COMMON DOH SURVEY CITATIONS UPDATE RANDY BENSON WHS HEALTHCARE QUALITY SERVICE JANUARY 2016

COMMON SURVEY CITATIONS ENVIRONMENT OF CARE/FIRE SAFETY ISSUES GOVERNED BY CHAPTER OF THE RCW AND CHAPTER OF THE WAC Inspectors are trained to survey acute care hospitals to confirm minimum compliance with appropriate state regulatory standards. They're looking for indications of system-wide deficiencies that pose risks to patient safety during a hospital visit/stay.

COMMON SURVEY CITATIONS TOP TEN ENVIRONMENT OF CARE CITATION ISSUES : ELECTRICAL WIRING AND EQUIPMENT (FM) CORRIDOR FIRE DOORS (FM) FIRE SPRINKLER TESTING AND MAINTENANCE (FM) FIRE EXTINGUISHERS (FM) ENVIRONMENT OF CARE MANAGEMENT – VENTILATION AND AIR PRESSURE TYPES OF CONSTRUCTION/HAZARDOUS AREAS (FM) SPACE HEATERS (FM) SOILED LINEN (IP) AND TRASH RECEPTACLES (FM) EMERGENCY PREPAREDNESS INFECTION PREVENTION

COMMON SURVEY CITATIONS ELECTRICAL WIRING AND EQUIPMENT (NFPA 70, NATIONAL ELECTRICAL CODE 9, 1, 2.) MISUSE OF EXTENSION CORDS DAISY CHAINS OR PIGGY-BACKED POWER CORDS OBSTRUCTED ELECTRICAL PANELS MISLABELED OR UNLABELED ELECTRICAL CIRCUIT BOXES OUTLETS THAT ARE NOT GROUND FAULT CIRCUIT (GFCI) APPROVED (PEDIATRIC PROTECTED OUTETS) PORTABLE SPACES HEATER USE (LOCATION) OPEN JUNCTION (BREAKER) BOXES (NFPA 70)

COMMON SURVEY CITATIONS CORRIDOR FIRE DOORS (NFPA 101, CMS STANDARD ) DOORS DO NOT CLOSE AND/OR LATCH PROPERLY DOORS PURPOSELY BLOCKED FROM CLOSING PENETRATIONS IN THE DOOR COMPROMISING THE SMOKE RESISTANCE OF THE DOOR (NICKEL RULE) OBSTRUCTIONS IN FIRE EVACUATION ROUTES (EQUIPMENT IN HALLWAYS)

COMMON SURVEY CITATIONS FIRE SPRINKLER TESTING AND MAINTENANCE (NFPA 101, , ,4.6.12, FPA 13, NFPA 25,9.7.5) OVERDUE TESTS/INSPECTIONS MISSING SPRINKLER HEAD ESCUTCHEON PLATES OR RINGS OBSTRUCTED SPRINKLER HEADS AREAS WITH NO SPRINKLER PROTECTION DAMAGED OR OTHERWISE COMPROMISED SPRINKLER HEADS

COMMON SURVEY CITATIONS FIRE EXTINGUISHERS (NFPA , , ) FAILURE TO PROPERLY MAINTAIN FIRE EXTINGUISHERS (MONTHLY INSPECTION OR FINDING A DISCHARGED EXTINGUISHER) NO DOCUMENTATION OF MONTHLY INSPECTION AND TWELVE MONTH RECHARGE (NOTE TIME FRAME)

COMMON SURVEY CITATIONS ENVIRONMENT MANAGEMENT – VENTILATION AND AIR PRESSURE (WAC ) FAILURE TO PROVIDE APPROPRIATE AIR PRESSURE RELATIONSHIPS THROUGHOUT THE FACILITY TO PREVENT RISK OF THE SPREAD OF INFECTIOUS ORGANISMS FAILURE TO PROVIDE ADEQUATE VENTILATION TO REDUCE THE RISK OF OBJECTIONABLE ODOR OR EXCESSIVE CONDENSATION (SURGICAL SERVICES)

COMMON SURVEY CITATIONS TYPES OF CONSTRUCTION/HAZARDOUS AREAS (FM) (NFPA 9.4.1, , , 18, , , , ) IMPROPER OR NO FIRE RATING ON DOORS LACKING ONE-HOUR FIRE-RATED CONSTRUCTION WHEN SPRINKED, MUST HAVE SMOKE RESISTANT PARTITIONS AND DOORS PROPERLY SIZED KICK PLATES ON FIRE DOORS CONSTRUCTION DOES NOT MEET NFPA 200 LIFE SAFETY CODE STANDARDS (BOTH STATE CERTIFICATE OF REVIEW AND CMS STANDARD, DOUBLE CITATION)

COMMON SURVEY CITATIONS SPACE HEATERS (NFPA , ) USE IN PROHIBITED AREAS OF THE HOSPITAL NON-PERMITTED SPACE HEATER USE HOTTER THAN 212 DEGRESS F. NO TIP-OVER SHUT OFF SWITCH PLUGGED INTO EXTENSION CORD OR POWER STRIP TOO CLOSE TO FLAMMABLE MATERIAL

COMMON SURVEY CITATIONS SOILED LINEN AND TRASH RECEPTACLES (NFPA , ) TOO LARGE TOO CLOSE TOGETHER NOT STORED IN A ROOM PROTECTED AS A HAZARDOUS AREA

COMMON SURVEY CITATIONS EMERGENCY PREPAREDNESS (WAC ) FAILURE TO HAVE A CURRENT DISASTER/EMERGENCY PREPAREDNESS PLAN (REVISION IN THE PAST THREE YEARS) (SIGNATURES) FAILURE TO EXERCISE THE PLAN ANNUALLY FAILURE BY 100% OF STAFF TO REVIEW THE PLAN ANNUALLY (BOTH GENERIC AND DEPARTMENT SPECIFIC)

COMMON SURVEY CITATIONS INFECTION PREVENTION (WAC , 1-5) FAILURE OF EOC STAFF TO USE PROPER HAND HYGIENE LACK OF A CURRENT PLAN (REVISIONS WITHIN LAST THREE YEARS) LACK OF DEMONSTRATED INFECTION PREVENTIONIST COMPETENCE LACK OF MANADATED STAFF EDUCATION ON PERTINENT ASPECTS OF IP PLAN LACK OF AN APPROVED LIST OF CLEANERS AND DISINFECTANTS FAILURE TO ROUTINELY INSPECT ALL EOC AREAS (FOOD SERVICES, CLINICAL ANCILLARY DEPTS., ETC)

COMMON SURVEY CITATIONS QUESTIONS & COMMENTS

COMMON SURVEY CITATIONS RANDY BENSON, Ph.D. WASHINGTON HOSPITAL SERVICES HEALTHCARE QUALITY SERVICE CONSULTANT (509)