Survey Time: Check Your Ice Machine Outlets, Brush Up on IC, Staff Safety

By A.J. Plunkett

The Joint Commission (TJC) is still catching up on the surveys backlogged during the COVID-19 pandemic—but they are catching up.

Be aware that you might soon be getting a notice that your survey is scheduled, although you still won’t be told an exact date because CMS requires the visits to be unannounced.

As you get ready, be prepared to get down on hands and knees to double-check some problems surveyors may be looking for, says Ernest Allen, ARM, CSP, CPHRM, CHFM, a life safety consultant at HealthTechS3 in Cleveland, Ohio.

One seemingly new item of interest to surveyors is ice machines, specifically the outlets they are plugged into, says Allen. They should be ground-fault interrupter (GFI) outlets.

“The Joint Commission has cited several hospitals for using a regular outlet instead of a GFI. These outlets are not always easy to check, often requiring you to get on your knees to look under or to the back side of an ice machine,” says Allen, a former TJC life safety surveyor who now conducts mock surveys as a consultant.

“On my surveys I have observed that about one-third of the time the electrical outlet in the wall is the regular type and not the GFI. Hospitals would be wise to include checking for this on their safety rounds,” he advises.

Inside Accreditation & Quality reached out to other compliance consultants to ask what hospitals can expect surveyors to look for or ask about as they go through records, talk to staff, and walk through hospital rooms and corridors.

List of surveyor questions

Gayle Nash, RN, MPH, CEO of Nash Healthcare Consulting, offered a lengthy list of questions surveyors have asked of staff and areas they’ve investigated in the last two years:

Patient rights

  • How does your organization deal with angry or verbally abusive patients or visitors?
  • How does your staff communicate with patients and visitors who do not speak English?
  • How are patients advised of their rights and how to report any concerns?
  • When does a patient’s informed consent expire for a procedure?
  • How do you notify a patient’s family and physician of their admission, discharge, or transfer from the hospital?

Infection control

  • What training has your staff received for infection control purposes?
  • List of COVID-19 vaccine compliance
  • Observation of hand washing
  • What is the dry time of disinfectant wipes?
  • Observation of high-level scope disinfection and request for competencies
  • How is antibiotic stewardship incorporated into your plan?
  • How are medical equipment items such as glucometers and IV pumps disinfected?

Sterile processing

  • How are reusable surgical instrument cleaning brushes managed?
  • What are the proper dose measurements for chemicals used and dosed at cleaning sinks? How are automated delivery systems calibrated?
  • Are hinged instruments sterilized in the open position?
  • Documentation of sterile processing team competencies
  • Review of sterilization logbook and documentation of lot numbers
  • Documentation of sterilization cycle minutes


  • If you sustain an injury, what is the process for reporting it?
  • Where and how do you dispose of sharps?
  • What ligature risks do you have on the behavioral unit, emergency department, etc.?
  • How do you identify patients at risk for suicide?
  • Are you using a valid tool to assess patient risk for suicide?
  • Have you checked defibrillator documentation and asked staff who checks crash carts and how?


  • What is the code for an infant abduction alarm?
  • Have you had a security drill this year?
  • How do you get security support when you have a combative patient or visitor?

Hazardous materials

  • How do you obtain a safety data sheet?
  • How many compressed gas cylinders may you have in a smoke zone?
  • How must compressed gas cylinders be separated?

Fire safety

  • Where is the nearest fire alarm?
  • How and where do you relocate patients in a fire if needed?
  • Who can authorize shutting off an oxygen valve?
  • Who can order building evacuation?

Medical equipment

  • How do you know equipment has been tested and is safe for use?
  • What type of outlet should defibrillators be plugged into?
  • How do you identify broken medical equipment and who gets notified?
  • How do you know what to clean medical equipment with?
  • Where do you find the manufacturer’s instructions for use for medical equipment?

Utility systems

  • Which electrical outlets work during a power failure?
  • What type of extension cords are allowed within the patient’s vicinity?
  • Do you have a waterborne diseases safety program?

Emergency management

  • How will you know if the disaster plan has been initiated?
  • What is the code for a mass casualty?
  • What is the code for a tornado?
  • What do you do if the hospital goes on lockdown?

National Patient Safety Goals

  • What is the expected turnaround time to report critical test results to the physician/advanced registered nurse practitioner/physician assistant?
  • What are the two patient identifiers?
  • Who can alter lethal alarm settings for cardiac monitors?

Patient care

  • Who monitors moderate sedation?
  • Observation of a timeout in procedural area
  • Anesthesia pre- and post-assessments

Medication management

  • Staff understanding of high-risk medications, “tall man lettering,” and look-alike, sound-alike drugs
  • Observation of a medication pass and security of the computer on wheels
  • Record trace to determine management of controlled substances, dose ordered vs. given, and wastage
  • Outpatient clinic staff understanding of medication security with medications stored in clean storage rooms
  • How often are anesthesia carts checked for medication security?


  • Understanding of contract management (e.g., who evaluates the contract and what metrics are used?)
  • Culture of safety questions related to providing for staff input, reporting incidents, etc.

Records reviewed

  • Restraint/seclusion—order present, observation documented, face-to-face requirement completed, care plan updated
  • Choice of follow-up services—documentation that patient was provided with choices of things such as home health agency, hospice, long-term care facility
  • How are patients and families informed about discharge plans?
  • Titration of drugs, including matching documentation to order
  • Review of care plans for completeness and timeliness of goals
  • Pain assessments and reassessments
  • Blood administration policies and whether staff are following them
  • Review of records for history and physical compliance
  • Tissue tracer to verify compliance with tissue standards
  • Review of resuscitation cart logbooks to ensure daily or twice-daily checks are performed based upon the hours of operation

Environment of care

Steven A. MacArthur, a senior consultant with Chartis Clinical Quality Solutions (formerly known as The Greeley Company) in Danvers, Massachusetts, offered a look at what life safety survey will be like, noting that many surveyors are new to the job.

“They’re going to be focusing on the stuff that has always been ‘lucrative’ for them,” he wrote.

He noted that the CMS report card last year focused heavily on the “the physical environment, so it’s going to remain the focus of the entire survey team.”

“Apparently there is a possibility for the LS survey portion of the survey to occur after—and maybe even well after—the clinical portion of the survey,” added MacArthur. “I haven’t seen any evidence of that, but it sounds like they don’t have a lot of bench strength for LS surveyors.”

That could make for a strange survey experience, especially if clinical surveyors get more involved in identifying physical environment deficiencies.

“That’s why it’s important to have a very clear understanding of what compliance looks like within your walls,” said MacArthur. “They are going to find stuff—after all, there are no perfect buildings. Let them get hung up looking for dusty sprinkler heads and maybe they’ll be satisfied.”

Expect surveyors to also focus on these areas:

  • COVID-19: “They have to be asking about COVID, both as a function of the journey so far and to gain a sense of where organizations are now,” noted MacArthur. “There’s been some sense that TJC is not accepting COVID as an excuse for compliance shortfalls,” even though the public health emergency remains in effect at least through the fall.

“They could ask if the emergency response plan is still in effect, and if the answer is no, then the expectation would be that organizations have completely recovered. Which, as I think about it, brings up a point—there is no sin in implementation of an emergency response plan/protocol for the duration of the PHE. I don’t know that anyone can really say that they have completed the recovery phase with everything that’s still going on, but I suppose there are enough variables that the sailing might be smoother in certain waters,” he wrote.

  • Emergency management: “They’ll be tackling emergency management to some degree. TJC doesn’t reconfigure an entire chapter and then ignore it, but truth be told, any healthcare organization that has (more or less) successfully navigated the last two-going-on-three years, with everything that’s gone on, has an appropriate emergency management function,” MacArthur said.

There are always improvements to be made, but just ensure the Emergency Operations Plan has been updated to reflect the updated TJC chapter. “If the reason that one has to have an emergency management program is to have a framework for responding to an emergency, the proof is in a pudding that we’ve been eating for almost three years,” said MacArthur.

  • Water management: “They’ll start to dig a little deeper into water management programs; at this point, folks should be at the point where they’ve started testing and monitoring based on what is prescribed by their water management plan, so there should be some data to support whether or not the risks associated with waterborne pathogens are being appropriately managed,” said MacArthur.

“At that point, the important consideration is to make sure that any out-of-range values have some sort of action—treatment and re-test, something like that.”

  • Management of the procedural environment: “Temperature, humidity, air pressure relationships, air exchange rates—these are all fodder for survey scrutiny. These are complicated environments with a lot of moving parts (and people), so it’s important to know which systems can reliably perform,” said MacArthur. Remember that temperature extremes experienced in areas where extremes are uncommon can expose vulnerabilities in systems or equipment. Be aware of which systems might be on the edge due to what’s being expected of them, including equipment vintage and other factors.
  • Infection control: Surveyors will also be looking for anything that ties the physical environment to infection prevention and control. “Depending on the survey team, there’s no reason to think that anyone is leaving their ‘white gloves’ at home,” said MacArthur. “Stained ceiling tiles, damaged surfaces, etc., are all in the mix.”
  • Behavioral health environment: The risk assessments should all be buttoned down, including the expansion of the risk assessment requirement into the outpatient behavioral health settings, MacArthur said. “Make sure staff are educated to the risks they are managing. I am advocating for particular focus on occurrence reporting data, including (and maybe especially) near misses of self-harm/harm to others,” he wrote. “I think this is going to continue to evolve as a focus. I’m hoping they’ll be moving beyond the whole ligature-resistance concept to a more comprehensive assessment of the management of patients. Nothing can get you into deeper trouble faster than issues with the management of behavioral health patients.”
  • Eyewash stations and the use of corrosive chemicals: “A basic understanding on the part of a survey team can spell survey doom if you don’t have a solid understanding of what (and where) elevated chemical risks exist in the organization,” MacArthur wrote. “The FAQ helped pull things back from the edges when it comes to locations where corrosives are stored, but I still see a lot of jugs of bleach in use in areas with minimal if any access to emergency eyewash equipment (and not the little squirty bottles). I think this area has the greatest potential for survey pain,” he said, if for no other reason than it always has been.
  • Business occupancies: Remember that all the above applies to the outpatient settings, with the addition of Life Safety chapter standards and elements of performance for business occupancies. That “means that they can fill the SAFER matrix to the brim with all sorts of findings, but anything that exists in the hospital and exists in the outpatient world will be in the spotlight,” MacArthur said.

Finally, wrote MacArthur, be especially aware of management of contracted activities. “I do see a lot of survey findings relating to deficiencies, etc., identified during contracted activities for which the organization has not closed the loop—the reason that inspection, testing, and maintenance activities occur is to ensure that everything is working correctly, patients are kept safe, etc. If something is not as it should be, the correction clock starts ticking.”

A.J. Plunkett is editor of Inside Accreditation & Quality, an HCPro publication.