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 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

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No Outdated Pharmaceutical of Food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 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

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 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

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 246-320-296
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. 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)

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 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)

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. RHQN Executive Director
Randy Benson
RHQN Executive Director