Q: How can my ASC better prepare for accreditation surveys and adherence to life safety codes?
Dr. Jack Egnatinsky: The AAAHC has a checklist it goes by called the physical environmental checklist. Organizations have this before the surveyors get there, and they are expected to do a comprehensive review of the checklist and to do a self-inspection. The PEC is designed to help ensure they are complying with life safety codes, which incorporate many nationally recognized standards from associations and other government or quasi-governmental organizations that are recognized for having construction/safety standards.
At the time of the survey, surveyors physically walk throughout the entire ASC, looking at things that are on the checklist, such as exit signs that are now required to have back-up batteries and a chevron, not an arrow, pointing to the exit. We look at emergency power, stairwells, wheelchair ramps, which all have very specific requirements. All of this is an open book; we’re not looking for anything the ASC shouldn’t know about. They should have access to everything CMS and other accreditation organizations have and should be able to identify and correct these deficiencies themselves.
What happens is the ASCs try to fix the deficiencies in-house without the assistance of qualified engineers or architects to help them with the checklist and to provide them with assistance or information they need. ASCs have to admit they don’t know all the information needed to fulfill that checklist properly.
One of the more common problems we find as we do a walkthrough are pipes penetrating a firewall. Every time a pipe penetrates a wall or ceiling, the holes need to be caulked with fire-preventative caulking. Sometimes, we see no caulking or caulking that is flammable. The reason [we require fire-preventative caulking] is if there is a fire in these areas and it gets into these open holes beyond the fire preventive ceilings/walls, the fire spreads very quickly and can have a major impact. More attention to detail can prevent that.
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