Electrical Panel Inspections During Survey

For more than four decades the Joint Commission has been looking at electrical panels during their accreditation surveys.  Very early on, emphasis was simply placed on whether or not access to electrical panels was clear and unobstructed. Surveyors typically expressed an expectation that there be at least 3 feet of clearance around an electrical panel door.   More attention was typically paid to panels located in egress corridors with lesser attention given to panels located inside rooms and closets.

Over time surveyors progressed to looking to see if cabinets were locked where appropriate (ie., Pediatric units, Psychiatric units, Geriatrics, etc.), and had proper labeling regarding arc flash and missing panel covers.  In recent surveys we have seen surveyors looking for not only these items but appropriateness of circuit labeling for identification of things like circuit number, spares, and future use, as well as fire alarm breaker demarcation EC.02.05.01 EP 8

As we move down the road, we can expect to find surveyors looking at breaker panels and probably finding new things to look at.  One of the obscure possibilities for the future is the requirement that all breakers in a box be the same brand. Whether it is Siemens or Square ā€œDā€ or any one of the many others, the breakers should be of the same brand to help assure compatibility.

While it is true that The Joint Commission does not have any specific standard requiring testing or inspection of electrical panels at any prescribed frequency, it would nevertheless be highly advisable for facilities to establish such a program, much like they do for medical gas systems. 

Facilities are encouraged to start with a written policy that identifies the inspection frequency (suggested annual) as well as identifying the qualifications of those individuals conducting the inspection (this can be done with hospital staff or contractors, but in either case should be done by individuals with appropriate levels of knowledge and experience). Once a clear policy is established, the organization should develop a set of clear procedures and forms which address:

  • Completion of a comprehensive inventory of panels

  • Criteria for inspecting the panels

  • A form for documenting the inspection and deficiencies found

  • A form for documenting repair/follow-up on identified deficiencies

  • A process for notification of staff if deficiencies remain after inspection

  • A connection to the ILSM program if deficiencies remain

Implementation of such a program and processes will improve the level of safety within the organization while improving the programs appearance to the surveyors during the Accreditation Survey.