CIHQ - All Rights Reserved 2017 Top Hits in the Physical Environment September 2017 Billy Kinch, MHA, HACP CIHQ - All Rights Reserved 2017

Presentation Objectives By the conclusion of this program, the participant will be able to: Identify the top findings from the physical environment Strategies for maintaining compliance CIHQ – All Rights Reserved 2017

How To Impress a Life Safety Surveyor When asked a question about the Life Safety Code. Your first response is always “IT DEPENDS!” Be able to point out what a sprinkler escutcheon is CIHQ - All Rights Reserved 2017

CIHQ - All Rights Reserved 2017 Top Findings Security Risk Assessment Psychiatric Units DOT Training Eye Wash Stations Junction Boxes Testing Documentation Emergency Lighting Emergency Power Generator Inspection Electrical Panels IT Closets Equipment Inventory Cylinder Storage Power Strips Temperature/Humidity Ventilation Medical Gas Shut-off Valves Fire/Smoke Barrier Sprinkler Hazardous Areas Doors Means of Egress CIHQ - All Rights Reserved 2017

Security Risk Assessment Infant Security National Center for Missing and Exploited Children http://www.missingkids.com/en_US/publications/NC05assessment.pdf Cyber Security CIHQ - All Rights Reserved 2017

CIHQ - All Rights Reserved 2017 Psychiatric Units Assessment Design Guide for the Built Environment of Behavioral Health Facilities https://www.fgiguidelines.org/wp-content/uploads/2017/03/DesignGuideBH_7.2_1703.pdf Ligature Points CIHQ - All Rights Reserved 2017

CIHQ - All Rights Reserved 2017 DOT Training Department of Transportation Training Requirements Hazmat Employee Loads, unloads, or handles hazmat Prepares hazmat for transportation Signs waste manifests Training required within 90 days of hire and 3 years thereafter Training Records the hazmat employee’s name; the completion date of the most recent training; training materials used (copy, description, or location); the name and address of the hazmat trainer; and certification that the hazmat employee has been trained and tested CIHQ - All Rights Reserved 2017

CIHQ - All Rights Reserved 2017 Eye Wash Stations ANSI Z358.1-2014 Plumbed vs. Non-plumbed Weekly Inspections Annual Inspections CIHQ - All Rights Reserved 2017

CIHQ - All Rights Reserved 2017 Junction Boxes Must be closed Creates a fire hazard CIHQ - All Rights Reserved 2017

Testing Documentation Sets the tone of the survey Inventory of devices Pass/Fail documentation Corrective action and retest for failed devices Other requirements based on device tested Updated versions of NFPA codes Checklist on CIHQ Website CIHQ - All Rights Reserved 2017

CIHQ - All Rights Reserved 2017 Emergency Lighting EXIT Signs NFPA 101-2012 7.10.9 Battery Powered Lights NFPA 101-2012 7.9.3 CIHQ - All Rights Reserved 2017

CIHQ - All Rights Reserved 2017 Emergency Power Manual Stop Button NFPA 110-2010 5.6.5.6 CIHQ - All Rights Reserved 2017

Generator Inspections Annual Fuel Quality Test Based on ASTM Standards Weekly inspections CIHQ - All Rights Reserved 2017

CIHQ - All Rights Reserved 2017 Electrical Panels Must have a 36-inch clearance Directory must be complete – including spares CIHQ - All Rights Reserved 2017

CIHQ - All Rights Reserved 2017 IT Closets Unsealed penetrations Plywood on walls – NFPA 101-2012 18/19.1.6.6 CIHQ - All Rights Reserved 2017

CIHQ - All Rights Reserved 2017 Equipment Inventory Written Inventory of Equipment Unique ID Number Equipment Manufacturer Equipment Model Number Equipment Serial Number Description of Equipment Location of Equipment (when kept in a fixed location) Department considered to own equipment Service Provider Acceptance Date CIHQ - All Rights Reserved 2017

CIHQ - All Rights Reserved 2017 Cylinder Storage Less than 300 cubic feet 300 - 3,000 cubic feet 3,000 – 30,000 cubic feet E-Cylinder = 23 cubic feet H-Cylinder = 244 cubic feet Full vs. Empty/In-Use CIHQ - All Rights Reserved 2017

CIHQ - All Rights Reserved 2017 Power Strips Patient Care Vicinity UL1363A or 60601-1 – Patient Care Equipment UL1363 – Non-patient Care Equipment Permanently Affixed 75% of Rating Included on Inventory Routine Maintenance CIHQ - All Rights Reserved 2017

Temperature/Humidity Proper ranges No corrective action ASHRAE 170-2008 CIHQ - All Rights Reserved 2017

CIHQ - All Rights Reserved 2017 Ventilation Improper pressures ASHRAE 170-2008 CIHQ - All Rights Reserved 2017

Medical Gas Shut-off Valves Properly Labeled Blocked Access CIHQ - All Rights Reserved 2017

CIHQ - All Rights Reserved 2017 Fire/Smoke Barrier Unsealed penetrations NFPA 101-2012 8.3.5 Not properly marked on the Life Safety drawings Doors NFPA 80-2010 5.2.4.2 CIHQ - All Rights Reserved 2017

CIHQ - All Rights Reserved 2017 Sprinkler Missing escutcheon NFPA 13-2010 6.2.7 Items being supported on sprinkle pipe NFPA 25-2011 5.2.2.2 Spare sprinkler heads/wrench NFPA 13-2010 6.2.9 Testing documentation CIHQ - All Rights Reserved 2017

CIHQ - All Rights Reserved 2017 Hazardous Areas Not properly identified on drawings Doors not latching NFPA 101-2012 18/19.3.2.1 Not properly rated room CIHQ - All Rights Reserved 2017

CIHQ - All Rights Reserved 2017 Doors Fire doors having missing or painted over rating labels NFPA 101-2012 8.3.3.2.3 Not properly latching NFPA 101-2012 8.3.3.1 Door wedges NFPA 80-2010 5.2.13.3 CIHQ - All Rights Reserved 2017

CIHQ - All Rights Reserved 2017 Means of Egress Hallway clutter NFPA 101-2012 18/19.2.3.4 Special Locking Arrangements NFPA 101-2012 18/19.2.2.2.5 Confusing Exits NFPA 101-2012 7.5.2.2 Wheeled Equipment CIHQ - All Rights Reserved 2017

© CIHQ – All Rights Reserved 2017 That’s Enough Thanks for listening. Any Questions?    © CIHQ – All Rights Reserved 2017