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Preparation for the DOH Environment of Care Survey Semi-Annual Report Randy Benson Executive Director, RHQN.

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Presentation on theme: "Preparation for the DOH Environment of Care Survey Semi-Annual Report Randy Benson Executive Director, RHQN."— Presentation transcript:

1 Preparation for the DOH Environment of Care Survey Semi-Annual Report Randy Benson Executive Director, RHQN

2  Eight Areas of Concern: 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

3  Air Flow WAC (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

4  Air Flow: Problem Areas Open Windows Closing or Altering Doorways Altering/Repairing Ventilation Systems Failure to Maintain Proper Isolation Room Air Flow

5  Tamper Proof Electrical Outlets WAC (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

6  Tamper Proof Electrical Outlets (con’t) Issues:  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

7  Wheelchair Maintenance and Sanitation WAC and Policy for Routine Maintenance and Cleaning Proof of Compliance With Policy Identification of Clean Wheelchairs Location of Clean Wheelchairs Appropriate Procedure for Cleaning Wheelchairs

8  Food and Medication Temperatures WAC , , (6), The Safety of All Medications and Food is Mandated (see also WAC , the Food Service Code) No Outdated Pharmaceutical of Food Daily Log of Temperatures of All Refrigerators and Freezers Housing Patient Food Items or Pharmaceuticals.

9  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

10  Fire Drills (NFPA 2000, WAC (7) Establish and Implement a Plan Investigate and Correct Fire Plan Deficiencies Orient and Educate Staff and Conduct Drills On a Regular Basis

11  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  Process For Conducting Fire Drills  Process For Evaluating Fire Drills  Process For Remedial Training  Posting of Fire Evacuation Routes

12  Back Flow Valves WAC (9)(b)(iii) Ensure a Safe Potable Water Supply by attaching backflow valves to certain types of equipment  Beverage Carbonators  Commercial Laundry Machines  Dialysis Units  Dish Washers  Ice Machines

13  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)

14  Management of the Environment of Care (EOC): WAC  Manage Environmental Risks and hazards,  Prevent Accidents and Injuries,  Maintain Safe Conditions For Patients, Visitors and Staff

15 Management Plan Must Cover the Eight Areas of the EOC  General Safety  Security  Hazardous Materials and Waste  Emergency Preparedness  Fire Safety  Medical Equipment  Utility Systems  Physical Environment

16 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)

17 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

18 Emergency Preparedness  Disaster Plan  Disaster Drills  Emergency Preparedness Risk Assessment  Staff Education About Emergency/Disaster Response Fire Safety  Maintain Fire Detection System  Maintain Policies  Conduct Fire Drills (Supervise Drills)  Educate Staff

19 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

20 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 126 o F)

21 Physical Environment (con’t)  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)

22  Staff Competency 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

23 Review By DOH Surveyors (con’t)  Proof of Current License  Current Certifications (e.g. CRNA, PT, Food Handler Green Card)  Documentation of Competency Education Transcript Everything in One Location Skills and Knowledge Department Specific Competencies Outside Education/Professional Organizations (e.g. IP, Clinical Dietitian, PT, Pharmacy)

24 Randy Benson RHQN Executive Director


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