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*TJCsvyrLS_Smith_Richard Smith, CHFM

Richard Smith, CHFM


Surveyor Program(s): Comprehensive Accreditation Manual for Hospitals

Surveyor Tenure: x 200??

Lives: Alabama

TJC Bio:

  • Mr. Smith formerly served as the Corporate Director of Facilities Compliance for Infirmary Health System
  • He Maintains certification as a Certified Healthcare Engineer (CHE), Certified Healthcare Safety Professional (CHSP), and Certified Health Facilities Manager (CHFM)

Other Background:

Comments & Recommendations


  • Focused on the task at hand – cuts no slack on issues. 11/20/09
  • He was not included on the TJC visit agenda when it posted – he came in on the very last day of the survey – he lives here locally in Fairhope, AL – states he now works full time for TJC 11/20/09 
  • he was thorough in his review of the physical plant. 06/19/09
  • Life Safety Code Specialist, Most of our RFIs came from the LSC specialist.  He didn’t miss a thing.  Very knowledgeable about the standards and spent time giving us lots of tips, but in the end, he cited us for everything he found.  Focus: penetrations, ILSM.02/2009
  • I did not spend much time with him but this is my second survey with him also and he is very tough. He will also teach and consult if allowed. 02/2009

  • Very thorough, lots of good suggestions 8/21/08

Recent Survey History:

• Searcy Hospital11/20/09  • Torrance State Hospital6/19/09
• Arizona State Hosptial02/20/09 • Mary Starke Harper Geriatric Psychiatry Center08/21/08

 • Greil Memorial Psychiatric Hospital03/08/08

 • Eastern Louisianna Mental Health System 1105


** Sample Survey Citations (Premier Level)**

[private Membership premier]


Sample Citations:


  • XX.00.00.00/EP 0/ Observed in Tracer Activities: xxxxx xxxxx xxxxx xxx xx x x xx xx xx xxx x xx xxxxxxx. /Indirect/


  • LS.01.01.01/EP 2/ Observed in Document Review: The hospital did not have a set of life safety code drawings/Indirect Impact
  • LS.02.01.10/EP 4/ Observed in Building Tour: Multiple fire doora did not have a rating label./Indirect Impact
  • LS.02.01.10/EP 9/ Observed in Building Tour: The fire wall at doors (in multiple locations) had a penetration that was not properly sealed./Indirect Impact
  • LS.02.01.30/EP 2/ Observed in Building Tour: The storage room door (in multiple locations) did not automatically close./Indirect Impact
  • LS.02.01.30/EP 11/ Observed in Building Tour: The the corridor door (in multiple locations) did not resist the passage of smoke./Indirect Impact
  • LS.02.01.30/EP  18/ Observed in Building Tour: The smoke wall (in multiple locations) had a penetration that was not properly sealed./Indirect Impact
  • LS.02.01.34/EP 1/ Observed in Building Tour: The fire alarm panel in each building, did not automatically transmits to one of the following (For full text and any exceptions, refer to NFPA 101-2000: 9.6.4): – An auxiliary fire alarm system with direct connection to the servicing fire department as described in NFPA 72-1999: 6-16 – Central station service as described in NFPA 72-1999: 5-2 – A proprietary supervising station system as described in NFPA 72-1999./Indirect Impact
  • LS.02.01.34/EP 2/ Observed in Building Tour: The room with the main fire alarm panel was not continuously monitored and did not have a smoke detector installed./Indirect Impact
  • LS.02.01.35/EP 5/ Observed in Building Tour: It was noted that numerous sprinkler heads located in the hallways (and kitchen area) were dust covered. The sprinkler headers in the shower area were noted to be encrusted with rust./Indirect Impact


  • EC.02.03.05/EP 11/ Observed in Building Tour: did not test our fire pump under flow every 12 months; did not inspect the main kitchen automatic fire extinguishing system every 6 months/Direct
  • EC.02.06.01/EP 26/ Observed in Building Tour: bathroom patient safety alarms found malfunctioning
  • EC.20.05.07/EP 4-6/ Observed in Building Tour: the generator was tested at intervals less than 20 days; emergency generator tests are conducted with a dynamic load that is at least 30% of the nameplate rating of the generator and the hospital did not conduct an annual load bank test as required which met the NPPA requirement.   Test of automatic transfer switches must be done at intervals of not less than 20 days and not more than 40 days./Direct Impact
  • LS.01.02.01/EP 3/ Observed in Document Review: did not implement ILSM for part of our e-SOC (some doors’ fire ratings were not labeled)
  • LS.02.01.10/EP 9/ Observed in Building Tour: The fire wall above the ceiling in multiple areas had a penetration that was not properly sealed./Indirect Impact
  • LS.02.01.10/EP 5/ Observed in Building Tour: Fire exit doors did not close and latch properly/Indirect Impact
  • LS.02.01.20/EP 31/ Observed in Building Tour: Exit signs not adequately lit/Indirect Impact
  • LS.02.01.30/EP 2,11, 18/ Observed in Building Tour: The fire wall above the ceiling in multiple areas had a penetration that was not properly sealed./Indirect Impact
  • LS.02.01.30/EP 18, 19, 23/ Observed in Building Tour: building features to protect individuals from the hazards of fire and smoke – specifically smoke barriers. Penetrations found. /Indirect Impact
  • LS.02.01.34/EP 2/ Observed in Building Tour: The master fire alarm panel is not monitored.
  • LS.02.01.35/EP 4,9/ Observed in Building Tour: The piping for approved automatic sprinkler systems was used to support a duct above the ceiling in multiple locations; it was further observed that in a staff lounge, there was a grease -producing device (George Foreman grill) and there was no type K fire extinquisher within 30 feet./Indirect Impact


You may provide surveyor feedback by clicking on the ‘Comments’ link above (2nd line, top left) and/or via the New Post Survey Questionnaire (PSQ).

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