consultant with Compass Clinical Consulting. A former Joint Commission surveyor, Ken has surveyed nearly 600 healthcare organizations, including military hospitals and Veterans Health Administration facilities. He has nearly 20 years of experience in the healthcare industry, with expertise in the accreditation and regulatory standards and a commitment to continuous quality improvement in the areas of life safety, fire safety, equipment management, emergency management, utilities management, and safety management. Read more about Ken.

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