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

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

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 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: 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(6), 246-320-201 The Safety of All Medications and Food is Mandated (see also WAC 246-215, the Food Service Code) No Outdated Pharmaceutical of Food Daily Log of Temperatures of All Refrigerators and Freezers Housing Patient Food Items or Pharmaceuticals.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

Fire Drills (NFPA 2000, WAC 246-320-296 (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 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 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 General Safety Security Hazardous Materials and Waste Emergency Preparedness Fire Safety Medical Equipment Utility Systems Physical Environment

Security 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 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

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 Physical Environment 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) 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 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 Education Transcript Everything in One Location Skills and Knowledge Department Specific Competencies Outside Education/Professional Organizations (e.g. IP, Clinical Dietitian, PT, Pharmacy)

RHQN Executive Director Randy Benson RHQN Executive Director randyb@wsha.org 206 577-1821