DOH Survey Citation Update; What’s New, What’s Hot, What’s Not!

 This Month’s Focus: Common DOH Survey Citations From the Last Six Months Fire Marshall  Fire Doors  Fire Drills  Combustible Materials Storage  Flammable Materials Environment of Care  Annual Report to Safety Committee  Wheel Chair Maintenance  Infection Prevention During Construction  Food Services

 The Fire Marshal: Fire Doors  Gaskets  Self-Closing  Nickel Rule  Fire Resistant Rating  Blocking Fire Doors

 The Fire Marshal (con’t) Fire Drills  One Per Shift Per Quarter  Employee Response Criteria  Fire Response Object  Evaluation  Education Time Frames Employee Knowledge Evacuation Routes and Strategies

 The Fire Marshal (con’t) Combustible Materials Storage  Oxygen Cylinders  Shredding Paper Receptacles Size Location Storage  Cardboard  Sprinkler Systems Flammable Materials  Documentation (cubicle curtains, bedspreads)

 Environment of Care New Area For Citations Focus on the Seven Areas of the Environment of Care  Safety Management  Security Management  Utilities Management  Medical Equipment Management  Emergency/Disaster Management  Hazmat Management  Life Safety Management

 Environment of Care (con’t) You Must Have a Plan That Includes:  Annual Assessment of Needs Within Each Area, Done By the Safety Committee  Plan For Achieving the Identified Goals in Each of the Seven Areas  Annual Evaluation of Achievements in Each of the Seven Areas  Annual Report to the Safety Committee and Board

 Environment of Care (con’t) Safety Management  Overall Safety of the Facility and Its Furnishings Furniture Wheel chairs** Beds Air Flow Safety Alerts** Recalls** (** New and with significant impact)

 Environment of Care (con’t) Security Management  Protection of Staff and Patients  Protection of Property  Staff Education  Placement and Testing of Panic Alarms

 Environment of Care (con’t) Utilities Management  Maintenance of Electrical Systems  Maintenance of Elevators  Maintenance of Potable Water System Back Flow Valves  Maintenance of HVAC (Positive and Negative Air Flow) Endoscopy, Dirty Utility, ORs

 Environment of Care (con’t) Medical Equipment Management  Process for Doing Preventive Maintenance on All Equipment Owned By the Facility  Clinical Equipment Focus Life Sustaining Equipment (Quarterly) Life Supporting Equipment (Semi-Annually) Non-Life Supporting Equipment (Annually)  Wheel Chairs Policy for Cleaning Policy for Storing Policy for Maintenance

 Environment of Care (con’t) Emergency/Disaster Preparedness  Plan (Updated Regularly)  Education (Annually)  Risk Assessments (Annually by Safety Committee)  Drills (Annually, Usually Two)  Supplies Inventory and Equipment Use Training (Portable Ventilators)

 Environment of Care (con’t) Hazmat Management  Hazardous Materials Inventory  Hazardous Materials Storage Oxygen Cylinders  Staff Training (Worker Right to Know)  Spill Kit Placement, Use, Policies  Disposal Chemical Radiologic Nuclear

 Environment of Care (con’t) Life Safety Management  Fire Safety Plan for the Entire Facility  Fire Drills  Fire Safety Training RACE PASS Evacuation Techniques  Meeting the NFPA 2000 Fire Safety Standards  Statement of Conditions (e.g. Infection Control Related to Construction, Fire Suppression System Repairs, etc.)

 Environment of Care (con’t) Food Services  Hair Nets/Caps  Jewelry  Green Cards  Food Storage  Food Preparation  Temperature Logs

 Environment of Care (con’t) Electrical Safety  Pediatric Protected Outlets  Extension Cords  Power Strips Housekeeping  Spray Bottle of Cleaners/Disinfectants  MSDS Forms For Cleaning Agents  Supply Storage Under Sinks

 DOH Survey General Comments Documentation of Preventive Maintenance Placement of Fire Evacuation Route Signage Policies For Cleaning Keyboards Secured Sharps and Syringes Defibrillator and Code Cart Checks

Randy Benson RHQN Executive Director (206)