© Copyright, The Joint Commission 2011 Joint Commission Findings, Impact & Update Joint Commission...

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2011

Joint Commission Findings , Impact & Update

Joint Commission & CMS: Issue Resolution

George Mills, Sr. Engineer

Standard Interpretation Group

The Joint Commission

SIG Engineering 2011 - 2

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Top 5 Most Cited Standards in 2010

Hospitals

1. 62% RC.01.01.012. 50% LS.02.01.20 3. 44% LS.02.01.104. 38% EC.02.03.055. 37% LS.02.01.30

Critical Access Hospitals

1. 47% EC.02.03.052. 44% LS.02.01.103. 40% EC.02.05.074. 33% LS.02.01.205. 27% EC.02.06.01


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#2: LS.02.01.20 (50%)

The hospital maintains the integrity of the means of egress.EP 13 Corridor ClutterEP 12 ProjectionsEPs 16 – 22 Suites issues

Equivalize > 5000 sq ftEP 1 Doors locked in means of

egress


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Corridor Storage “If the corridor looks cluttered…it probably is” Corridor clutter is not a PFI issue Carts Allowed:

Crash Carts Isolation Carts Chemo Carts

Based on a HITF Interpretation (TJC, CMS & other AHJs) the following carts are not allowed: Linen Hampers Latex Carts

Anything in the egress corridor more than 30 minutes is storage


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Corridor Storage

Dead end corridors may be used for storage Less than or equal to 50sqft space

Converting patient room: Long term include door closure

Surge issue: based on policy patients may be treated in the egress corridor during surge conditions


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#3: LS.02.01.10 (44%) Building and fire protection features

are designed and maintained to minimize the effects of fire, smoke, and heat.EP 9 PenetrationsEPs 5 – 7 Door issuesEPs 1 & 2 Building Type issuesEP 8 Duct issues


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#4: EC.02.03.05 (38%) The hospital maintains fire safety

equipment and fire safety building features.Features of fire protection

NOTE: #1 for Critical Access Hospitals


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#5: LS.02.01.30 (37%) The hospital provides and maintains

building features to protect individuals from the hazards of fire and smoke.EPs 16 – 23 Smoke Barriers & DoorsEP 2 Hazardous Areas


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Life Safety Code Specialist

LSCS Background Facilities or Environment of Care based Prefer CHFM certification

LSCS Agenda On-Site Two Days Interfaces with survey team member(s)

LSCS Survey Focus Life Safety Chapter EC.02.05.03 EC.02.05.07 EC.02.05.09

Other “Observations”


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Life Safety Code Specialist May also survey

LD.04.01.05 EP 4 Accountability LD.04.04.01 EP 2 Hi-Priority LD.01.03.01 EP 5 Resources

All HAP and CAH will be surveyed for a minimum of 2 days by a LSCS Greater than 1.5 million sq ft will be surveyed

for a third day by the LSCS An additional day is added for every three

buildings that are classified as healthcareExample: for a HAP organization with 2 million

square feet of healthcare occupancy and 5 buildings classified as healthcare occupancy:

the number of LSCS days would be 4


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LD.04.01.05 EP 4: What to do when the documentation isn’t

there… During survey specific documentation is reviewed If the documentation is not available write the observation

as non-compliant Also score LD.04.01.05 EP 4

If the documentation becomes available later in the survey to the survey team, the team can: Consider removing the previous finding if documentation

confirms the activity was completed as per the EP LD.04.01.05 EP 4 may also be removed during survey

If the survey team would prefer not to evaluate the documentation the organization can submit clarification

If the organization clarifies after survey: SIG Engineers will review and evaluate compliance LD.04.01.05 EP 4 remains


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What Triggers ITL(Immediate Threat to Life)

Significantly compromised fire alarm system

Significantly compromised sprinkler system Significantly compromised emergency

power supply system Significantly compromised medical gas

master panel Significantly compromised exits Other situations that place patients, staff or

visitors at extreme danger


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What Triggers AFS 13

AFS 13 is only related to previously accepted PFIsFailure to make sufficient progress

(LS.01.01.01 EP 2)Failure to implement appropriate ILSMs

(LS.01.02.01 EP 3) Failure to manage previously accepted

PFIs affects the Joint CommissionBoth organizations are aware of

deficiencies that have been managed using the PFI process


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Deficiency Resolution Resolution to a deficiency:

Resolve it immediately Correct it within 45 days:

Management process that documents the deficiency and actions to resolve

ILSM must be considered Plan For Improvement located in the

Statement of Conditions™ Corrected within 6 months of the

Projected Completion Date ILSM must be considered


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45 Day Corrective Action Documented

Origination date Completion date Kept available for rolling 3 years Life Safety deficiencies Must not exceed 45 days If greater than 45 days create a Plan For

Improvement (PFI) If originally a work order, close out as complete

and generate the PFI Must be made available to the Joint Commission

During survey to confirm management of the deficiency

During CMS/Joint Commission validation process upon request


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How Many Open PFIs Are Too Many?

The PFI process was created to allow organizations to self assess and create a Plan for Improvement

The self disclosure has never defined how many is too many

The ILSM process was created to allow both the organization and The Joint Commission to be aware of Life Safety Code deficiencies

Failure to make progress on previously accepted PFIs, including failure to implement ILSMs results in Conditional Accreditation


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How Many Open PFIs Are Too Many?

Survey Process:Evaluate both closed and currently open

PFIs in the View All screenSpot check during building tour both some

closed and open PFIs to evaluate how well the organization is managing the PFI process

Evaluate the scope of PFI entries Are there life safety deficiencies Are they greater than maintenance items

(i.e. screws missing from a door hinge)


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Statement of Conditions: PFI PFIs should be related to the LS Chapter

Corridor clutter is not a legitimate PFI PFIs should provide specific information

No blanket statements “…penetrations on 3rd floor”

Specific references to Life Safety Drawings is acceptable 32 penetrations as identified on LS

Drawing 3rd Floor, Center Tower dated 3/3/2010

Projected Completion Date is for all listed items (i.e. “32 penetrations”)


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Equivalencies

The Joint Commission accepts two forms of equivalencies Traditional Equivalency

A process of field verification identifying alternative methods of fire safety that off-set the identified deficiency

Fire Safety Evaluation System (FSES) A process of calculating the features of life

safety and deducting any deficiencies, with the outcome determining if the building is equivalized based on the FSES


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History Audit Trail

The History Audit Trail is used by SIG Engineers when considering extensions or other activities related to an organization

Prior to surveying, the surveyor must preview the History Audit Trail to discover if equivalencies or other actions have occurred by SIG Engineers

When surveying, brief but accurate information entered in the File Room is important

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Building Maintenance Program

(BMP)The BMP is no longer available to offset

findings during survey, but is considered “best practice”

All EPs related to the original ten BMP items are ‘C’ categories


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Contingency Planning

Utilities exist to provide a safe and comfortable environment of care

Failure of utilities could directly impact patient care delivery

Activities associated with managing utilities are designed to ensure the reliability of the systems day to day

Contingency plans are developed to ensure reliability of utilities systems

Contingency plans address at least two issues: Utility/Equipment failure or disruption Emergency related failures or disruption


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Contingency Planning: Survey Organizations ensure their

contingency plans are current and accurate

Discuss the organization Memorandum of Understanding and its impact in the community

Evaluate against Standards & Elements of Performance

Suggest the organization include exercising these contingency plans with their Emergency Exercise


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EC.02.05.01 Utilities Mgmt.

EP 7 The hospital maps the distribution of utility systems

EP 8 The hospital labels controls for a partial or complete emergency shutdown

EP 9 The hospitals has procedures for responding to utility system disruptions

EP 10 The hospitals' procedures address shutting off the malfunctioning system and notifying staff in affected areas

EP 11 The hospitals procedures address performing emergency clinical interventions during utility systems disruptions

EP 12 The hospitals procedures addresses the following: How to obtain emergency repair services

EP 13 The hospital responds to utility system disruptions as described in its procedures


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EM.02.02.09: Utility DisruptionEmergency Operations Plan identifies alternative

means of providing: EP 2 electricityEP 3 water needed for consumption and

essential care activitiesEP 4 water needed for equipment and sanitary

purposesEP 5 fuel required for building operations or

essential transport activitiesEP 6 medical gas/vacuum systemsEP 7 Utility systems defined as essential, such

as Vertical & horizontal transport Heating & cooling systems Steam for sterilization

EP 8 Utility needs identified in the HVA


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Time DefinedThe Joint Commission EC chapter defines time as:

Daily, weekly, monthly and quarterly are calendar references

Semi-annual is 6 months from the last scheduled event +/- 20 days

Annual is 12 months from the last scheduled event +/- 30 days

3 years is 36 months from the last scheduled event +/- 45 days

NOTE 1: The above does not apply to required frequencies such as emergency generator testing (see EC.02.05.07 EP 4 & 8)

NOTE 2: An alternative of developing either a unique, written policy or adopting NFPA definitions when available is acceptable


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Semiannual: +/- 20 daysAnnual: +/- 30 days

Due Date

Due Date

Scheduled Month

Scheduled Month

20 202020

30 303030

July Sept OctAug NovJune Dec

Jan F M A J J O N

Semiannual

Annual

+ +

JanM A S D

Frequencies required by Code may not be modified (i.e. EC.02.05.07 EP 4 & 8)


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Does Every mean Every ? EC.02.03.05

EP 13 Every 6 months the hospital inspects any automatic fire extinguishing systems in a kitchen. The completion date of the test is documented. Every 6 months +/- 20 days

EP 12 Every 12 months the hospital tests visual and audible alarms, including speakers. The completion date of the test is documented. Every 12 months +/- 30 days

At least monthly the hospital inspects portable fire extinguishers. The completion dates of the inspections are documented. Tested within the calendar month


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PRA EC.02.06.05 EPs 2 & 3

Preconstruction Risk Assessment (PRA)Construction or renovation in occupied

healthcare facilities can result in environmental problems such as:NoiseVibration Creation or spread of contaminantsDisruption of essential servicesEmergency ProceduresAir quality


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Interim Life Safety Measures Order of Standards (LS.01.02.01)

EP 1 & 2 regardless of ILSM policyEP 3 must clearly define the ILSM

policy including AFS 13 Process When to implement What to do to protect occupants Both construction related and non-

compliance with the LSCEPs 4 – 14 align with policy and

implementation strategies


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Fire WatchAn organization experiencing a compromising

situation (4 out of 24 hours) must implement a fire watch until the fire alarm system or sprinkler system has been returned to service or is stable. In many situations, this distinction comes

down to whether an event or activity is scheduled or unscheduled.

A scheduled activity would be an event known to and under the knowledge of and control of organization staff a construction project servicing or upgrading the fire alarm system

or sprinkler system.


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Service SituationFire WatchRequired?

ILSM EvaluationRequired?

Putting a shield over one smoke detector to prevent dust/false alarms for more than 4 hours

No Recommended

Rationale: Other features of fire protection are not compromised during the event, such as additional smoke detectors or sprinkler heads in the affected area.

Covering all smoke detectors during a controlled event, such as only during the time contractors are working in an affected area, although after hours, the entire area is fully operational

No Yes

Rationale: During a controlled event the organization is managing the deficien cy. The area would be continually monitored, and ILSM should be implemented as per policy.

Shutting off a zone valve to the sprinkler system or disabling a fire alarm zone for more than 4 hours

● Scheduled event (that is, working on, servicing, or upgrading fire alarm system or sprinkler system)

Not in allcases

Yes (emphasison occupantnotification)

Rationale: During a controlled event, the organization is managing the defi ciency. The area would be continually monitored, and ILSM would be implemented as per policy.

●

Unscheduled event (that is, shutting off a zone valve to the sprinkler system or disabling a smoke zone for more than 4 hours in response to a system failure)

Yes Yes


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EC.02.06.05 EP 1 Effective 1/1/2011 the Joint Commission will

recognize the Facilities Guidelines Institute (FGI) Guidelines for Design & Construction of Health Care Facilities

ASHRAE 170 has been attached to the Guidelines Ventilation Table 20 – 60 % RH requirement of relative humidity in

seven affected areas of the Surgical Environment, and one in Diagnostic & Treatment. NOTE CMS has not adopted this, but remains

at 35 – 60%RH The established 60% upper range however

should be maintained for issues such as mold growth.


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RH% Treatment Areas

Class A Operating/Procedure room Class B and C operating rooms Operating/surgical cystoscopic rooms Delivery room (Caesarean) Treatment rooms Trauma room (crisis or shock) Laser eye room Diagnostic & Treatment: Gastrointestinal

Endoscopy Procedure Room


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General Life Safety Interpretations

ASHRAE 188 Prevention of Legionellosis Associated with Building Water Systems

This 29 page DRAFT document provides guidance related to Legionella mitigationSite survey to identify risk points

i.e. water towers Mitigation strategies

Water treatments • what to do if contamination occurs,

such as secondary treatment


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Central Sterile Layout Physically separated soiled and clean work rooms

Soiled Work Room: Work surface, sink, washer/sterilizer decontaminators Soiled room is not to have direct contact with the OR

Clean assembly /work room Hand washing station Sufficient workspace and equipment

Self-closing door or pass through is acceptable between soiled and clean work rooms

Storage provisions for humidity, temperature, and ventilation Location of storage may be within the clean assembly/

workroom in a permanently designated space

Guidelines for Design & Construction of Health Care Facilities FGI 2010 edition 3.7-5.1.2 - 3.7-5.1.2.3


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Ventilation (Table 7-1)

FunctionPressure

Relationship

Min Outdoor

ACH

Minimum Total ACH

All Room Air

Exhausted Directly Outdoors

Relative Humidity

Design Temp.

°F

Equip. Room

Negative N/R 10 Yes N/R N/R

Soiled or Deconta

mNegative 2 6 Yes N/R 72 – 78

Clean Work Room

Positive 2 4 N/R Max 60 72 – 78

Sterile Storage

Positive 2 4 N/R Max 60 72 – 78

ANSI/ASHRAE/ASHE Standard 170-2008 Table 7-1


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Changes to EC.02.03.05 EP 2

Existing: Every six months the hospital tests

valve tamper switches and water-flow devices. The completion date of the tests is documented.

NOTE: for additional guidance on performing tests see NFPA 72-1999 (Table 7-3.2)


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Revised: EP2 For hospitals that use Joint Commission

accreditation for deemed status purposes: At least quarterly the hospital tests water-flow devices. Every 6 months the hospital tests valve tamper switches. The completion date is documented.

NOTE: For additional guidance on performing tests see NFPA 25-1998 (Section 2-1.3 & 2.3.3) and NPFA 72-1999 (Table 7-3.2 and Section 7-5.2).


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EP 2 (continued) For hospitals that do not use accreditation for deemed status purposes: Every 6 months, the hospital tests valve tamper switches and water-flow devices. The completion date of the tests is documented. Note: For additional guidance on performing tests, see NFPA 72, 1999 edition (Table 7-3.2).


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NEW: EC.02.03.05 EP 25

For hospitals that use Joint Commission accreditation for deemed status purposes:Documentation of maintenance, testing,

and inspection activities for fire alarm and water-based fire protection systems includes the following:

Next Slide for ContentsNote: For additional guidance on documenting

activities: NFPA 25, 1998 edition (Section 2-1.3) NFPA 72, 1999 edition (Section 7-5.2)


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NEW: EC.02.03.05 EP 25Continued Text: Name of the activity Date of the activity Required frequency of the activity Name and contact information,

including affiliation, of the person who performed the activity

NFPA standard(s) referenced for the activity

Results of the activity


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NEW: EC.02.03.05 EP 25

For hospitals that use Joint Commission accreditation for deemed status purposes: Documentation of maintenance,

testing, and inspection activities for fire alarm and water-based fire protection systems includes the following:

Note: For additional guidance on documenting activities: NFPA 25, 1998 edition (Section 2-1.3) NFPA 72, 1999 edition (Section 7-5.2)


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Fire & Smoke Damper Inspections

Ensure inaccessible dampers truly are by random sampling

Confirm ILSM policy is implemented for any horizontal exits or egress enclosures that are compromised by inaccessible dampers

Evaluate adequacy of damper accessibility plan


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LS.02.01.34 EP 2 Master Alarm Panel

The master fire alarm control panel is located in a protected environment (an area enclosed with 1-hour fire-rated walls and ¾ hour fire rated doors) that is continuously occupied OR in an area with a smoke detector. NFPA 72-1999 1-5.6 & 3-8.4.1.3.3.2


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Fire Extinguisher: Dating

Month, day year and initials of inspector as per NFPA 10-1998 EC.02.03.05 EP 15

4-3.4 Inspection Recordkeeping.4-3.4.1 Personnel making inspections shall keep records of all

fire extinguishers inspected, including those found to require corrective action.

4-3.4.2 At least monthly, the date the inspection was performed and the initials of the person performing the inspection shall be recorded.

4-3.4.3 Records shall be kept on a tag or label attached to the fire extinguisher, on an inspection checklist maintained on file, or in an electronic system (e.g., bar coding) that provides a permanent record.

DO NOT COUNT DAYS, BUT ENSURE MONTHLY INSPECTION


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Perimeter shelving and sprinkler provision:Are perimeter wall shelving that

extends to the ceiling required to be fastened to the wall?

NO Shelving is not required for storage There is no correlation between

• Shelving• Clearance • The need to secure any shelving


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18” rule

18”18”

OK OK OKWrong

Wall Wall

Ceiling

Perimeter Shelving Perimeter

Shelving


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Rated doors must have legible labels on the door and jambsJambs prior to 1966 may not have a rating label

Are ILSM in place where non-compliant door assemblies are found?


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Firestop: Existing application is acceptable

whenIt was installed in a manner

consistent with original design specifications

It is in acceptable condition currently If the firestop is cracking, etc, then it is to be removed and repaired using current technologies


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Expanding foam used for insulation purposes is NOT an acceptable firestop in any fire or smoke barrier This product does have a UL label: for insulation properties

Easily ignited Toxic gases may occur when burned

NOTE: There are several acceptable fire stop products that expand when installed


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Non Flammable Medical Gas Volume & Storage: Scoring

Score EC.02.03.01 EP 1 …fire risk12 ‘E’ cylinders (<300ft³) per smoke compartment

(22,500ft²) may be open to the egress corridor in a rack or appropriate holders

Between 300 and 3000ft³ must be stored in a room that is limited construction with doors that can be locked

“In use” verses “in storage” Properly secured to a gurney is considered “in use” Properly racked is “in storage” Empty are NOT considered part of the 12 in storage Empty and full must be stored (racked) separately


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Non-Flammable Gas Storage: NFPA 99-2005

NFPA 99-2005 edition has additional language regarding O2 storage requirements, specifically:

Storage of nonflammable gases:9.4.1 > 3000 cubic feet9.4.2 300 – 3000 cubic feet 9.4.3 0 - 300 cubic feetOther:5.1.3.3.2 design and construction5.1.3.3.3 ventilation of locations for manifolds5.1.3.3.3.2 ventilation for motor driven equipment5.1.3.3.3.3 ventilation for outdoors

NOTE: CMS also recognizes 9.4.3 reference


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Non-Flammable Medical Gas Unsafe Conditions: Scoring

Score EC.02.06.01 …unsafe condition Unsecured cylinders

Laying on top a gurney mattress; leaning against the wall Free standing

Transfilling liquid oxygen Transfer of any gases from one cylinder to another in patient

care areas of health care facilities is prohibited. Transfilling of liquid oxygen shall be performed in an area that

is• mechanically ventilated• sprinklered• ceramic or concrete flooring• separated with at least 1 hour construction from any patient

care areas


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Tank Farm EC.02.05.09 EP 1 states the hospital tests, inspects and

maintains critical components of the piped medical gas systems. Tank Farm is included in this EP The bulk storage tank(s) and associated systems are

critical components of the piped medical gas system Tanks above ground, not on roofs No electrical service above tanks 10’ Clear from vehicles & sidewalks 50’ from wood frame buildings

• At least 1’-0” from other buildings• At least 10’ form any opening in wall of adjacent

structures• Concrete pads at all spill points (3’ min)

Permanent signage: OXYGEN – NO SMOKING – NO OPEN FLAMES

Access controlled (i.e. locked)


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Q. Is a UPS used to condition power or supply power when normal power is interrupted until emergency power is established a SEPSS?

A. The UPS in this application is a bridging device, and is not a SEPSS


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NFPA 110: Emergency & Standby Power Systems

Automatic Transfer Switches (ATS) are self-acting devices that have normal electrical power entering and leaving the ATS The power continues on to distribution panels

When a ATS senses a disruption in power it sends a signal to the alternative power source seeking power This start circuit initiates the emergency generator

starter The ATS is also equipped with a test switch to

simulate the power disruption Recommended practice is to rotate which ATS

initiates the start circuit to the emergency generator


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Generator Loading The 30% requirement assures the diesel engine achieves correct

operating temperature The output of the EPSS is not as critical as the operating

temperature during the generator tests Two common ratings on the nameplate: KW & Amps The diesel engine drives the alternator, creating electrical charge Power factor and the nameplate ratings

With a static load the power factor is 1.0 With a dynamic load the power factor is .8

The nameplate rating measures the capacity of the system with a diesel engine driving the alternator The 30% is taken from the nameplate without calculating the

power factor EPs 5 & 8: …uses a dynamic or static load that is at least

30% of the nameplate rating…


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ElectricalUnlocked distribution panels in patient

care areas Based on policy Consider risk assessment Score EC.02.01.06 EP 1

Open junction boxes Score at EC.02.03.01 EP 1

• Risk: arcing resulting in fire or loss of service


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Supervisory Signals: EC.02.03.05 EP 1At least quarterly, the hospital tests

supervisory signal devices (except valve tamper switches). The completion date of the tests is documented. Note: For additional guidance on performing tests, see NFPA 72, 1999 edition (Table 7-3.2). Table 7-3.2 actually only states that

Supervisory Signal Devices must be tested quarterly• The Table does not actually define the

specific devices


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EC.02.03.05 EP 1: NFPA 72-1999, 2-9 lists Supervisory Signal Initiating

Devices: 2-9.1 Control Valve Supervisory Signal Initiating

Devices 2-9.2 Pressure Supervisory Signal Initiating Devices 2-9.3 Water Level Supervisory Signal Initiating

Devices 2-9.4 Room Temperature Supervisory Signal

Initiating DevicesThis is further reinforced by the listing in NFPA 72-1999,

Table 7-2.1, 13.h as devices addressed in NFPA 72-1999


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General Life Safety Interpretations Staff Safety

EC.02.02.01 EP 3: Precautions & PPE EP 4: Spill procedures EPs 5 – 10: minimizes risk

EC.04.01.01 EP 1: Monitoring & Reporting EPs 2 – 11: Specifics

Manifests: EP 11DOT training for those signing


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Unsafe Conditions & Suicide Risk EC.02.06.01 EP 1:

Interior Spaces meet the need of the patient population and are safe and suitable to the care, treatment and services provided.

Any unsafe condition can be scored here, provided it is in the patient care interior spaces

Suicide risk may be addressed by clinical interventions or policies Work with other survey team members


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Outdoor Safety

EC.02.01.01 EP 5The hospital maintains all grounds and

equipment Grounds includes

SidewalksParking lotsPark waysPicnic and patio areasPlay structures


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Outdoor Safety

EC.02.01.01 EP 5 The hospital maintains all grounds and

equipment Equipment includes

Lawn maintenance equipment Snow removal equipment Maintenance equipment

Paving Road repair

Lighting


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CE: Lessons Learned from 2010

Scope issues Contamination issues

Alarm HazardsDisabled or otherwise

compromised Telemetry Infusion pumps

Surgical Site FiresSentinel Event Alert

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Defibrillators: FAQ

Q. Are defibrillators considered life support equipment?

A.YES. Maintenance activities then must be identified

for equipment on the inventory A maintenance strategy for defibrillators could

include a range of activities from a visual inspection of the single-use AED (automatic external defibrillator) to the scheduled PM maintenance of a defibrillator

Note: the daily and weekly observations are assessed as per policy (see PC.02.01.11 EP2)


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Emergency Management:Key Concepts

All hazards approachCollaboration with community

partnersSituational awarenessActive mitigation and

preparation, not just a written plan

Monitor and evaluate


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Pre-Session documents

Emergency Operations PlanAll hazards approachAddresses the six critical areasInventory of resources and assets

Hazard Vulnerability Analysis (HVA)Mitigation and preparedness activities

for the top 2 or 3 events Disaster drill and real event evaluations

Monitors and evaluates the six critical areas


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Conducted by EM Committee/Team Use Multi-disciplinary Approach

Experts within your facility Community

Share information with: Community-prioritizes events Hospital Leadership

For each emergency, the organization defines Mitigation, Preparation, Response,

Recovery Directs the survey process related to EM

Hazard Vulnerability Analysis


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Six Critical Areas

1. Communication2. Resources & Assets3. Safety & Security 4. Staff Responsibilities 5. Utilities Management6. Patient Clinical & Support

Activities


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Overview of the 2011 EM Changes

Stand alone EM session Up to 90 minutes

Focus on mitigation and preparedness No disaster scenarios; use hospital

disaster critiques Data collection tool and EM Tips

document Focused discussion on six critical areas Look at resources and assets inventory;

appropriate storage, expirations, training

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Questions?


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SIG Engineers: 630 792 5900

George Mills, MBA, FASHE, CEM, CHFM, CHSP

Senior Engineer SIG

Michael Chisholm, CPE, CHFM

Engineer SIG

Anne Guglielmo, CFPS, LEED, A.P., CHSP

Engineer SIG


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The Joint Commission Disclaimer

These slides are current as of 4/22/2011. The Joint Commission reserves the right to change the content of the information, as appropriate.

These slides are only meant to be cue points, which were expounded upon verbally by the original presenter and are not meant to be comprehensive statements of standards interpretation or represent all the content of the presentation. Thus, care should be exercised in interpreting Joint Commission requirements based solely on the content of these slides.

These slides are copyrighted and may not be further used, shared or distributed without permission of the original presenter or The Joint Commission.

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Surveying

Maintenance Strategies

Medical EquipmentUtilities Systems


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Existing: Every six months the hospital tests

valve tamper switches and water-flow devices. The completion date of the tests is documented.

NOTE: for additional guidance on performing tests see NFPA 72-1999 (Table 7-3.2)