*
2014 and 1st Qtr 2015
Ron Neet, CPE, CEM
Life Safety, EOC, & EM Manager
Providence Health and Services
Learning Objectives - At the conclusion of this
presentation, the participant will be able to:
1. Identify the components of a Joint Commission Life
Safety & EOC Survey.
2. Identify the top compliance issues in Life
Safety and the Environment of Care.
3. Be able to describe the “Environment of Care”
“triggers” to a CMS “Immediate Jeopardy” finding
and the consequences associated with the finding.
4. Be able to describe and implement “tips” for a
successful survey.
Trivia
How many light bulbs should you
consider for lighting at the exit?
Only one is required
At least two
More than two
Trivia - Answer
7.8.1.4 Required illumination shall be
arranged so that the failure of any single
lighting unit does not result in an
illumination level of less than 0.2 ft candles
(2 lux) in any designated areas.
– Surveyors are looking for two bulbs in the
outside exit area.
– Have you evaluated at night?
Trivia
In Chapter 7 Means of Egress – 2000
LSC is it:
– A. Not an Exit
– B. No Exit
– C. I don’t care
Trivia - Answer
7.10.8 Special Signs.
7.10.8.1* No Exit. Any door, passage, or stairway that
is neither an exit nor a way of exit access and that is
located or arranged so that it is likely to be mistaken
for an exit shall be identified by a sign that reads as
follows:
NO
EXIT
Such sign shall have the word NO in letters 2 in. (5 cm)
high with a stroke width of ⅜ in. (1 cm) and the word
EXIT in letters 1 in. (2.5 cm) high, with the word EXIT
below the word NO.
“No Exit” not to scale.
Trivia
What is the “maximum” height you can
mount a portable fire extinguisher?
– 4ft
– 3 ½ ft
– 3 ft
– 5 ft
Trivia - Answer
1-6.10 Fire extinguishers having a gross
weight not exceeding 40 lb (18.14 kg) shall
be installed so that the top of the fire
extinguisher is not more 5 ft (1.53 m) above
the floor.
Fire extinguishers having a gross weight
greater than 40 lb (18.14 kg) (except
wheeled types) shall be so installed that the
top of the fire extinguisher is not more than
3 1/2 ft (1.07 m) above the floor
Trivia
What is the “minimum” distance
that a portable fire extinguisher is
mounted off the floor?
–
–
–
–
4ft
3 ft
4 inches
12 inches
Trivia - Answer:
In no case shall the clearance
between the bottom of the fire
extinguisher and the floor be less
than 4 in. (10.2 cm).
Trivia
What information is required to be
shown on a set of Life Safety
Drawings?
Standard LS.01.01.01, EP 2, requires an organization to have a
current SOC. Part of having a current SOC is creating and
maintaining an up-to-date and complete Basic Building Information
(BBI). The BBI requires organizations to indicate the location of
current LS drawings. So, if your organization could not supply
current LS drawings, then it was not in compliance with the
requirement for a current BBI and consequently an up-to-date SOC
Trivia – Answer
According to The Joint Commission’s “Life Safety” chapter, Life
Safety Code drawings must clearly display the following
information:
1) A legend that clearly identifies features of fire/Life safety
2) Areas of the building that are fully sprinklered (if the building
is partially sprinklered)
3) Locations of all hazardous storage areas
4) Locations of all fire-rated barriers
5) Locations of all smoke barriers
6) Suite boundaries, including the sizes of the identified suites —
both sleeping (maximum 5,000 square feet) and nonsleeping
(maximum 10,000 square feet) suites
7) Locations and size (sqft) of designated smoke compartments
8) Locations of chutes and shafts
9) Any approved equivalencies or waivers
Trivia
Provide some parameters regarding
the 18” inch storage rule:
– 1.
– 2.
– 3.
– 4.
The Rule
Sprinklers and storage areas (including
perimeter wall shelving)
There must be 18” clear from the bottom of the sprinkler
deflector to any storage or shelving. This is measured as a
horizontal plane in the room (not conical measurement from
the sprinkler head). This is a vertical measurement.
Horizontally sprinklers can be as close as 4” (closer in some
instances with special installations). (See NFPA 13-2010,
8.6.3.3 “Minimum Distances from Walls. Sprinklers shall be
located a minimum of 4 in. (102 mm) from a wall.”) and
A.8.6.6 regarding shelving
Trivia
What is the “height” that a manual
fire alarm pull station should be
mounted off the floor?
–
–
–
–
2 ½ ft – 5 ½ ft
4ft - 5 ft
3 ½ ft - 4 ½ ft
12 inches
Trivia – Answer
Per NFPA 72 2-8.1 Each manual fire alarm
box shall be securely mounted. The
operable part of each manual fire alarm
box shall not be less than 3 ½ feet and
not more than 4 ½ feet above the floor.
Trivia
What is the recommended height to
mount a sharps container?
– 52-56 inches
– 50-54 inches
– 40-46 inches
– It depends
Hint: NIOSH DHHS Publication Number 97-111 Selecting,
Evaluating, and Using Sharps Disposal Containers – 1998
Trivia - Answer
The Joint Commission Life
Safety and Environment of
Care Survey Process
• The Joint Commission survey process
continues to evolve along with its
standards. Providence Health & Services
has created a “CORE SURVEY TEAM” to
conduct mock Joint Commission surveys
at all of its 36 hospitals in the 5 western
states.
• The size and composition of the Joint
Commission survey team varies according
to the size of the organization and types
of services being surveyed. However, the
team includes some combination of
nurse, physician, and/or administrative
surveyor . A life safety code &
Environment of Care specialist is also on
the survey team for all hospitals.
• Today, all surveys are unannounced,
and organizations are encouraged to
maintain a state of continuous
readiness. The unannounced survey
process emphasizes the need for
training and involvement of all staff
in managing the patient care
environment.
The Life Safety Code Specialist
The life safety code (LSC) specialist focuses on
compliance with the Life Safety Code, the Joint
Commission’s Statement of Conditions(eSOC) and Plans
for Improvement (ePFI), the Environment of Care
standards, and in most surveys Emergency Management.
The Life Safety specialist is usually a Facilities
Manager/Director and/or Safety Officer with >20+ years
experience.
Depending on the size of the facility, the survey process
will take anywhere from 1 to 3 days.
The Life Safety/EOC survey usually consists of
the following elements:
1. Document Review – 2 hrs. to half day
2. Building Tour - will tour the building and may want to
tour construction sites – from half day to 1 ½ days
depending on size of facility
3. Environment of Care Session
4. Emergency Management session
Note: Some surveys do a combined EOC and EM
session
The Providence Core Survey Team
1. Core Surveys are designed to mirror actual Joint Commission
Surveys, and survey to all of the JC and CMS standards
2. Digs much deeper into standards compliance than typical JC
3. Member of Core Survey Team attends all actual JC surveys to assist
facility. (Usually one of the clinical team members)
4. Looks for survey trends and any “HOT BUTTONS” that the JC
surveyors are identifying.
5. Communicates these survey trends and “HOT BUTTONS” to all
Providence Hospitals so they can ensure compliance.
6. Utilize several approaches to communicate information to all
affected staff across the “Providence System”, i.e., mass email
distribution lists, weekly newsletters, monthly conference calls,
regulatory updates when needed, and annual regulatory update 2day conferences
Life Safety, Environment of Care, & Emergency
Management Sessions
Day 1 - Morning - Life Safety Code Document Review:
Attendees: Facilities/Physical Plant Manager, Life Safety Specialist, Construction Project Manager,
Physical Plant Engineers/Specialists, Facilities Admin Asst.
1 eSOC with ePFI's
2 Facility Life Safety Drawings
CMS Categorical Waivers in place (Ensure if any door locking arrangements exist that release with
3
FA, waiver has been adopted)
3 Fire Alarm System testing, inspections and repair of deficiencies for last 2 years
Inventory of all fire alarm activation, notification, and door release devices (Include AHU shutdown
4
devices and chime strobes)
5 Sprinkler System testing, inspection and repair of deficiencies for last 2 years
6 Generator testing, inspection and repair of deficiencies for last 2 years
Qualifications and Certifications for all staff performing maintenance and servicing of Fire/Life Safety
7
Systems, Life Support equipment, and bldg components
8 Elevator fire service monthly testing
9 Medical Gas system testing, inspection and repairs for last 2 years
Air exchange rates, air pressure relationships, temperature and humidity checks for all
10
anesthetizing, procedural locations, central processing, and sterile storage areas
11 Construction projects currently underway and locations, daily construction inspection checklists
12 Pre-Construction Risk Assessments, ILSM's and ICRA's implemented or in place at time of survey.
13 Construction Risk Assessment, ILSM and ICRA policies.
Day 1 – Afternoon (and day 2 at larger facilities) – Building LS & EOC Tour
Day 2 or 3 - Environment of Care document review:
Attendees: Environment of Care Plan Managers and optional EOC/Safety
committee members
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Safety and Security Risk Assessments
All EOC management plans
All EOC management plan quarterly reports for last 2 years
All EOC annual evaluation of plans (except CAH's)
EOC meeting minutes for last 2 years
Utilities Equipment inventory list - (Will select random piece of critical equipment to trace for
compliance with CMS S&C 14-07)
Medical Equipment inventory list - (Will select random piece of critical equipment to trace for
compliance with CMS S&C 14-07)
If AEM is used, are Facility and Bio-Med equipment and systems inventoried by "following mfgs" or
"following AEM"?
Hazardous Materials inventory list - 6 months hazardous waste manifests
Hazardous Waste inventory list - 6 months Medical waste manifests
DOT training certifications for HAZMAT handlers and shippers
Hazardous Surveillance Rounds (EOC rounds) for last 2 years (including satellites)
Performance Improvement data for all EOC Plans
Fire Drills and Critiques for last 2 years (including satellites)
Fire Response Plan (Fire Plan)
Infant and Pediatric Abduction Plans and drills for last 2 years
Nuclear Medicine Hot Lab Security Plan and Isotope Courier Delivery Procedure
Day 2 - Emergency Management document review
Attendees: EM Plan Manager and optional EM committee members
1 Identification of Plan manager and designated Senior leader responsible for Emergency Mgmt
2 Emergency Operations Plan
3 Hazard Vulnerability Analyses
4 Emergency Supply Inventory list
5 Annual evaluations of EOP, HVA and Emergency Supply Inventory
6 Annual reviews of MOU's for alternate care sites and transportation agreements
7 Disaster drill critiques for last 2 years
8 Utility Contingency Plans
Documentation that the hospital has communicated, in writing, with each of its licensed
9 independent practitioners regarding his or her role(s) in emergency response and to whom he or
she reports to during an emergency.
Day 2 or 3 – End of survey report
• Written and verbal report out of survey findings to C-Suite and
leadership team. Report all deficiencies identified and any
recommendations to assist facility and staff with future
compliance.
Top Joint Commission Findings in
Life Safety and the Environment of
Care for 2014 & 1st Qtr 2015
Non-Compliance Rate for the Most Challenging EC/LS Standards by EPs
2014 and 1st Qtr 2015
Standard
EP
Description
In areas designed to control airborne contaminants, ventilation
6 (15) system provides appropriate pressure relationships, air-exchange
rates, and filtration efficiencies
EC.02.05.01
Hospital labels utility system controls to facilitate partial or complete
(53%)
8
emergency shutdowns.
Hospital designs and installs utility systems that meet patient care
1
and operational needs.
Exits, exit accesses, exit discharges are clear of obstructions or
13 impediments to public way, such as clutter, construction material, and
LS.02.01.20
snow and ice.
(50%)
Doors in a means of egress are not equipped with a latch or lock that
1
requires the use of a tool or key from the egress side.
Interior spaces meet the needs of the patient population and are safe
1
EC.02.06.01
and suitable to the care, treatment, and services provided.
(56%)
The hospital maintains ventilation, temperature, and humidity levels
13
suitable for the care, treatment, and services provided.
%
33
21
10
22
17
39
17
53% EC.02.05.01: Risks with Utility Systems
EP 15 - TJC is scoring problems with pressure differentials and air exchange
rates in critical areas. Staff need to know what their special pressure
relationship is, either positive or negative and what they can do while
working in that environment to maintain the appropriate pressure
relationship, such as keeping doors closed.
A meter, ball-in-the-wall, or performing a tissue test are all appropriate
means to determine air pressure relationships.
TJC and CMS are looking for verification that periodic testing and balancing
are occurring in critical care areas and staff are aware of what the readings
mean, as well as what risks are present when pressure relationships are
incorrect.
EP 8 – This is the EP that addresses Utility system emergency shutdown
labeling. TJC is looking for placards mounted on or by the emergency shutoffs
of all major utilities and bulk med gas systems. These locations should be the
first major isolation points under the facilities control, examples include:
Natural gas shutoff valve just past the main regulator
Main normal-power electrical breaker(s)
Main domestic water and fire sprinkler water valves
Bulk O2 “source” valve
Med gas manifold “source” valves
Vacuum and med air plant “source” valves
Main steam shutoff valve(s)
Main chilled water shutoff valve (s)
Diesel or propane tank main shutoff valve (s)
Placards should list: “name of utility” Emergency Shutoff, area(s) served, and
cautionary language “shut in event of emergency only”.
50% LS.02.01.20: Maintaining means of Egress
EP 13 Exit access and discharge clear of obstructions, to public way.
This is the corridor clutter or junk in the hallways.
CMS has allowed a categorical waiver for corridor clutter and if
adopted, will allow crash carts, infection control Isolation carts,
rolling (portable) patient lift equipment, and patient transport
equipment (stretchers and wheel chairs) to be stored in corridors
providing there is an unobstructed 5’ clear width, and the entity has
addressed in their fire plan, removal of such equipment during an
emergency or fire event.
EP 1 Doors in means of egress unlocked in direction of egress.
CMS has also allowed a categorical waiver for door locking
arrangements when their are “clinical needs” as long as certain
procedures are followed, i.e. Behavioral health units, mother/baby
units, some inpatient rehab units. Entity must adopt the waiver and
have a written summary of the “clinical need”.
56% EC.02.06.01 Maintains safe functional environment
EP 1 Interior spaces meet the needs of the patient population and are
safe and suitable to the care, treatment, and services provided.
This is kind of a catch-all. This EP is also used for serious pressure
relationship deficiencies and if cited, will be cited as a condition-levelfinding requiring a re-survey in 45 days. In some instances where
immediate corrections have occurred, TJC has rolled these back to
EC.02.05.01 EP 15 as a standard-level finding.
EP 1 is also where TJC will soon be surveying for correct special
relocatable power taps in the healthcare setting.
EP 13 Maintains ventilation, temp, humidity levels suitable for care.
Operating room environments, Cath Labs, C-section OR’s, sterile
processing, decontam, sterile supply storage areas all have special
requirements relative to temperature and humidity. Temp and humidity
in these areas must be either continuously monitored and alarmed, or
logged daily on a special log sheet. Out-of-parameter temp and/or
humidity excursions must be addressed by entities policy/procedure.
25
3
EC.02.03.05
(48%)
19
4
2
5
LS.02.01.10
(46%)
Documentation of maintenance, testing, and inspection activities for
fire alarm and water-based fire protection systems.
Every 12 months, the hospital tests duct detectors, electromechanical
releasing devices, heat detectors, manual fire alarm boxes, and
smoke detectors.
Every 12 months, the hospital tests automatic smoke-detection
shutdown devices for air-handling equipment.
Every 12 months, the hospital tests visual and audible fire alarms,
including speakers.
At least quarterly, the hospital tests water-flow devices. Every 6
months, the hospital tests valve tamper switches.
Every quarter, the hospital tests fire alarm equipment for notifying offsite fire responders.
17
14
14
11
10
10
9
The space around pipes, conduits, bus ducts, cables, wires, air ducts,
or pneumatic tubes that penetrate fire-rated walls and floors are
protected with an approved fire-rated material.
24
5
Doors required to be fire rated have functioning hardware, including
positive latching devices and self-closing or automatic-closing
devices. Gaps between meeting edges of door pairs are no more than
1/8 inch wide, and undercuts are no larger than 3/4 inch.
20
4
Openings in 2-hour fire-rated walls are fire rated for 1 1/2 hours.
17
48% EC.02.03.05 Maintains fire safety equipment and bldg. features. TJC
looks at most/all of the 21 EPs in this standard during document review.
There are 6 EPs that have risen to the top.
EP 25 Documentation of maintenance, testing, and inspection activities
for fire alarm and water-based fire protection systems includes the
following:
- Name of the activity,
- Date of the activity,
- Required frequency of the activity,
- Name and contact information, including affiliation, of the person who performed the activity,
- NFPA standard(s) referenced for the activity,
- Results of the activity
EP 3 Most of the FA devices are tested under this EP. Over half the
hospitals across the nation are failing this. TJC is looking for complete
inventories of all devices, by device and location, with pass/fail results for
each device. A common flaw is not meeting the new timing requirements
for the PM’s, or not including an inventor list of door release devices.
Another flaw is not closing the loop when making device repairs and
retest.
EP 19 Every 12 months, the hospital tests the automatic smoke-detection shutdown
devices for air handling equipment. Common flaws are either not completing this
separate AHU shutdown test in addition to the EP3 duct detector tests, or not
including a complete inventory of all air handlers showing pass/fail of each when
auto shutdown is tested.
EP 4 This covers the testing of all audible/visual FA devices, including speakers. The
most common flaw found with this EP is doing the tests by saying something like “all
strobes” or “all audible & visual devices” were tested and passed. But TJC is looking
for a complete and detailed inventory of strobes, chimes, horns, speakers, etc., by
location or other identifier, with pass/fail results for each device.
EP 2 Quarterly testing of water flow devices and 6-mo testing of valve tamper
switches. Hospitals cited under this EP either are not providing complete inventories
of devices with pass/fail, or are not meeting the timing requirements for testing.
Another flaw is not closing the documentation loop on repairs and retest.
EP 5 Quarterly testing of FA equipment for notifying off-site responders. The most
common flaw here is not documenting the completion of this test or not showing
response times on report.
Joint Commission’s Maintenance Timing Requirements
•
•
•
•
•
Every 36 months/every 3 years = 36 months from the date of the last event, plus or
minus 45 days
Annually/every 12 months/once a year/every year = 1 year from the date of the last
event, plus or minus 30 days
Every 6 months = 6 months from the date of the last event, plus or minus 20 days
Quarterly/every quarter = 4 times a year, once in each quarter every three months,
plus or minus 10 days
Monthly/30-day intervals/every month = 12 times a year, once per month
46% LS02.01.10 Building Features Minimize Effects of Fire and Smoke. This
standard is usually scored at EP 5 for fire doors, or EP 9 for penetrations.
EP 5 The fire door issue is often that the door does not auto-close and latch
appropriately. This is usually caused from doors being banged into by carts,
stretchers, and or rolling equipment. Another flaw found here is the gap
between meeting door edges >1/8th inch or undercuts >3/4 inch.
EP 9 The penetration issue is usually due to lack of an above ceiling permit
program or contractors not sealing around conduits and pipes during new
installations. A vigorous barrier inspection PM program along with
inspection of new installation work by the facilities staff can usually catch
most of these deficiencies.
EP 4 Openings in 2-hour fire-rated walls are fire rated for 1 ½ hours.
Usually this EP is cited for missing labels on 90 minute fire doors including
trash and linen chute doors, or failure of auto-closing and latching devices.
2
11
LS.02.01.30
(43%)
18
4
LS.02.01.35
(43%)
5
6
EC.02.02.01
(36%)
5
7
All hazardous areas are protected by walls and doors.
Corridor doors are fitted with positive latching hardware, are arranged
to restrict the movement of smoke, and are hinged so that they swing.
The gap between meeting edges of door pairs is no wider than 1/8
inch, and undercuts are no larger than 1 inch.
Smoke barriers extend from the floor slab to the floor or roof slab
above, through any concealed spaces, and extend continuously from
exterior wall to exterior wall. All penetrations are properly sealed.
Piping for automatic sprinkler systems is not used to support any
other item.
Sprinkler heads are not damaged and are free from corrosion, foreign
materials, and paint.
There are 18 inches or more of open space maintained below the
sprinkler deflector to the top of storage.
Hospital minimizes risks associated with selecting, handling, storing,
transporting, using, and disposing of hazardous chemicals.
Hospital minimizes risks associated with selecting and using
hazardous energy sources.
21
19
14
17
12
11
18
11
43% LS02.01.30 Protects Against Hazards of Fire & Smoke. These EP’s are
primarily scored due to smoke door issues or problems with hazardous areas.
EP 2 If a space meets the definition of a “Hazardous Areas”, it must be
protected per NFPA 101-2000 18/19.3.2.1. This includes auto-closing doors
and positive latching. Again, door closure and/or latch failures, or door
damage usually leads to this finding.
EP 11 Corridor doors. Common findings under this EP include door damage,
gaps >1/8th inch in meeting edges of double door assemblies, malfunctioning
positive latching hardware, or undercuts >1 inch.
EP 18 Smoke barriers. This EP is usually cited for penetration issues found
in your smoke barrier walls. TJC has a history of choosing one or more
smoke barrier walls and inspecting them from exterior wall to exterior wall.
43% LS.02.01.35 Maintains Systems for Extinguishing Fires
EP 4 Usually cited during building tour when discovered that things
are tied off or draping over sprinkler pipe above the ceiling.
Contractors and staff placing cables or wiring often tie these off to
the sprinklers.
EP 5 Damaged, dirty, corroded, or painted sprinkler heads are cited under this
EP. Also dust bunnies on sprinkler heads deposited from the air handler system
are also cited.
EP 6 The infamous 18” clearance from the bottom of the sprinkler head
deflector.
36% EC.02.02.01 Manage Risks Related to Hazardous Material & Waste
EP 5 This deals with hazardous waste and hazardous product
management. Quite often the finding is related to hazardous chemicals
and not having an eye wash station in the immediate area where the
corrosive or toxic chemical is being used. Another common finding is the
eye wash weekly logs. They are either missing or have gaps in the testing
entries.
EP 7 You will see hazardous radiation issues scored against this EP, either
staff not returning their dosimeter badges or failure to inspect lead shields
each year.
CMS “Immediate Jeopardy” triggers
Immediate Jeopardy - “A situation in which the provider’s noncompliance with
one or more requirements of participation has caused, or is likely to cause, serious
injury, harm, impairment, or death to a resident.”
Only ONE INDIVIDUAL needs to be at risk. Identification of Immediate Jeopardy for
one individual will prevent risk to other individuals in similar situations.
Serious harm, injury, impairment, or death does NOT have to occur before
considering Immediate Jeopardy. The high potential for these outcomes to occur in
the very near future also constitutes Immediate Jeopardy.
After determining that the “harm” meets the definition of Immediate Jeopardy,
consider the following points regarding entity compliance:
•
The entity either created a situation or allowed a situation to continue which
resulted in serious harm or a potential for serious harm, injury, impairment or
death to individuals.
•
The entity had an opportunity to implement corrective or preventive measures
Infection Control
ISSUE
TRIGGERS
Failure to protect from widespread
1. Pervasive improper handling of body
nosocomial infections; e.g., failure to
fluids or substances from an individual
practice standard precautions, failure to
with an infectious disease;
maintain sterile techniques during invasive 2. High number of infections or
procedures and/or failure to identify and
contagious diseases without
treat nosocomial infections
appropriate reporting, intervention and
care;
3. Pattern of ineffective infection control
precautions; or
4. High number of nosocomial infections
caused by cross contamination from
staff and/or equipment/supplies.
Physical Environment
ISSUE
TRIGGERS
Failure to provide safety
from fire, smoke and
environment hazards
and/or failure to educate
staff in handling emergency
situations.
1. Nonfunctioning or lack of emergency equipment
and/or power source;
2. Smoking in high risk areas;
3. Incidents such as electrical shock, fires;
4. Ungrounded/unsafe electrical equipment;
5. Widespread lack of knowledge of emergency
procedures by staff;
6. Widespread infestation by insects/rodents;
7. Lack of functioning ventilation, heating or
cooling system placing individuals at risk;
8. Use of non-approved space heaters, such as
kerosene, electrical, in resident or patient areas;
9. Improper handling/disposal of hazardous
materials, chemicals and waste;
10. Locking exit doors in a manner that does not
comply with NFPA 101;
11. Obstructed hallways and exits preventing egress;
12. Lack of maintenance of fire or life safety
systems; or
13. Unsafe dietary practices resulting in high
potential for food borne illnesses.
“TIPS” for a Successful Life Safety
and EOC survey
• Be present at the opening conference (Facilities Mgr/Director and Safety
Officer)
• At the opening conference, disclose verbally and/or in writing, which CMS
categorical waivers the facility has formally adopted. Adoption means
approved by the facility’s EOC committee and the waivers have been written
into comments section of eBBI on JC website.
• Have at least 2 years of operational and maintenance records available,
organized, inventory’s of all devices, and easy to read. Recommend
organizing them by JC standard and EP.
• Be familiar with the LS and EOC standards and elements of performance.
• Have a written policy and program in place that includes periodic air balance
and pressurization checks of critical spaces, i.e., OR’s, C-Section rooms, Cath
Labs, Sterile Processing, Decontam, Endoscopy procedure rooms, Scope
cleaning rooms, Negative Pressure Isolation rooms, etc. How do you ensure
you are in compliance 100% of the time?
Tips…..Continued
• Are you monitoring temperature and humidity in all required locations?
i.e., OR’s, C-Section rooms, Sterile Core areas, Cath Labs, Sterile
processing, all sterile supply storage locations, etc. Are the spaces
monitored via a building automation system or are you using manual
devices and logs? How do you ensure the continual accuracy of all field
mounted temp and humidity devices?
• Have a written humidity and temperature policy that describes your
program and also describes actions for clinical and non-clinical staff to
take when excursions from the established operating ranges occur.
• Have an effective “above-the-ceiling permit” program in place as part of
your barrier management program. Strongly enforce it with staff and
contractors.
• Ensure your EOC program includes management of all off-site and
satellite buildings under the hospital’s license. This includes annual
evacuation fire drills, FA and sprinkler testing/maintenance (same as
hospital), EM drills, environmental tours, etc.
•
Have representation from your I.S. department on your EOC committee
to represent and “ability to speak to” those vital network and
communication “utility” systems.
•
Have representation for all construction processes on your EOC
committee.
•
During EOC and EM sessions, brag about your accomplishments. Have
staff attend that can represent and talk about all EOC functional areas.
Note: The more you share and talk during the sessions, the less questions the JC surveyor will ask.