Volume 2025 | No. 2
SURVEYOR
PHYSICAL ENVIRONMENT AND LIFE SAFETY
CHAPTERS 13 & 14: LIFE SAFETY 13.01.01 Doors
Examples of ACHC Sur veyor findings: ■ The respiratory clean supply storage room tests negative to the corridor (and should be positive). ■ The environmental services dirty linen room is positive pressure to the corridor and should be negative pressure. ■ A sterile supply room is closed for construction/painting, but the door is not sealed at the bottom, and the pressure is positive, blowing air from the construction space into the OR corridor. ■ The organization's humidity policy indicates that the organization has adopted the categorical waiver for 20% relative humidity, but no risk assessment had been completed or is available. ■ Surgical equipment and supplies are stored in an area that is not actively monitored for temperature and humidity.
Frequency of the citation: 29%
Overview of the requirement: Doors opening onto corridors, doors to hazardous rooms, and doors in the path of egress must meet specific requirements to promote safety in the event of a fire. Comment on deficiencies: Direct observation identifies most instances of noncompliance. Surveyors noted: ■ Improper door operations. ■ Obstructed door swing. Examples of ACHC Surveyor findings: ■ Thirteen corridor doors were found not to latch upon closure. ■ Doors are held open with door stops. ■ The basement rear door to sterile processing is being tied open by staff for supply delivery. ■ Doors do not open 90 o because of equipment that blocks the swing.
Compliance tips for:
Ventilation, light, temperature and humidity control is critical to controlling infection risk, to the integrity of sterile instruments and supplies, to the storage of pharmaceuticals and food products. Most air pressure relationships can be easily adjusted if incorrect, so frequent auditing is important. ■ Review policies to ensure that these conditions are addressed for function- specific spaces. ■ Take action as soon as readings indicate the environment does not meet required conditions. ■ Implement more frequent monitoring and immediate correction to air pressure issues. ■ When adopting the CMS categorical waiver for 20–60% relative humidity, evaluate how surgical equipment, packaging materials, and sterilization integrity may be affected, and document mitigation strategies. ■ Conduct a documented risk assessment to determine appropriate actions during temperature and humidity excursions, considering patient care impact, equipment function, and infection prevention.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Compliance tips for:
Nerd Trailblazers (prepare the path for others)
All doors opening to a corridor and doors to hazardous areas require latching devices for secure closure. In the path of egress, doors must open to at least 90 degrees and extend no more than seven inches into the corridor when fully opened. ■ Audit doors for positive latching. ■ Using environmental rounding to check for and correct door swing obstructions. ■ Educate staff that propping doors open or limiting full door swing operation for convenience creates a safety risk. ■ Incorporate door latching and obstruction observations into fire drill critiques and building rounds to reinforce real-world readiness.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
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