Preparation for the DOH
Environment of Care Survey
Semi-Annual Report
Randy Benson
Executive Director, RHQN
 Eight Areas of Concern:
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Air Flow
Tamper Resistant Electrical Outlets
Wheelchair Maintenance and Sanitation
Food and Medication Temperatures
Fire Drills
Back Flow Valves
Management of the EOC
Staff Competency
 Air Flow WAC 246-320-405 (9)(c)(ii)
 Areas of Mandated Negative Air Flow:
 Dirty Utility Rooms
 Procedural Suites (Endoscopy)
 Specific Types of Isolation
 Areas of Mandated Positive Air Flow:
 Surgical Services
 ORs - - Sub Sterile - - Post OP - - Cath Lab
 Clean Utility Rooms
 Patient Rooms
 Air Flow: Problem Areas
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Open Windows
Closing or Altering Doorways
Altering/Repairing Ventilation Systems
Failure to Maintain Proper Isolation Room
Air Flow
 Tamper Proof Electrical Outlets
 WAC 246-320-405 (9)(e)(ii)
 Outlets Designed to Prevent Death or Injury
From Insertion of Paper Clips, Pins, Other Sharp
Objects
 Required In:
 Pediatric Patient Rooms
 Alcohol and Substance Abuse Units
 Psych Units
 All Exam Rooms
 All Waiting Areas
 Tamper Proof Electrical Outlets (con’t)
 Issues:
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Plastic Caps Are Not Acceptable
Age or Mental Condition of Patient or Visitor
Any Room That May House a Peds Patient
All Exam Rooms (ER, Clinic, PT, RT, Lab)
All Waiting Areas (Nursing Units, ER, Clinic)
Very Specific Standards
 Wheelchair Maintenance and
Sanitation
 WAC 246-320-176 and 246-320-296
 Policy for Routine Maintenance and
Cleaning
 Proof of Compliance With Policy
 Identification of Clean Wheelchairs
 Location of Clean Wheelchairs
 Appropriate Procedure for Cleaning
Wheelchairs
 Food and Medication Temperatures
 WAC 246-320-211, 246-873, 246-320-305
(6), 246-320-201
 The Safety of All Medications and Food is
Mandated (see also WAC 246-215, the
Food Service Code)
 No Outdated Pharmaceutical of Food
 Daily Log of Temperatures of All
Refrigerators and Freezers Housing Patient
Food Items or Pharmaceuticals.
 Food and Medication Temps
(con’t)
 Issues
Temperatures Not Taken Every Day
Automated Temperature Recording
Alarms
No Process for Reporting Temperatures
Outside of Normal Range
 Normal Range Not Identified
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 Fire Drills (NFPA 2000, WAC 246320-296 (7)
 Establish and Implement a Plan
 Investigate and Correct Fire Plan
Deficiencies
 Orient and Educate Staff and Conduct
Drills On a Regular Basis
 Fire Drills (con’t)
 Issues
 Use Of An Object Representing Fire
 A Card, A Flashlight, A Strobe Light
 Frequency of Fire Drills
 One Per Shift Per Quarter
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Process For Conducting Fire Drills
Process For Evaluating Fire Drills
Process For Remedial Training
Posting of Fire Evacuation Routes
 Back Flow Valves
 WAC 246-320-405 (9)(b)(iii)
 Ensure a Safe Potable Water Supply by
attaching backflow valves to certain
types of equipment
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Beverage Carbonators
Commercial Laundry Machines
Dialysis Units
Dish Washers
Ice Machines
 Back Flow Valves (con’t)
 Food Prep Sinks
 Chemical Feeders (Kitchen or Housekeeping)
 Must Have a Policy In Place For Preventing
Backflow Into the Potable Water System
 Must Have An Annual Evaluation and
Assessment of the Effectiveness of the
Backflow Valves (Annual PM)
 Management of the Environment
of Care (EOC): WAC 246-320-296
 Manage Environmental Risks and hazards,
 Prevent Accidents and Injuries,
 Maintain Safe Conditions For Patients,
Visitors and Staff
 Management Plan Must Cover the
Eight Areas of the EOC
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General Safety
Security
Hazardous Materials and Waste
Emergency Preparedness
Fire Safety
Medical Equipment
Utility Systems
Physical Environment
 General Safety
 Maintain Environment Free of Hazards
 Investigate and Report Injuries (RCAs)
 Maintain Policies Related to Safety (e.g.
Wheelchairs)
 Educate Staff on Safety Related Issues
 Security
 Maintain Policies Related to Security
 Educate Staff About Security Issues
 Maintain a Secure Environment (for Staff,
Patients, Visitors)
 Hazardous Material and Waste
 Establish and Implement a Program to
Safely Handle Hazardous Materials
According to Local, State and Federal
Regulations
 Provide Safe Storage Space for Hazardous
Materials (O2, Shredable paper, Lab
Chemicals, etc)
 Investigate All Spills (RCAs), Clean Up
Spills (as appropriate), Report All Spills
 Educate Staff About the “Worker Right to
Know” Program
 Emergency Preparedness
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Disaster Plan
Disaster Drills
Emergency Preparedness Risk Assessment
Staff Education About Emergency/Disaster
Response
 Fire Safety
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Maintain Fire Detection System
Maintain Policies
Conduct Fire Drills (Supervise Drills)
Educate Staff
 Medical Equipment
 Policies
 Preventive Maintenance System
 Inventory
 Documentation
 Assure Quality of Service by Outside Vendors
 Develop and Maintain a Quality Control
Program
 Investigate All Equipment Failures (RCAs)
 Educate Staff On Proper Operation of
Equipment
 Utility Systems
 Maintain a Safe and Comfortable Environment
 Ensure Operational Reliability of Utilities
(HVAC, Elevators, Water, Electrical Grid, etc.)
 Investigate All Utility Failures (RCAs)
 Conduct and Document Preventive
Maintenance
 Physical Environment
 Storage Areas Safe, Fire Protected, Secure
 Plumbing (e.g. Hot Water Temp of 126oF)
 Physical Environment (con’t)
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Ventilation (Proper Air Flow In All Areas)
Clean Interior Surfaces and Finishes
Windows
Functional Patient Call System
Outside Environment Is Safe (e.g. Grounds,
Snow Removal, Sidewalks, Lighting)
 Staff Competency
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Safety, Job Specific, Mandated By Admin.
Generic and Department Specific
Orientation and Ongoing
Access To Experts
Documentation
Review By DOH Surveyors
 Current Job Description (3 years)
 Current Evaluation
 Review By DOH Surveyors (con’t)
 Proof of Current License
 Current Certifications (e.g. CRNA, PT, Food
Handler Green Card)
 Documentation of Competency
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Education Transcript
Everything in One Location
Skills and Knowledge
Department Specific Competencies
Outside Education/Professional Organizations
(e.g. IP, Clinical Dietitian, PT, Pharmacy)
Randy Benson
RHQN Executive Director
randyb@wsha.org
206 577-1821