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GuidelinesforEnvironmentalHealthPracticesinVillageHealthClinics

ii

PrefacePublishedby

AlaskaNativeTribalHealthConsortium(ANTHC)

DivisionofEnvironmentalHealthandEngineering(DEHE)

1901BragawStreet,Suite200

Anchorage,AK99508

(907)729‐3600

Historyandsupersession:

- “EnvironmentalHealthStandardsforVillageHealthClinics,”AlaskaAreaNativeHealthService(AANHS)CircularNo.93‐74:ThisisthelastcircularpublishedbytheAANHSforvillagehealthclinicstandards.

- “GuidelinesforEnvironmentalHealthPracticesatVillageHealthClinics,”April2002,AlaskaNativeTribalHealthConsortium(ANTHC):ANTHCcouldnotissueadocumentsupersedinganAANHSCircular.TheguidelinesweredevelopedtoupdateinformationprovidedintheAANHScircularforusebytribalhealthorganization,environmentalhealthprograms.

- “GuidelinesforEnvironmentalHealthPracticesatVillageHealthClinics,”2011,ANTHC:Thisdocumentisanupdateofthe2002guidelines.

Intendedpurpose:

ReportsresultingfromthesurveysofVillageHealthClinics(VHCs)maybeusedbybothlocaland/orregionalnativehealthboards.Theguidelinesmaybeadoptedand/ormodifiedasappropriatebytribalhealthorganizationswishingtousethemasanenvironmentalhealthstandardforVHCs.TheguidelinesareintendedasatooltoassistinVHCsurveysandarenotasubstituteforanyofthereferencescited.

Tribalhealthorganization,environmentalhealthprogramsareencouragedtosendtheirvillagehealthclinicsurveystotheAlaskaAreaNativeHealthService,RealPropertyOfficer.TheRealPropertyOfficercanassistwithfollowinguponconditionsfoundatclinicsparticipatingintheVillageBuiltClinicLeasingProgram.Moreimportantly,theRealPropertyOfficermayuseinformationgleanedfromthesurveystohelpsubstantiatetheneedtoincreasetheleasingprogramfunds.


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MajorAdditionsandRevisionsfrom the2001 Guidelines

Topicsarenowalphabetizedbysubjectandarehyperlinked.

Theappendicesarehyperlinkedtoreturntothereferringsectionafterviewing.

Newsectionshavebeenaddedtoinclude:

- Dental- CombinedLaboratoryandPharmacy.

FireSafetyisnowonesection,combiningGeneralandLodginginClinics.

Titleshavebeenupdated.Thisincludes:

- EnvironmentalServices(housekeeping),- Handhygiene(handwashing),and- AirborneInfectionIsolation(negativepressurerooms)

2011VHCGuidelinesRevisionCommittee

Chair ValerieHerrera,REHS,MPH,LT,USPHSAlaskaNativeTribalHealthConsortium(ANTHC),DivisionofEnvironmentalHealthandEngineering(DEHE),InstitutionalEnvironmentalHealthConsultant

Members KeithCook,REHS,CIH,MPH,CAPT,USPHS

ANTHC/DEHE,InstitutionalEnvironmentalHealthManager

MichaelBox,REHS,CIH,MS,CDR,USPHSANTHC/DEHE,InstitutionalEnvironmentalHealthConsultant

Acknowledgements

JeffSmith,R.S.,CAPT,USPHSANTHC/DEHE,DirectorofEnvironmentalHealthServices

EmilyMenard,M.A.ANTHC/DEHE,TechnicalWriter

Katie‐LynneBurbage,LTJG,USPHSANTHC/DEHE,AssistantEnvironmentalHealthConsultant


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Table of Contents

I. BUILDING CONDITION AND DESIGN .......................................................................... 1

1.1. BuildingCondition...............................................................................................................................................................................1

1.2. CombinedLaboratoryandPharmacy..........................................................................................................................................2

1.3. Electrical..................................................................................................................................................................................................3

1.4. HeatingandVentilation(Mechanical).........................................................................................................................................5

1.5. Lighting....................................................................................................................................................................................................7

1.6. Plumbing..................................................................................................................................................................................................7

II. DENTAL ................................................................................................................. 8

2.1. DentalUnitWaterline.........................................................................................................................................................................8

2.2 Sterilization............................................................................................................................................................................................9

2.3 WasteAmalgam....................................................................................................................................................................................9

III. ENVIRONMENTAL SERVICES (HOUSEKEEPING) .......................................................... 10

3.1. CleaningandSanitizing...................................................................................................................................................................10

3.2. CleaningSchedule..............................................................................................................................................................................10

3.3. CleaningSupplyStorage..................................................................................................................................................................11

3.4 LaundryServices................................................................................................................................................................................11

IV. FIRE SAFETY (LIFE SAFETY) .................................................................................... 12

4.1 ExitsandExitSigns...........................................................................................................................................................................12

4.2 General...................................................................................................................................................................................................13

4.3 LodginginClinics(LifeSafety).....................................................................................................................................................16

V. FURNISHINGS ....................................................................................................... 17

5.1. Appliances.............................................................................................................................................................................................17

5.2. Clinical....................................................................................................................................................................................................17

5.3. Furniture................................................................................................................................................................................................17

VI. INFECTION PREVENTION AND CONTROL ................................................................... 18

6.1. BloodandPotentiallyInfectiousMaterialSpills...................................................................................................................18

6.2. EnvironmentalSurfacesandNon‐patientCareItems,Disinfecting..............................................................................18

6.3. HandHygiene(Handwashing).....................................................................................................................................................19

6.4. InsectandRodentControl..............................................................................................................................................................20

6.5. Patient‐careMedicalDevices,DisinfectingandSterilizing...............................................................................................21

6.6 PersonalProtectiveEquipment(PPE)......................................................................................................................................24

6.7 Thermometers,Disinfection..........................................................................................................................................................25


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6.8 Toys,Disinfection...............................................................................................................................................................................25

VII. JOINT COMMISSION (TJC) ACCREDITATION .......................................................... 26

VIII. SAFETY AND HEALTH .......................................................................................... 26

8.1. Asbestos.................................................................................................................................................................................................26

8.2. BloodbornePathogenProgram(BPP)......................................................................................................................................27

8.3. CompressedGases.............................................................................................................................................................................27

8.4. HazardCommunication...................................................................................................................................................................28

8.5. InjuryControl......................................................................................................................................................................................29

8.6. Lead.........................................................................................................................................................................................................30

8.7. MedicineandPoisonControl........................................................................................................................................................31

8.8. RadiationProtection.........................................................................................................................................................................32

8.9. Tuberculosis(TB)Precautions.....................................................................................................................................................32

IX. SANITATION ......................................................................................................... 33

9.1. Refuse......................................................................................................................................................................................................33

A. ClassificationsandPractices.........................................................................................................................................................33

B. CollectionFrequency........................................................................................................................................................................33

C. InsideStorage......................................................................................................................................................................................33

D. OutsideStorageAreas......................................................................................................................................................................33

E. RegulatedMedicalWaste(RMW)................................................................................................................................................34

F. StorageandDisposal........................................................................................................................................................................36

G. Sharps.....................................................................................................................................................................................................36

9.2. SewageDisposal.................................................................................................................................................................................37

A. CommunitySewageSystem...........................................................................................................................................................37

B. DisposalMethods...............................................................................................................................................................................37

C. IndividualSewageSystems............................................................................................................................................................37

9.3. WaterSupply.......................................................................................................................................................................................37

A. Distribution..........................................................................................................................................................................................37

B. Source.....................................................................................................................................................................................................38

C. StorageandDisinfection.................................................................................................................................................................38

D. Testing....................................................................................................................................................................................................39


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I. APPENDICES

Appendix1 ReferencesExplanations(FGI,TJC).........................................................................................................................................‐40‐

Appendix2 ADECDivisionofSpillPreventionandResponse...................................................................................................................42

Appendix3 ADEC,DrinkitPure,DisinfectionProceduresforSurfaceWaterandWellWaterSources................................44

Appendix4 NIOSHPublications,PreventingNeedlestickInjuries..........................................................................................................45

Appendix5 IntegratedPestManagement(IPM)Information...................................................................................................................46

Appendix6 FireExtinguisherMonthlyandAnnualInspectionProcedures.......................................................................................48

Appendix7 NFPA99:Healthcarefacilities,Specialprecautionsforoxygencylinders.................................................................50

Appendix8 ComparingTJCAccreditationStandards–AHC,CAH,andHAP(DEVELOPING).....................................................52

Appendix9 TJCEC,EM,LSChapterOutlines.....................................................................................................................................................54

Appendix10 ComparingNFPAandInternationalCodesforLodging(UNDERREVIEW)...............................................................55

Appendix11 VillageHealthClinicSurveyFormExample–(UNDERREVIEW)...................................................................................56

Appendix12 HandHygieneExcerptsfromCDCandWHOGuidelines.....................................................................................................62

Appendix13 WHOHandHygieneTechniquesDemonstrated.....................................................................................................................64

Appendix14 MethodsForDisinfectionandSterilizationofPatient‐CareItemsandEnvironmentalSurfaces.....................66

Appendix15 NFPACodesReferencedbyTJC,EnvironmentofCare(EC)News,September2009.............................................67

Appendix16 StateofAlaskaFireMarshallStatement.....................................................................................................................................68

Appendix17 Lighting:DeterminationofIlluminanceCategories..............................................................................................................69

Appendix18 NFPASecondaryMeansforEscapeCriteria‐Windows......................................................................................................70

Appendix19 BestManagementPracticesforWasteAmalgam:Amalgamwaste...............................................................................71

Appendix20 HandwashingStationExample(withoutrunningwater)..................................................................................................72

Tables:

Table1:BleachDisinfectionTable..................................................................................................................................................................................39

Table2:DeterminationofIlluminanceCategories..................................................................................................................................................69

Figures:

Figure1:BiohazardLabelExample................................................................................................................................................................................35

Figure2:WHOHandHygieneTechniquewithAlcohol‐BasedFormulation................................................................................................64

Figure3:WHOHandHygieneTechniquewithSoapandWater........................................................................................................................65

Figure4:MinimumAverageIlluminance.....................................................................................................................................................................69

Figure5:ADABestManagementPracticesforAmalgamWaste.......................................................................................................................71


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ReferencesCitedThefollowingreferencesandcodeswereusedtosupporttheseguidelines.Intheeventofaconflictoroverlapbetweencodesorreferences,themorestringentshallapply(seeVBCLeasingProgram,AlaskaAreaNativeHealthServiceCircularNo.91‐75).Theusershouldhaveaccesstothecitedreferencesandcodes.ThisaccessmaybeattheofficeformorecommonlyusedreferencesandcodesorthroughtheAlaskaNativeTribalHealthConsortium,DivisionofEnvironmentalHealthandEngineeringforotherstandards.

AnexplanationofrelevanceforspecificcodescanbefoundinAppendix1.

ALASKA (AK) ADMINISTRATIVE CODES (AAC) AND STATUTES (AS):

AKAdditionalHazardCommunicationStandards,8AAC61.1110,September2011.Availableat:http://www.legis.state.ak.us/basis/folio.asp

AKBoiler&UnfiredPressureVessels,AS18.60.320,September2011.Availableat:http://labor.state.ak.us/lss/forms/boiler‐stats‐regs.pdf

ADECDrinkingWater,18AAC80,November11,2010.Availableat:http://www.dec.state.ak.us/regulations/pdfs/18%20AAC%2080.pdf

ADECHazardousWaste,18AAC62,August8,2003.Availableat:http://www.dec.state.ak.us/regulations/pdfs/18%20AAC%2062.pdf

ADECPesticideControl,18AAC90,April10,2010.Availableat:http://www.dec.state.ak.us/regulations/pdfs/18%20AAC%2090.pdf

ADECRadiationProtection,18AAC85,April9,2009.Availableat:http://www.dec.state.ak.us/regulations/pdfs/18%20AAC%2085.pdf

ADECSolidWasteManagement,18AAC60,September5,2010.Availableat:http://www.dec.state.ak.us/regulations/pdfs/18%20AAC%2060.pdf

ADECWastewaterDisposal,18AAC72,December23,2009.Availableat:http://www.dec.state.ak.us/regulations/pdfs/18%20AAC%2072%20As%20amended%20through%20December%2023,%202009.pdf

BEST MANAGEMENT PRACTICES (BMP)

Thiscitationmaybeusedwhenaspecificstandardorrecommendationcouldnotbefound,butintheopinionoftheauthorsitshouldbementioned.ExperiencehasshowntheseareoftenitemstheJointCommission(TJC)maycite.

INTERNATIONAL CODES:

InternationalBuildingCode(IBC),2006,13AAC50.020InternationalFireCode(IFC),2006,13AAC50.025InternationalFuelGasCode(IFGC),2006InternationalMechanicalCode(IMC),2006,13AAC50.023InternationalPrivateSewageCode(IPSC),2000InternationalPropertyMaintenanceCode(IPMC)2006UniformPlumbingCode(UPC),2006,8AAC63.010

Availableat:http://www.iccsafe.org/Store/Pages/FreeCodes.aspx


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NATIONAL FIRE PROTECTION ASSOCIATION (NFPA):

NFPA1:FirePreventionCode,2000EditionNFPA10:StandardforPortableFireExtinguishers,2007EditionNFPA30:Flammable&CombustibleLiquidsCode,2000EditionNFPA31:StandardfortheInstallationofOil‐BurningEquipment,2001NFPA49:HazardousChemicalsData,1994EditionNFPA50:StandardforBulkOxygenSystemsatConsumerSites,2001NFPA54:NationalFuelGasCode,1999EditionNFPA55:StandardfortheStorage,UseandHandlingofCompressedandLiquefiedGasesinPortableCylinders,1998

EditionNFPA58:LiquefiedPetroleumGasCode,2001EditionNFPA70:NationalElectricalCode®,2008Edition–usedbyAAC(1999usedbyTJC)NFPA72:NationalFireAlarmCode®,1999EditionNFPA86:StandardforOvensandFurnaces,1999EditionNFPA99:StandardforHealthCareFacilities,1999EditionNFPA101:LifeSafety®Code(LSC),2000EditionNFPA110:StandardforEmergencyandStandbyPowerSystems,1999Edition

PATIENT ACCESSIBILITY LAWS:

AmericanswithDisabilitiesAct(ADA),asamended2008AmericanswithDisabilitiesActAccessibilityGuidelines(ADAAG)ChecklistforBuildingsandFacilities,October1992FederalRehabilitationActAmendments(FRAA)of1998HealthInsurancePortabilityandAccountabilityActof1996(HIPAA)PrivacyRuleThePrivacyAct(PA)of1974TheRehabilitationActof1973UniformFederalAccessibilityStandards(UFAS)of1984

PHYSICAL ENVIRONMENT

AmericanSocietyofHeating,Refrigerating,andAirConditioningEngineers(ASHRAE)Handbook,2000FacilityGuidelinesInstitute(FGI),GuidelinesforDesignandConstructionofHealthCareFacilities¸2010(seedetailed

explanationinAppendix1).Readonlycopyavailableat:http://www.fgiguidelines.org/2010guidelines.htmlLightingforHospitalandHealthCareFacilities,anIlluminatingEngineeringSocietyofNorthAmericaRecommended

Practice(IES)‐RP‐29‐06VentilationofHealthCareFacilities(VHCF),ANSI/ASHRAE/ASHEStandard170‐2008,supplementto2010FGIGuidelines

THE JOINT COMMISSION (TJC)

2011StandardsforAmbulatoryHealthCare(seedetailedexplanationinAppendix1).EnvironmentofCare(EC)EmergencyManagement(EM)HumanResource(HR)InfectionPreventionandControl(IC)InformationManagement(IM)LifeSafety(LS)ProvisionofCare,Treatment,andServices(PC)RightsandResponsibilitiesoftheIndividual(RI)


ix

TOPICAL REFERENCES:

ASBESTOS

OccupationalSafetyandHealthAdministration(OSHA),Asbestos(29CFR1910.1001).Availableat:http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=standards&p_id=9995

BLOODBORNE PATHOGENS

OSHA,BloodbornePathogenStandard(29CFR1910.1030),December12,2008,http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=standards&p_id=10051

NIOSH,Selecting,Evaluating,andUsingSharpsDisposalContainers;DHHS(NIOSH)PublicationNo.97‐111,January1998.

CHILD RELATED

AmericanPublicHealthAssociationandtheAmericanAcademyofPediatrics,CaringforOurChildren,NationalHealthandSafetyPerformanceStandards.ThirdEdition,2011(CFOC).Availableat:http://nrckids.org/CFOC3/index.html

DENTAL

CentersforDiseaseControlandPrevention(CDC),GuidelineforInfectionControlinDentalHealth‐CareSettings,2003(CDC‐ICDHS).Availableat:http://www.cdc.gov/oralhealth/infectioncontrol/guidelines/index.htm

OrganizationforSafety&AsepsisProcedures(OSAP),FromPolicytoPractice:OSAP’sGuidetotheGuidelines,2004

DEPARTMENT OF TRANSPORTATION

TransportationofRegulatedMedicalWaste(49CFR173.197),July,8,2011.Availableat:http://ecfr.gpoaccess.gov/cgi/t/text/text‐idx?c=ecfr&sid=15c4069898339aaa466c8961192f763a&rgn=div8&view=text&node=49:2.1.1.3.9.5.25.32&idno=49andhttp://cms.h2e‐online.org/ee/rmw/rmw‐regulations/department‐of‐transportation/

FOOD

UnitedStatesFoodandDrugAdministration(FDA),FoodCode,2009.Availableat:http://www.fda.gov/Food/FoodSafety/RetailFoodProtection/FoodCode/FoodCode2009/default.htm

HAZARD COMMUNICATION

OSHA,HazardCommunicationStandard(29CFR1910.1200),March11,1994.Availableat:http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=standards&p_id=10099


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INFECTION PREVENTION (GENERAL)

AssociationforProfessionalsinInfectionandControlandEpidemiology(APIC),APICTextofInfectionControlandEpidemiology,3rdEdition,online,2009.

APICGuidelineforSelectionandUseofDisinfectants,Rutala,WilliamA.PhD,MPH,CIC,AmericanJournalofInfectionControl.24(4):313‐342,August1996.

CentersforDiseaseControlandPrevention(CDC)HealthcareInfectionControlPracticesAdvisoryCommittee(HICPAC),GuidelineforDisinfectionandSterilizationinHealthcareFacilities,2008(CDC‐DS).Availableat:http://www.cdc.gov/hicpac/pdf/guidelines/Disinfection_Nov_2008.pdf

CDCHealthcareInfectionControlPracticesAdvisoryCommittee(HICPAC),GuidelineforEnvironmentalInfectionControlinHealth‐CareFacilities,2003(CDC‐EIC).Availableat:http://www.cdc.gov/hicpac/pdf/guidelines/eic_in_HCF_03.pdf

CDCandtheHICPAC/SHEA/APIC/IDSAHandHygieneTaskForce,GuidelineforHandHygieneinHealth‐CareSettings,October25,2002(CDC‐HH).Availableat:http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf

CDC,GuidetoInfectionPreventionforOutpatientSettings:MinimumExpectationsforSafeCare,2011(CDCFIPOS).Availableat:http://www.cdc.gov/HAI/prevent/prevent_pubs.html

WorldHealthOrganization(WHO)PatientSafety,WHOGuidelinesonHandHygieneinHealthCare,2009(WHO‐HH).Availableat:http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf

LEAD

OSHA,LeadStandard(29CFR1910.1025),August15,1980.Availableat:http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=standards&p_id=10030

OSHA,ConstructionLeadStandard(29CFR1926.62),August18,2008.Availableat:http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10641

PHARMACY

U.S.Pharmacopeia23NationalFormulary18(USPNF)(recognizedintheFederalFood,Drug,andCosmeticAct(21U.S.C.§321etseq.)).

RADIATION

IonizingRadiation(29CFR1910.1096).Availableat:http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10098

TUBERCULOSIS

CDC,GuidelinesforPreventingtheTransmissionofMycobacteriumtuberculosisinHealth‐CareFacilities,1994MMWR43(RR13);1‐132,December30,2005,(CDC‐TB).,Availableat:http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5417a1.htm?s_cid=rr5417a1_e

OSHA,RespiratoryProtectionStandard(29CFR1910.134).Availableat:http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=12716


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I. BUILDING CONDITION AND DESIGN

NOTE:NewdesignandconstructionshouldmeetrequirementsinthemostrecenteditionoftheInternationalBuildingCode(IBC)and/ortheNationalFireProtectionAssociation(NFPA)101LifeSafetyCodeand/orotherrelevantauthorityadoptedbytheStateofAlaskaorapplicableaccreditingentity.

ExistingstructuresaregovernedbyregulationsstipulatedinIBC102.6Existingstructuresand/orNFPA101:1‐4.1NewandExistingBuildings.Wherespecificrequirementsdiffer,themoststringentorappropriatecoderequirementshouldbefollowed.NOTE:BasedonIBCdefinitions,mostvillageclinicswillbeclassifiedasBusinessGroupBstructures(IBC304.1).Insomecases,whereovernightaccommodationsareprovided,theseclinics,ortheportionoftheclinicwithsleepingaccommodations,mayalsoberegulatedasResidentialR‐1occupancies(IBC310.1).

Forrelatedissuesthatmayarisebutarenotaddressedinthisguideline,pleasecontacttheANTHC/DEHEstaff.

1.1. BuildingCondition

A. Theclinicexteriorandinteriorshouldbeofsoundconstructionandbekeptingoodrepair.Theinteriorsurfaces,includingwallsandceilings,shouldbeconstructedofasmooth,easilycleanablematerial.Thefloorshouldbeconstructedofamaterialthatisdurableandeasilycleanable(FGI3.1‐7.2.3,TJC:EC.02.06.01).

B. Newfacilitiesshouldbesized,designedandconstructedtobeaccessibleandincompliancewiththefollowing:

- TheRehabilitationAct

- TheUniformFederalAccessibilityStandards

- AmericanswithDisabilitiesAct,AccessibilityGuidelines(ADAAG)forBuildingsandFacilities

C. Existingfacilitiesshouldbebroughtintocomplianceduringanyremodelingorrenovation(TJC:EC.02.06.01).

Healthcareworkers(HCWs)andstaffsurveyingfacilitiesshouldusethechecklistsprovidedbyADAAGforaone‐timethoroughsurveyforaccessibility.Subsequentsurveysshouldreferencethethoroughsurveyandcommentonprogressmadetowardaccessibility.

ChecklistsforacompleteADAAGsurveymaybefoundat:

http://www.access‐board.gov/adaag/checklist/a16.html

D. Entranceandexittoexamroomsshouldbeaccessibletostretchersandbackboards.Aminimum3feet(ft.)8inches(in.)clearanceshouldbeavailableiftransportinbedsisprovided.Allotherdooropeningsshouldhaveaminimumclearwidthof32in.(FGI3.5‐7.2.2.1/.2,NFPA101:38.2.2.2,IFC1008.1.1).


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E. Anarcticentryshouldbeprovided,wherenecessary.Itshouldbedesignedandmaintainedinsuchamannerastoensuretheproperregulationoftemperaturesintheclinicbuildingandnotimpedeentranceoregress(BMP,FGI1.2‐6.2.1.4).

F. Generalpurposeexamroomsshouldhaveaminimum80squarefeetoffloorarea(FGI3.1‐3.2.2.2).Examroomsdesignatedforaspecialpurpose(minorsurgeryorcastprocedures),ifprovided,shouldhaveaminimum100squarefeetoffloorarea(FGI3.1‐3.2.3.2).

G. Entrancedoorstotheclinicshouldbeequippedwithhighqualitylockingsystemswhichmayincludedeadboltlocksand/orelectronicaccessoptions.Thesedevicesshouldbeinworkingorderandprovideasecurebuildingthatisinaccessibletounauthorizedpersons(TJC:EC.02.01.01).Ifthedeadboltrequirestheuseofakeyfromthedeadboltsideasignmustbepostedbythedoorwiththefollowingwords:"Thisdoortoremainunlockedwhenthebuildingisoccupied."Akeymustbeimmediatelyavailabletoanyoccupantinsidethebuildingwhenitislocked(NFPA101:7.2.1.5.1;IBC1008.1.8.3).

H. Adequatestoragespaceshouldbeprovided(FGI1.2‐2.2.3.6).Furnaceroomsandelectricalroomsshouldnotbeusedforthestorageofcombustibles(IFC315.2.3).Custodian’sclosetsandotherstorageareasshouldbeorganizedtopreventtrippinghazards,fireandexplosionhazards,andpestharborage(29CFR1910.176(c)).

I. Thebuildingdesignshouldbesuchthatprovisionsforhealthcareareoptimizedandpatients’rightstoprivacyaremaintained.Thisincludes,butisnotlimitedto,provisionsfordoors,curtains,andopaquewindowsasnecessarytomaintainprivacy(TJC:RI.01.01.01EP7,FGI3.1‐3.2.1.1).

J. Bathroomsshouldbeenclosedfromfloortoceilingwithahardwallandlockingdooraccess(TJC:RI.01.01.01EP7).Staffshouldhavemeanstounlockpatientbathroomdoors,sooccupantsmayberemovedinanemergency(NFPA101:19.2.2.2.5‐thoughthisappliestohealthcarefacilities,theremotenatureofmanyclinicsdoesnotalwaysallowforquicktransporttoahospital.Consequently,clinicstaffmaybecaringforpatientsthatbelonginahealthcarefacility).

1.2. CombinedLaboratoryandPharmacy

Havinga“laboratory”and“pharmacy”combinedinoneroomisnottheidealsituationasitcombinesdirtyprocesses(laboratory)withcleanprocesses(pharmacy)inonespace.Withappropriateseparation,facilitiesandprocesseswithacombinedlaboratory/pharmacymayworkifboththelaboratoryandpharmacyarelimitedinscope.Thefollowingshouldbeevaluated:

A. Separation:Thereshouldbeadefinedseparationbetweenpharmacyandlaboratoryprocesses.Asinkmaybesharedbetweenthetwo,butonlyifpharmacyisononesideofthesinkandlaboratoryontheother.Thereshouldbenosharedcounterspaceunlessthecounterisdividedbythesink.

B. Individualstaffshouldbeprohibitedfromworkinginbothlaboratoryandpharmacyareasatthesametime.Eitherlaboratoryorpharmacyoperationsshouldbeconductedatanyonetime.Ifastaffmemberisworkingonthelaboratoryside,theymustcleanandsanitizethelaboratoryarea,thenwashtheirhandsbeforeworkingonthepharmacyside.


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C. Separaterefrigerators:Ifrefrigerationisrequiredforbothpharmaceuticalandlaboratoryfunctionsthenaseparaterefrigeratorisneededforeachfunction.Therefrigeratorshouldbeinthespaceallottedfortheappropriatefunction.

D. Sink:Aminimumofonesinkisneededinthecombinedroom,especiallyiflabspecimenssuchasblood,otherbodilyfluidsorfeceswillbemanipulated.Ifthereisonlyonesink,itshouldbeatthedemarcationpointforthelabandpharmacy.

E. Handhygiene:Ifasharedsinkisused,alcoholbasedhandrubshouldalsobeavailableonthepharmacyside.Alcoholbasedhandrubisstillhighlyadvisedifsinksareprovidedforbothpharmacyandlaboratoryprocesses.SeeHandHygienesection.

F. Pharmaceuticalstorage:Pharmaceuticalsstoredinacombinedlaboratory/pharmacyshouldbestoredincloseablestorageunits(suchasshelvingandcabinetswithsmooth,easilycleanabledoors).

G. Secured:Acombinedlab/pharmacyshouldbelockedwhennotinuse.

Therearenoknownreferencesthatgiveguidanceoncombined,limitedlaboratory/pharmacyprocesses(eitherallowingorprohibitingthem).Recommendationsintheseguidelinesweremadewithconsultationwiththefollowing:“BiosafetyinMicrobiologicalandBiomedicalLaboratories,5thedition,HHSPublicationNo.(CDC)21‐112,revisedDecember2009”seep.25and37definitionsofBiosafetyLevel1and2;FGI‐3.1‐4.1.2.2&3,3.3‐3.2.6.6

1.3. Electrical

A. AllelectricalwiringshouldbeinstalledandmaintainedinaccordancewiththelatesteditionofNFPA70.Allmajorrepairsorchangestotheelectricalsystemshouldbedonebyaqualifiedelectrician.(TJC:HR.01.02.05).Documentationofmaintenanceandrepairsshouldbekept(TJC:EC.05.05EP2).

1. Under29CFR1910.333(c)(2),OSHAoutlinesqualifiedpersons,orthosepermittedtoworkonornearenergizedparts,“shall,ataminimum,betrainedinandfamiliarwiththefollowing:

i. Theskillsandtechniquesnecessarytodistinguishexposedlivepartsfromotherpartsofelectricequipment,

ii. Theskillsandtechniquesnecessarytodeterminethenominalvoltageofexposedliveparts,and

iii. Theclearancedistancesspecifiedin1910.333(c)andthecorrespondingvoltagestowhichthequalifiedpersonwillbeexposed.

Typeoftraining:Thetrainingrequiredbythissectionshallbeoftheclassroomoron‐the‐jobtype.Thedegreeoftrainingprovidedshallbedeterminedbytherisktotheemployee”(29CFR1910.333(c)(2)).

B. Sufficientduplexgrounded‐typereceptaclesshouldbeavailablefornecessarytaskperformance.Eachexaminationandworktableareashouldhaveaccesstoaminimumoftwoduplexreceptacles(FGI3.1‐8.3.6.1&.2).


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C. GroundFaultCircuitInterrupter(GFCI)shouldbelocatedinbathroomsandoutletslocatedwithin6feetoftheoutsideedgeofsinks,rooftops,andoutdoorlocations.TheNationalElectricCode(NEC)doesnotrequireGFCInearsinkswithinpatientcareareas.Thereasonistonotdisruptcareessentialforpatientlifeorsurvival.ThisisnotafactorformostclinicexamroomsandtherecommendationistoinstallaGFCI(NFPA99:3‐3.2.1.2,NFPA70:210.8(b)).

D. Clinicsdesignedandbuiltusingthe2008NationalElectricalCodeshouldhavewaterfountainspluggedintoaGFCI.Priorto2008,thisrequirementwasnotlisted.However,ariskassessmentcandetermineotherareasthatwillbenefitfromadditionalGFCIinstallations.(NFPA99:3‐3.2.1.2,NFPA70:210.8(b)).

E. Outletorswitchcoversshouldbekeptingoodrepair.Allelectricalreceptaclesintendedtosupplyareasoccupiedbychildrenshouldbelistedtamperresistantorshouldemployalistedtamperresistantcover.Asofthewritingoftheseguidelines,theauthorswereunawareofanylistedtamperresistantcovers.Surveyorsshouldcloselyscrutinizeanyclaimthatacoverislisted.Plasticchildresistantplugsorcapsshouldbediscouragedsincetheyaredifficulttokeepinplace.TamperresistantoutletsarenotrequiredinhealthclinicsbytheNEChowever;ariskassessmentmaydeterminetheuseoftamperresistantoutletsisappropriate.Ifafterariskassessmentitisdeterminedtoimplementchildresistantoutlets,plasticchildresistantplugsorcapsshouldbethelastselectionchoicesincetheyaredifficulttokeepinplaceandcanposechokinghazards.Leadingsafetyorganizationsdiscourageand/orprohibitplasticplugsorcapsinenvironmentsintendedforchildren(CFOC5.2.4.2,BMP).

Riskassessmentguidancefordeterminingrequirementsfortamperresistantelectricaloutlets:

TheidealsolutionisatwostepprocessrequiringariskassessmentasrecommendedbyTJC.

1. Determinewhichoutletsyouwanttoaddress.

2. Installtamperresistantreceptacles.

Installationoftamperresistantreceptaclesnegatestheneedtoaddcapsorcoverswhichonlyworkwheninuse.Aspreviouslymentioned,mostfacilitieshaveadifficulttimekeepingcapsintheoutletstheywanttoprotect.Inaddition,somegroupscitestudieswherecapsareonlyeffectiveforchildrenundertwoyearsold.Olderchildrenoftendonothavetroubleremovingthem.Somefacilitiesconsideruseofoutletcoverplates.However,duetotheirthickness,theymaypreventthefullinsertionofaplugandasaconsequencecreateadditionalhazardsincludingpotentialfires.Ensureselection(s)areULlistedbecausemanyarenot.Trialselection(s)beforepurchasingstockandapplyingtotheareasidentifiedtoprotect.

TheNECmaybeusedtodeterminethemostcurrentthinkinginregardstoelectricalsafety.The2002NECcoderegardingthisissueis:

517.18GeneralCareAreas(C)PediatricLocations:Receptacleslocatedwithintherooms,bathrooms,playrooms,activityrooms,andpatientcareareasofpediatricwardsshallbelistedtamperresistantorshallemployalistedtamperresistantcover.


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F. Thecircuitsinthebreakerboxesshouldbeproperlylabeled.Thebreakerboxshouldbecovered,butaccessibletoauthorizedpersons.Athree‐footclearanceshouldbeavailableinfrontofelectricalpanelsof600Vorless.RefertoTableS‐1under19CFR1910.303foradditionalinformation(29CFR1910.303(f),29CFR1910.303(g)(2)(i),29CFR1910.303(g)(1)(i)(A),TableS‐1).

G. Cordsandplugsforelectricalequipment,includingportableequipment,shouldnotbefrayed,wornordamaged.Cordsandplugsforshouldbevisuallyinspectedfordamageandifdamageisfoundtheequipmentmustberemovedfromserviceuntilappropriatelyrepaired(29CFR1910.303(b),29CFR1910.334(a)).

H. Extensioncordsandpowerstripsshouldonlybeusedaccordingtotheirmanufacturer’slistingandthelistedamperageratingshouldneverbeexceeded.Specifically,theyshouldnotbeusedaspermanentwiring,permanentlymountedorpluggedtogetherinsequence,onecordintoanother(daisy‐chained).Extensioncordsshouldnotpassthroughwalls,doorsorceilings(29CFR1910.305(g)(1)(iii),(iv)(A‐F)).

I. ElectricalappliancesshouldbelistedbyanindependentcertifyingsafetylabsuchasUnderwritersLaboratory(UL)(29CFR1910.303(a)).

1.4. HeatingandVentilation(Mechanical)

A. ForAirborneInfectionIsolation(AII)roomguidance(negativepressurerooms)seeTuberculosis(TB)section.

B. Centralheatingappliancesshouldbeinstalledandmaintainedinaccordancewithmanufacturer’sinstructionsandthelatesteditionoftheIMCorNFPA30,31,and54(whereappropriate).Allmajorrepairs,renovations,orchangestotheheatingandventilationsystemshouldbedonebyalicensedorqualifiedheating,ventilation,andair‐conditioningtechnician(TJC:HR.01.02.05).

C. Fuelgaspipingandappurtenances(valves,connectors,etc)shouldbeinstalledandmaintainedinaccordancewiththeIFGC403‐415orNFPA54.

D. Outsideairshouldbesuppliedforcombustionandventilation(NFPA54:6.8.3,86‐4‐3.2.1).Combustionairopeningsshouldbeunobstructedforadistanceofnotlessthansixinchesinfrontoftheopening(IMC306.1.1).

E. Theheatingsystemshouldbearrangedtoprovideuniformheatthroughoutthebuildingataminimumtemperatureof68˚Fwhenoccupiedandnotlessthan50˚Fwhenunoccupied.Areasintendedforpatientcareshouldbemaintainedat75˚F.(IBC1204.1,FGI3.3‐8.2.1).


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F. Bathroomsandjanitor’sclosetsshouldbemechanicallyventilated.

Existingbathroomsandjanitor’sclosetshouldprovide10roomairchangesperhour(ACH).

Clinicsdesignedafter2006havemorespecificrequirements:

- Janitor’sclosetsshouldbeprovidedwith10roomACH,ofwhich0.5cfmofoutdoorairpersquarefootoffloorspaceisrequired.

- Bathroomsshouldallowforoutdoorairatarateof75cfmperwaterclosetorurinal.(VHCFTable7.1;IBC1203.4.2.1refersbacktoIMC;IMCTableM403.3).

G. Examroomsandlabsshouldhaveventilationataminimumrateof6ACH(VHCFTable7.1).Smallclinicswithlessthanfourexamroomsareonlyrequiredtohavenaturalventilation(FGI3.3‐1.1.1,3.3‐8.2.2).

H. Heatingsystemsshouldbethermostaticallycontrolledallowingforadjustingtemperatureasappropriateforpatientactivitiesandcomfort(FGI3.3‐8.2.1).

I. Onlylistedportableheaters,forexample,Underwriter’sLaboratory(UL)listed,shouldbeusedasaback‐upheatsourceinthefacilityandshouldonlybeusedwhilethefacilityisoccupied(NFPA31:1‐7).Asabestmanagementpractice,onlyspaceheatersequippedwithanautomatictipovershut‐offswitchshouldbeusedandtheheatingelementshouldnotexceed212oF(NFPA101:19.7.8).

J. ListedkeroseneheaterssuchasToyostoveandMonitorshouldbeinstalledinstrictaccordancewiththemanufacturer’sguidelinesandshouldmeetallapplicablerequirementsofthelatesteditionofNFPA31.

K. AllfueltanksandconnectionsshouldbeproperlyconstructedandinstalledinaccordancewiththelatesteditionofIFGC403‐411orNFPA54andNFPA58.

L. Fuellinesshouldbesupportedandprotectedtopreventunintentionalreleases.Thisincludessupportandprotectionagainstphysicaldamageandexcessivestressesarisingfromsettlement,vibration,expansion,contraction,oriceconditions(29CFR1910.106(c)(4)).

M. Fueltanksshouldbelocatednocloserthan100feetfromanyprivateorcommunitywatersupply.Thisseparationdoesnotapplyto

tanksthatcontainpropane,

ortoabove‐groundstoragetanksor

drumsthatintheaggregate,haveastoragecapacityoflessthan500gallonsofpetroleumproducts,andthatstoreonlypetroleumproductsnecessaryfortheoperationandmaintenanceofpumps,powergenerationsystemsorheatingsystemsassociatedwithapotablewatersource(ADEC18AAC80.020).


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N. Inareassubjecttofrostheaves,fuellinesbetweenthefueltankandthebuildingshouldbeequippedwithalistedandlabeledflexibleconnectororothermeanstopermitthetankorbuildingtosettlewithoutimpairingthetightnessofthepipingconnections.Flexibleconnectorsareofteninstalleddownstreamfromtheballvalveattachedtothetank.Thisshouldbeincorporatedintonewclinicsandsuggestedforexistingclinicssubjecttofrostheaves(IMC1303.11,1302.8;NFPA54:2.13.2).

O. Iftotalfueltankstoragecapacityexceeds1,320gallonsorifasingletankexceeds660gallons,thetanksshouldhavesecondaryspillprotection.Ifaspillfromsuchalocationcouldaffectwaterwaysandthetotalfueltankstoragecapacityexceeds1320gallons,aSpillPreventionControlandCountermeasuresPlanshouldbeimplemented(IFC603.3.1;40CFR112.7).

P. Intheeventofafuelorhazardousmaterialspill,usetheADECSpillReportingFlyer,foundinAppendix2,tocontacttheappropriateauthorities.Iffuelstoragecapacityexceeds1,000gallons,thenthisflyermustbepostedintheclinic.

1.5. Lighting

A. Aminimumleveloflighting(illuminance)shouldbeprovidedintheclinic.Recommendedminimumilluminanceisspecifictoataskandlightlevelsshouldbemeasuredatthelevelofactivity.Table3A:DeterminationofIlluminanceCategoriesisprovidedasAppendix17andcanbeusedasaguidetodetermineifminimumlevelsofilluminancearebeingmet.

B. Themainclinicentranceshouldbeprovidedwithafunctioningexternallightsourcesufficienttoaidinsafeingressandegressoftheclinicduringdarkperiods(BMP,TJC:EC.02.06.01).

C. Emergencylightingshouldbeprovidedforallvillagehealthclinics.Clinicswithfloorspaceof1,000squarefeetorgreaterorwithastairwayexitshouldhaveanemergencylightingsystemwithbatteryback‐uppowerwiredintothemainelectricalcircuitryoftheclinicbuilding.Asimilaremergencylightingsystemisrecommendedforclinicswithlessthan1,000squarefeetbutataminimum,wall‐mountedrechargeableflashlightsshouldbeprovidedforanemergencylightingsourceintheeventofapoweroutage.(FGI3.3‐8.3.2.3).Testingrequirementsareoutlinedinsection4.1.E.

D. Allbuilt‐inlightfixtureslessthaneightfeetfromthefloororinareaspronetobreakageshouldbeshieldedtopreventunintentionalcontactwithliveparts(29CFR1910.303(g)(2)(i,ii)).

1.6. Plumbing

TheStateDepartmentofLaborandWorkforceDevelopmentadoptedtheUniformPlumbingCode(UPC),2006edition,publishedbytheInternationalAssociationofPlumbingandMechanicalOfficials(IAPMO)(8AAC63.010underauthorityofAS18.60.705).

A. AllplumbingandplumbingfixturesshouldbeinstalledaccordingtothelatesteditionoftheUPCorIMC.Existingsystemsshouldbemaintainedinproperoperatingcondition(UPC101.5.5,310.4).CompetentpersonnelfamiliarwiththeapplicableprovisionsoftheUPCorIMCshouldconductplumbingwork.Thiscompetencyshouldbeonfileandavailabletotheclinic(TJC:HR.01.02.05).


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B. Ifwaterunderpressureisavailabletotheclinic,atleastonehandwashingsinkshouldbeprovidedineachexamroom.Inaddition,onehandwashingsinkshouldbeprovidedconvenienttothetoiletroom,exclusiveoftheexamroom.BalancingpotentialrisksofscaldingagainsttherisksofexposuretoLegionella,APICrecommendsfacilitieswithrunningwaterprovideacontinuoussupplyoftemperedwaterwitharangebetween105˚Fand120˚Fforhandwashing(APICCH105‐5).Facilitiesinfreezingclimatesareencouragedtoinstallcoldtemperaturealarmstopreventdamagefromfreezing.

C. Ifwaterunderpressureisnotavailabletotheclinic,achemicaltoilet,box‐and‐pailtypetoilet,orotherapprovedtoiletsystemshouldbeprovided.Waterforhandwashingandfordrinkingshouldbeprovidedasrequiredbythewatersectionoftheseguidelines(BMP).

D. Autilitysinkshouldbeprovidedinthecustodian’scloset.Ifplumbingisnotavailable,acceptablemeansshouldbemadeavailableforcleaning.Vacuumbreakersorbackflowpreventiondevicesshallbeinstalledwhereathreadedhosebiborsupplynozzleisusedforconnectionofhosesortubing(UPC603.4.7,FGI3.1‐8.4.2.3(3)(b)).

E. Allfixturesshouldbekeptcleanandingoodrepair(EC.02.06.01).

II. DENTAL

TheClinicGuidelinesshouldbeusedtoassessdentalareasofaclinic.Thissectionhighlightsadditionalissuestheenvironmentalhealthspecialistshouldconsiderinadentalarea.

2.1. DentalUnitWaterline

Mostdentalunitwaterlines(i.e.,narrow‐boreplastictubingthatcarrieswatertothehigh‐speedhandpiece)areservedbyself‐containedsystems.Simplyusingpotablewaterordistilledwaterinthesesystemswillnoteliminatebacterialcontaminationintreatmentwaterifbiofilmsarenotcontrolled.Considerthefollowingwhensurveyingclinicswithdentalservices.

A. Determinewhattypeofwatertreatmentdeviceisusedtocontrolbiofilmsinthewaterlines.Ensuretheinstructionsforthetreatmentdevicearefollowed.

B. Themanufacturer’sinstructionsforthetreatmentdeviceshouldbefollowedtodetermineifandhowoftenmonitoringofthewaterqualityisdone.Ifmonitoringisindicatedbythemanufacturer,acceptablewatermonitoringresultswouldbe<500CFU/ml.(CDCGuidelinesforInfectionControlinDentalHealth‐CareSettings,2003,p.28‐29).


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2.2 Sterilization

Manysmallclinicsmaynotsterilizetheirmedicalequipment(itmaybeeitherdisposableorsenttoanotherfacilityforprocessing),butmostdentaloperationswillneedtosterilizetheirequipmentonsite.Usethe“DisinfectingandSterilizingMedicalDevices”sectionoftheseguidelinestoassessthedentalsterilizationprocess.

FurtherinformationondentalunitwaterlineproductsandgeneraldentalsafetyandinfectioncontrolissuesmaybefoundontheUnitedStatesAirForceDentalEvaluationandConsultationServicewebsite.AcurrentlinktothiswebsitemaybefoundontheANTHCIEHprogramwebsiteat:http://www.anthc.org/cs/dehe/envhlth/ieh/.

2.3 WasteAmalgam

Amalgamisanalloyofmercurywithanothermetal.Indentistry,amalgamisusedasadirectrestorativematerial.Amalgamalsocontainssilver.BothsilverandmercuryareResourceConservationandRecoveryAct(RCRA)toxicmetals.ReferencesindicatethatmercuryinwasteamalgammayleachinalandfillinexcessofthespecifiedamountintheToxicityCharacteristicLeachingProcedure(TCLP)test.ConductingaTCLPatthecliniclevelislikelynotfeasible,consequently,thesurveyorshouldevaluatethewastedisposalmethodforwasteamalgamandencouragebestpractices.

A. Bestpracticeswouldincludenotdisposingofwasteamalgaminthegarbage,infectiouswaste“redbag,”orsharpscontainer.Amalgamwasteshouldberecycled.ThefollowingstepsfromtheAmericanDentalAssociation(ADA,BestManagementPracticesforAmalgamWaste–October2007,http://www.ada.org/sections/publicResources/pdfs/topics_amalgamwaste.pdf)shouldbefollowed(Appendix19):

1. Stockamalgamcapsulesinavarietyofsizestominimizetheamountofamalgamwastegenerated.

2. Amalgamwastemaybemixedwithbodyfluids,suchassaliva,orotherpotentiallyinfectiousmaterial,sousepersonalprotectiveequipmentsuchasutilitygloves,masks,andprotectiveeyewearwhenhandlingit.

3. Contactanamalgamwasterecycleraboutanyspecialrequirementsthatmayexistinyourareaforcollecting,storingandtransportingamalgamwaste.

4. Storeamalgamwasteinacoveredplasticcontainerlabeled“AmalgamforRecycling”orasdirectedbyyourrecycler.Yourrecyclermayhavetheirownrequirements,soaskyourrecycleraboutcontainersandwhatmaybeplacedinthem.

5. LookforrecyclerswhocomplywiththeADA‐ANSIstandard.Thisstandardismeanttoencouragerecycling.TheANTHC/DEHE/EHS/IEHwebsitemaybeconsultedformoreinformationandanupdatedlistofrecyclers


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III. ENVIRONMENTAL SERVICES (HOUSEKEEPING)

3.1. CleaningandSanitizing

A. Theclinicshouldbemaintainedinacleanandsanitarycondition.Theclinicshouldpostandimplementawrittencleaningscheduleforcleaningandmethodofdecontaminationbaseduponthelocationwithinthefacility,typeofsurfacetobecleaned,typeofsoilpresent,andtasksorproceduresbeingperformedinthearea(29CFR1910.1030(d)(4)(i)).

B. Respectively,eachfacilityshouldhavewrittenpoliciesandproceduresidentifyingareabeingcleanedwhileoutliningcleaningprocedures,agents,equipment,personalprotectiveequipmentandspecificschedules.(APICCH100‐5).

3.2. CleaningSchedule

A. Cleaningschedulesandproceduresshouldbeginwiththeleastsoiledareaandprogresstothemostsoiledareastartingfromhightolowsurfaces.Aposteddescriptionandscheduleforcleaningandhousekeepingdutiesshouldbepostedinthefacility.Facilitypolicies,proceduresandschedulesshouldbedevelopedtomeettheneedsofanarea.Itemswhichshouldbeaddressedincludebutarenotlimitedto:

1. Hightouchsurfacessuchasbedrails,examtables,doorknobs,patientequipment,lightswitches,televisionremotes,knobsonmonitors,andbloodpressurecuffsrequirefrequentcleaning.Specialattentionshouldbegiventothesesurfacesaftereachpatientisseenandbeforethenextpatient.

2. Examrooms–cleanonadailybasis(ormoreoftenifneeded),thefloorsshouldbemoppedwithadisinfectant‐detergent(orcarpetsvacuumed)andthewastecontainersshouldbeemptied.

3. Dustingshouldbeperformedusingachemicallytreateddustclothorwetmopwhichwillpreventthedispersalofdust.

4. Horizontalsurfacesincludingtables,beds,chairs,ledges,lights,wallfixtures,andtopsofdoorsshouldbewipeddailywithacleanclothdampenedwithanEPA‐registereddisinfectant‐detergent.

5. Bathroomsshouldbecleanedandstockedatleastdaily.

6. Ifthemopandbuckettechniqueisused,thesolutionmustbechangedfrequentlyandwheneverusedtocleangrossspillsofbloodandotherpotentiallyinfectiousmaterials.Mopsshouldbechangedwiththesamefrequencyasthedisinfectantsolutionandlaundered.

Encouragestafftoswitchtomicrofibermopuse.Thishasmanyadvantagesincludinglimitedchangingofthecleaningsolution(asanewmicrofibermopisusedforeachroom)andlighterweight.TheANTHC/DEHEInstitutionalEnvironmentalHealthstaffmaybecontactedformoreinformationonmicrofibermops.

Ifmicrofibermopswillnotbeused,staffshouldbeencouragedtousethedoublebucketmoptechniquetoextendthelifeofthecleaningsolution.

MoreinformationonmicrofibermopsmaybefoundatthisEPAwebsite:http://www.epa.gov/region9/waste/p2/projects/hospital/mops.pdf


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7. Detergentandwaterareadequateforcleaningadministrativeoffices(non‐patientareas)‐weeklycleaningissufficientunlessvisiblysoiled.Wasteshouldbecollecteddaily.(APICCH100andCDCGuidelineforDisinfectionandSterilizationinHealthcareFacilities,2008)

8. Glutaraldehydeisahighleveldisinfectant/sterilantandisneitherrecommendednornecessaryfordisinfectionofenvironmentalsurfaces.Glutaraldehydeistootoxicandexpensiveforthisapplication(APICGuidelineforSelectionandUseofDisinfectants,p.329)

3.3. CleaningSupplyStorage

A. Alockablecustodian’sclosetwithshelving,mopandbroomholders,utilitysink(ifplumbed)andamplespaceforequipmentandsuppliesshouldbeprovided(FGI3.1‐5.5.1.2).Inexistingfacilitieswhereitmaynotbefeasibletoinstallacustodian’scloset,alockablecabinetshouldbeprovidedforstoringcleaningsupplies(EC.02.02.01).Chemicalsshouldnotbestoredatoraboveeyeheight(BMP).

B. Storageareasforhousekeepingsuppliesshouldbeidentified(FGIA3.1‐5.5.1.2).

C. TheSurveyorshouldcloselyevaluatethetypeofdisinfectantsusedandwhetherornottheyaredispensedinconcentratedform.Manyconcentrateddisinfectantsarecorrosiveandcausepermanenteyedamage.Ifanautomixingstationisnotusedforconcentratedchemicals,ensuresplashresistantgogglesareusedandaneyewashisavailable.AlwaysuseappropriatePPEperMSDSguidance(29CFR1910.132(d)(1)).

Formostreadytousedisinfectants,nitrilegloveswillsuffice.ForspecificinformationongloveselectionseePPEsection.

3.4 LaundryServices

A. Clinicsoftenusedisposabletablecoversandgownstopreventtheneedtolaundercontaminateditems(APICCH49‐5).Thedecisiontousedisposableitemsisdeterminedbyclinicmanagement.

B. Iftheclinicdoesnotusedisposablegowns,thencontaminatedlaundryshouldberemoved,containerizedandmarkedasothercontaminateditemssimilartotheprovisionsforregulatedmedicalwaste(29CFR1910.1030(d)(3)(vi)),((d)(4)(iv)(A)(2)).Contaminatedlaundryincludeslaundrywhichhasbeensoiledwithbloodorotherpotentiallyinfectiousmaterialsormaycontainsharps(29CFR1910.1030(b)).Cleanlaundryshouldbestoredseparatelyfromcontaminatedlaundry(APICCH101‐5).

Someclinicswithresidentialtypewashingmachinesmaychoosenottolaundercontaminatedlaundrybuteitherdisposeofthecontaminatedlaundryasregulatedmedicalwasteorsendittoaninstitutionallaundry(forexampleinahospital).Ifcontaminatedlaundryisroutinelylaunderedattheclinic,themachinesshouldeitherprovideahotwatercyclewithtemperaturesreaching160oFataminimumforover25minutesorasuitablechemicaldisinfectant(suchasatotalavailablechlorineresidualof50–150partspermillion)(CDC‐EIC,100‐101).


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IV. FIRE SAFETY (LIFE SAFETY)

Onthe14thofJune2006,theAlaskaAdministrativeCodewasupdatedwiththe2006EditionoftheInternationalBuildingCode,InternationalFireCode,andInternationalMechanicalCode.TJCusestheNFPALifeSafetyCodeandotherNFPAreferencesintheirsurveyprocess(refertoTJCstandardsforeditionoftheNFPAused).Thefollowingsectionreferencesbothcodes.ForexistingclinicsbuiltbeforethestateadoptedtheInternationalCodes,theclinicsshouldbeincompliancewithNFPAcodes.Forclinicsapprovedforconstructionorrenovatedafter9/15/01,themostrestrictivecodeshouldbeused.Thissectionwasnotwrittentobeusedforaplanreview.Anynewclinicorsubstantialrenovationshouldhaveaplanreviewconductedtoensurecompliancewiththeapplicablecodes.MostclinicsbuiltinAlaskawillrequireStateFireMarshallplanreview(13AAC50.027,http://www.dps.state.ak.us/Fire/contactus.aspx).TheANTHC,DEHEstaffarealsoavailableforplanreviews.

4.1 ExitsandExitSigns

A. Clinicsshouldhaveatleasttworemotelylocatedexits.Exceptionsdoexistforoneexit.

a. IfthebuildingiscoveredbyIFC1019.1,2,oneexitmaybepermittedifthebuildingisonestoryandhaslessthan50occupantswithatraveldistanceoflessthan75feettotheexit.

b. IfthebuildingiscoveredbyNFPA101:39.2.4.2,oneexitmaybepermittedifthebuildinghaslessthan30occupantsperfloorandatotaltraveldistancetotheexitislessthan100feet(forbuildingsnotexceedingthreestories).

Beforeeitherexceptionisused,theappropriatecodesshouldbereviewedorauthorityhavingjurisdictionconsulted(IFC1005.1,2;NFPA101:39.2.4.2).Ariskassessmentshouldalsobeconsideredtodetermineiftheexceptioniswarranted(TJC:EC.01.01.01).

B. Exitsandexitaccessdoorsshouldbemarkedbyanapprovedexitsignreadilyvisiblefromanydirectionofegresstravel.Accesstoexitsshouldbemarkedbyreadilyvisibleexitsignsincaseswheretheexitorthepathofegresstravelisnotimmediatelyvisibletotheoccupants(29CFR1910.37(b),NFPA101:39.2.10andIFC1011.1).

C. Exitsignsshouldbecontinuouslyilluminatedbyeitherexternalmeans(requiresback‐uppowerforemergencylighting),byinternalmeans,orbeself‐luminous.Externalorinternallightingshouldprovide90minutesofilluminationifprimarypowerisinterrupted(NFPA101:7.10.5.2,39.2.10;IFC1006,1011).Exitsignsshallbevisuallyinspectedforoperationoftheilluminationsourcesatintervalsnottoexceed30days.Exitsignsconnectedtoorprovidedwithabattery‐operatedemergencyilluminationsourceshallbetestedandmaintainedthesameasemergencylightingasoutlinedin4.1.E(NFPA101:7.10.9).

D. Meansshouldbeprovidedtoensureexitaccesswaysarecontinuouslyilluminatedtoatleastone‐footcandleduringuse.TheLifeSafetyCodespecifiesthesourceofilluminationshouldbefromareliablesource(suchasapublicutility)(NFPA101:7.8.2.1).TheInternationalFireCoderequiresanemergencysystemtoautomaticallyilluminateexitaccesswaysinbuildingsrequiringtwoormoreexits(IFC1006).Existingclinicsshouldworktowardhavinganemergencyilluminationfortheexitaccessways.Thisshouldberequiredinneworrenovatedclinics.


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E. Battery‐poweredemergencylightingshouldbefunctionallytestedforaminimumdurationof30secondsanddocumentedat30dayintervalsandtestedannuallyforadurationof1.5hours(TJC:EC.02.05.07,29CFR1910.37(a)(4)).Dependingonthetypeofemergencylight,themonthlytestmaybeperformedbypressingthetestbutton.Responsiblestaffmayfinditeasiertodothe1.5hourtestbyturningoffthecircuitbreakerservingtheemergencylight.Thisshouldonlybedoneafterverifyingthereisnocriticalequipmentonthatcircuit.

F. Allexitsshouldbekeptfreeofobstructionsorimpediments,includingsnow,toallowinstantuseinthecaseoffireorotheremergency(29CFR1910.37(a)(3)).

4.2 General

A. Smokedetectorsarenotrequiredinone‐story,villagehealthclinicsthatdonotallowlodgingandtheoccupancywillnotexceed300people(NFPA101:38.3.4.1,39.3.4.1;IFC907.2.2)."Lodging"isatermappliedforuseandnotnecessarilyanareadesignatedforlodging(NFPA101:3.3.156,26.1.1.1;IBC302.1).Ifaclinicallowspeopletospendthenight,thenthe"lodging"provisionsapply.Ifnotrequired,existingsmokedetectorsshouldremainfunctionalorberemoved(NFPA101:4.6.12.2;IFC901.6).ForsmokedetectorrequirementsinclinicsallowinglodgingseeLodgingsection.

B. Clinicsshouldhavefireextinguishers.

1. TheplacementanddistributionshouldbeinaccordancewithNFPA10.Ingeneral,thetraveldistancetoa2‐A:10‐B:Cratedfireextinguishershouldnotbemorethan30feet.

2. Foreffectiveuse,itisrecommendedextinguishersbeplacednearexitsandbeplacedsothetopofthefireextinguisherisnotmorethan5feetfromthefloorandnotlessthan4inchesabovethefloor.

3. Theextinguishersshouldbereadilyvisiblewiththeoperatinginstructionsfacingoutwardandtheextinguishershouldnotbeblocked.

4. Theextinguishershouldbeonhangarsorinbracketssuppliedbythemanufacturer,mountedincabinets,orplacedonshelves.(NFPA10:F.5.2.1)

C. Extinguishersshouldbeinspectedmonthlyforpropercondition.Thedateofinspectionshouldberecordedeitheronatagattachedtotheunitorkeptonfile.Ifinspectioninformationiskeptinafile,recordsshallbekeptforatleastthelast12monthlyinspectionsandavailableuponrequest(NFPA10:7.2.4.5).Clinicmanagementcandesignateanyonetoconductthismonthlycheck.Appendix6providesasamplechecklistprovidedbytheStateofAlaska.

D. ExtinguishersshouldundergomaintenanceannuallybysomeonerecognizedbytheStateofAlaskatoholdapermitforinspectingportablefireextinguishers.Appendix6providesasamplechecklistprovidedbyNFPA.Documentationshouldbeavailableuponrequest.

TheStateofAlaska,DivisionofFireandLifeSafetyissuespermitsforthoseresponsibleforinstallation,maintenance,andrepairofportablefireextinguishersuponcompletionofspecificrequirements.Visithttp://www.dps.state.ak.us/fire/teb/fireextinguisherpermits.aspxformoreinformation.(NFPA101:39.3.5,38.3.5;NFPA10:6.1.2andF5.2.1;IFC906.1,13AAC50.030(h))


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E. Stored‐pressurefireextinguishersthatarerechargeableandrequirea12‐yearhydrostatictestalsorequireasix‐yearinternalexamination(appliestomostrechargeableextinguishersinclinics).Whenmaintenanceproceduresareperformedduringperiodicrechargingorhydrostatictesting,the6‐yearrequirementshallbeginfromthatdate.Ifthefireextinguisherisnewlyinstalled,the6‐yearvisualinspectionrequirementbeginsfromdateofmanufactureandshouldbemaintainedaccordingtoNFPA10:7.3.1.2.1and7.3.3.

Ifclinicschoosetodiscardorrecyclerechargeablefireextinguishersratherthanrecertifyorrecharge,contacttheAlaskaDivisionofFireandLifeSafety,TrainingandEducationBureau,RuralFireTrainingSpecialist,theymayhaveresourcestoreusethefireextinguishers,eliminatingtheburdenonthelandfill(http://www.dps.state.ak.us/Fire/contactus.aspx).

1. Nonrechargeablefireextinguishersarenotrequiredtobehydrostaticallytestedbutshallberemovedfromserviceatamaximumintervalof12yearsfromthedateofmanufacture(NFPA10:7.3.1.2.3).

F. Staffshouldreceiveannualfireextinguishereducationtofamiliarizestaffwiththegeneralprinciplesoffireextinguisheruseandthehazardsinvolvedwithitsuse.Thistrainingshouldbedocumented(29CFR1910.157(g)).

G. Staffshouldparticipateinannualfiredrills.Documentationofdrillsshouldbemaintainedattheclinic(TJC:EC.02.03.03).

H. Specialattentionshouldbepaidtotheinstallationofheatingdevices.Ascheduleforboilermaintenanceshouldbeestablished(TJC:EC.02.05.01).AboilerinspectionscheduleshouldalsobeestablishedwiththeAlaskaDepartmentofLaborandWorkforceDevelopment,LaborStandardsandSafetyDivision,MechanicalInspectionSection(907)269‐4925.Mostboilersshouldbeinspectedevery2years(AS18.60.320).Automaticutilityhotwaterheatersthatareusedforspaceheatingusingthepotablewatersystemareexemptfromstateinspection,ifthehotwaterheater:

1. isequippedwithasafetyreliefvalveandoperationalcontrolsrequiredbythelatestBoilerConstructionCodepublishedbytheAmericanSocietyofMechanicalEngineersthathasbeenadoptedbytheDepartmentofLaborandWorkforceDevelopmentunderAS18.60.180;

2. containsonlywater;

3. doesnotexceed120gallonsincapacity,awatertemperatureof210degreesFahrenheit,apressureof150poundsofsquareinchgaugepressure,oraheatinputofmorethan200,000BTUanhour;and,

4. containsatemperingvalvethatwillregulatetheoutletdomesticwatertemperatureatnotmorethan140degreesFahrenheit.


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I. ClinicsaccreditedbyTJCareexpectedtocomplywiththeLifeSafetyCodewhichstates.“Hazardousareasincludingbutnotlimitedto,areasusedforgeneralstorage,boilerorfurnacerooms…shallbeprotectedinaccordancewithSection8.4”.Thisrequiresthehazardousareatobe:

1. separatedfromotherpartsofthebuildingbyfirebarrierswitharatingofatleast1‐hourandopeningsprotectedby3/4–hourfireprotectionratedself‐closingdoors

2. protectedbyanautomaticextinguishingsystem(NFPA101:39.3.2.1/2;NFPA101:8.4

TheStateofAlaskarecognizesandenforcestheInternationalBuildingCode(IBC)whichhasspecificrequirementsthatdifferfromtheLifeSafetyCode.TheIBCrequiresa1‐hourfire‐resistance‐ratedseparationoranautomaticfire‐extinguishingsysteminfurnaceroomswherethelargestpieceofequipmentisover400,000Btuperhourinput(IBC508.2.2).

Thetablebelowprovidesexamplesoffireratingsforconstructiontypes.

One‐hourfireresistantbarriersmustcomplywithNFPA251,StandardMethodsofTestsofFireEnduranceofBuildingConstructionandMaterials.Belowisatableofcommonfireresistanceratedwallassembliesbyrating:

ConstructionType Covering FireRating

Steelstud,24in.oncenter(oc),max

5/8 in. Xgypsumboardonbothsides

1‐hour

Woodstud,16in.oc,max 5/8 in. gypsumboardonbothsides

1‐hour

Masonryblock,6in.width N/A 1‐hour

Steel,24in.oc,max5/8 in. Xgypsumdoubledonboth

sides2‐hour

Woodstud,16in.oc,max5/8 in. gypsumboarddoubledon

bothsides2‐hour

Masonryblock,8in.width N/A 2‐hour

J. Allfixed‐in‐placefuelfiredheatingdevicesshouldbeproperlyventedtoensurecombustionproductremoval.Airforcombustion,ventilation,anddilutionoffluegasesmustbeprovidedinaccordancewiththeequipmentmanufacturers’instructionswhichcanincludeprovidingorexhaustingairfromoutsidetheclinicenvironment(NFPA54:9.3.1;UPC507.0).

K. Allpressurereliefvalvesonwaterheatersshouldbeventedatasafeheightanddirection,awayfrompersonsthatmaybeinthevicinity(IMC1006.6).

L. Smokingshouldnotbeallowedinanyoftheclinicbuildings(TJC:EC.02.01.03).


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M. Ifalifesafetyfeature(device,equipment,system,condition,arrangement,levelofprotection,oranyotherfeature)isrequiredforcompliancewiththeLifeSafetyCode,itmustbecontinuouslymaintainedwiththeapplicableNFPArequirementsorasdirectedbytheauthorityhavingjurisdiction(AHJ).Additionally,existinglifesafetyfeaturesnotrequiredbytheLifeSafetyCodeorAHJbutobvioustothepublic,mustbemaintainedorremoved(NFPA101:4.6.12.1/2).

N. Ensurethatalcohol‐basedhandsanitizerdispensersarenotinstalleddirectlyadjacentto,directlyaboveorbelowanelectricalreceptacle,switch,appliance,deviceorotherignitionsource.Thewallspacebetweenthedispenserandthefloorshallremainclearandunobstructed(IFC3405.5).

4.3 LodginginClinics(LifeSafety)

TheInternational,NFPA,andStateofAlaskacodesvaryregardingrequirementsforlodgingandtransientsleepingquarters.Therefore,theNFPAcodesarecitedforexistingclinicsthatallowvisitingstafftospendthenight.ThetableinAppendix10showsexplanationsofthecodesforexistingandnewclinics.

A. UseofanyportionofaclinicforovernightsleepingaccommodationswouldclassifytheentirebuildinginwhichthesleepingaccommodationsoccurredaslodgingorboardingundertheLifeSafetyCode(NFPA101:26.1.1.1&26.1.2.1).Theonlyexceptiontothiswouldbeacomplete,fireratedseparationbetweensleepingquartersandtheclinicwhereegresspathsarenotshared(thisarrangementhasnotbeenreferencedduringtherevisionoftheseguidelines).

B. ClinicswithgasfiredappliancesshouldhaveaCOdetectorinthesleepingquarters.Allclinicsbuiltafter2008andthatallowlodgingrequiretheuseofcarbonmonoxidedetectorswhengasfiredappliancesareoperated(13AAC50.020).Thisishighlyrecommendedforallclinics

C. Approvedsingle‐stationsmokealarmshouldbeinallsleepingrooms.Theycanbebatteryoperatedandnotinterconnectedprovidedthattheclinicisabletodemonstratethattheirtesting,maintenance,andbatteryreplacementprogramswillensurereliability(NFPA101:26.3.3.5).

Aprocessshouldbeestablishedforsystemandsinglestationsmokedetectortesting,maintenance,andbatteryreplacementifrequired.Alwaysfollowmanufacturer’srecommendationsinadditiontothefollowing:

1. Initialorreacceptancetestsandinspectionsshouldoccurwithdetectorsinplaceandbedocumented.

2. Visualinspectionshouldoccurwheninstalledandeverysix‐months.

3. Detectorsensitivityshouldbecheckedoneyearafterinstallationandeverytwoyearsthereafter.Thesensitivitytestshouldensuresmokeentryintothesensingchamberandanalarmresponse.Testingwithsmokeorlistedaerosolapprovedbythemanufacturerispermitted(NFPA72:7‐2.2,7‐3.1,7‐3.2).

D. Forplanningpurposes,pertheStateofAlaskaFireMarshal,“clinicsbuiltafter2008thataccommodate[lodging]willbeanR‐1occupancyclassificationorfirearea…Anautomaticsprinklersystemmustbeprovidedthroughoutthebuilding.Healthclinicsmayutilizea13DsprinklersystemthroughoutthebuildingorprovideafirewallwithaNFPA13RsystemthroughouttheR‐1occupancy;afirewallcanbeutilizedtoseparatebuildings”.SeeAppendix16forcompletestatementmadebytheAlaskaStateFireMarshal.


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E. Everysleepingroomshouldhaveaprimarymeansofescapeandasecondarymeansofescape(NFPA101:26.2.1.1,2).ThesecondarymeansofescapecanbeawindowifmeetingrequirementsofNFPA101:24.2.2.3.ExcerptprovidedinAppendix18‐NFPASecondaryMeansofEscapeCriteria‐Windows.

F. Ifanexistingclinichasasingle‐stationsmokealarmwithatleastonemanualfirealarmboxarrangedtoinitiatethesmokedetectionalarmthentheclinicdoesnotneeda"firealarmsystem"(NFPA101:26.3.3.1).Otherwise,theclinicshouldbeprovidedwithafirealarmsystemtoinclude(NFPA101:26.3.3.1):

1. Initiation‐bymanualmean(NFPA101:26.3.3.2),amanualfirealarmboxinthenaturalexitaccesspathneareachrequiredexit(NFPA101:9.6.2.3),and

2. Notification‐automatically(NFPA101:26.3.3.3)withbothaudibleandvisiblesignals(NFPA101:9.6.3.2)operatedthroughoutthebuilding(NFPA101:9.6.3.7).

V. FURNISHINGS

5.1. Appliances

A. Atelephonelineorsecuremethodforcommunicatingshouldbeavailableforemergencycommunicationandconsultationtoensurepatientprivacy(HIPPA,TJC:RI.01.01.01(7)andIM.02.01.01).

5.2. Clinical

A. Medicalrecordsandmedicalinformationshouldbekeptconfidential(PA,HIPAA).Alockingfilingcabinetshouldbeprovidedforthestorageofmedicalrecordsandshouldbelockedwhennotinuse.Filingcabinetscontainingmedicalrecordsshouldnotbestoredinpublicaccessareassuchasthewaitingroom(TJC:RI.01.01.01(7)andIM.02.01.01).

5.3. Furniture

A. Furniturethatcanreadilyabsorbliquidshouldnotbeplacedinareaswhereitwillbeexposedtospillsorheavyspoilage.Theplacementandtypeoffurnitureshouldfollowthesamereasoningasforcarpets.Selectfurnitureappropriateforareas,specificallychoosingfurniturethatiseasilycleanedandnoteasilycontaminatedwhereinfectioncontrolisaconcern(FGI4.1‐7.2.4.2,APICCH106‐5).

B. Carpeting,ifmaintainedincleanandgoodrepair,isallowedinareasoftheclinicnotsubjecttofrequentspillageorheavyspoilage.Examplesofareaswherecarpetshouldbeavoidedinclude:kitchens,laboratories,restrooms,andutilityrooms(APICCH106‐5).

C. Furnitureshouldnotobstructexits(NFPA101:39.2.5.1,IFC1018.1).


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VI. INFECTION PREVENTION AND CONTROL

6.1. BloodandPotentiallyInfectiousMaterialSpills

A. Spillsofbloodorotherpotentiallyinfectiousmaterialsshouldbedisinfected(29CFR1910.1030(d)(4)(ii)(A)).Clinicsmayuseapre‐packagedspillkitforthispurposeaslongasthekitusesanEPAregisteredtuberculocide(listB)orEPAproductregisteredagainstHIV/HBV(ListD)(CPL2‐2.69(XIII)(D)(23)).

EPAapproveddisinfectantsmaybefoundat:http://www.epa.gov/oppad001/chemregindex.htm.AnyEPAapproveddisinfectantshouldbeusedandmixedaccordingtothemanufacturer'sdirections.Adilutesolutionofbleachmayalsobeusedaccordingtothefollowingprocedure:

- Putonglovesandotherbarriers,suchasafaceshield,ifindicated.

- Wipeupexcessmaterialwithdisposabletowelsorotherabsorbentmaterials.

- Cleanupspillwithsoapandwater.

- Disinfectcontaminatedsurfaceswithadilutesolutionofhouseholdbleachandwater(1partbleachin99partswaterforsmoothsurfaces).Contacttimeforthissolutionisthetimefortheapplicationtodry.Thedilutedbleachsolutionshouldnotbemorethan24hoursold(APIC100‐5;CPL2‐2.69(XIII)(D)(23)).

Dilutionexample:Approximately1.5ouncesor3tablespoonsofbleachpergallonofpotablewater.

B. Ifanabsorbentmaterial(suchascarpetingorfurnitureupholstery)stillisstainedwithbloodorotherpotentiallyinfectiousmaterialafterextractioncleaningprocedures,thecarpetshouldbediscardedorthefurniturereplacedorreupholstered(APICCH100).Usingsquarecarpettileswillfacilitatethisprocess.

C. Brokenglasswareorothersharpobjectsthatmaybecontaminatedshouldnotbepickedupdirectlywiththehands.Theseitemsshouldbecleanedupusingmechanicalmeanssuchasabrushanddustpan,tongsorforceps.Thesharpobjectshouldbedisposedinasharpscontainerandthedeviceusedtopickitupshouldbedisinfectedordiscarded(29CFR1910.1030(d)(4)(ii)(D)),(CPL2‐2.69(24)).

6.2. EnvironmentalSurfacesandNon‐patientCareItems,Disinfecting

SeeEnvironmentalServices(Housekeeping)section


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6.3. HandHygiene(Handwashing)

TheCentersforDiseaseControlandPrevention(CDC)HealthcareInfectionControlPracticesAdvisoryCommittee(HICPAC)andtheHICPAC/SHEA/APIC/IDSAHandHygieneTaskForceissuedtheGuidelineforHandHygieneinHealth‐CareSettings(2002).BoththisguidelineandtheWHOGuidelinesonHandHygieneinHealthCarearethemainhandwashingreferencesusedinthisdocumentandarerecognizedastheleadingresourcesforacomprehensivehandhygieneprogram.BothguidelinescanbedownloadedattheCDC'swebpage,HandHygieneintheHealthcareSettingat:http://www.cdc.gov/HAI/prevent/prevent_pubs.html.

A. Allhealthcareworkers(HCWs)andstaffsurveyingclinicsshouldbefamiliarwiththerecommendationsoutlinedintheCDCand/orWHOguidelinesforsuccessfulhandhygienepractices.Athoroughreviewoftheguidelinesisrecommendedpriortoidentifyingprocessesthatneedimprovement.Handhygienerequiresacomprehensiveprogramincludingahandhygienepolicy,acultureofhandhygiene,monitoring,andaprocessforfeedback.KeyCDCrecommendationsforhandhygieneinclude:

1. Beforetouchingapatient,evenifglovesareworn

2. Beforeexitingthepatient’scareareaaftertouchingthepatientorthepatient’simmediateenvironment

3. Aftercontactwithblood,bodyfluidsorexcretions,orwounddressings

4. Priortoperforminganaseptictask(placinganIV,preparinganinjection)

5. Ifhandswillbemovingfromacontaminated‐bodysitetoaclean‐bodysiteduringcare

6. Aftergloveremoval

AnexcerptoftheCDCguidelinesandvisualdemonstrationfromtheWHOguidelinesareprovidedinAppendix12andAppendix13.

”AccordingtotheCentersforDiseaseControlandPrevention,eachyear,millionsofpeopleacquireaninfectionwhilereceivingcare,treatment,orservicesinahealthcareorganization.Consequently,healthcare‐associatedinfections(HAIs)areapatientsafetyissueaffectingalltypesofhealthcareorganizations.OneofthemostimportantwaystoaddressHAIsisbyimprovingthehandhygieneofhealthcarestaff”(TJC:NPSG.07.01.01).

*ClinicsaccreditedbyTJCmustcomplywiththecurrentCDCand/orWHOhandhygieneguidelines(TJC:NPSG.07.01.01).

B. Clinicsmusthavehandwashingstationsreadilyavailableinallexaminationandtoiletrooms.Thisincludesanadequatesupplyofhandsoap,warmwater,disposablepapertowelsprovidedbyadispenser,allnexttoahandwashingsinkandappropriatetrashreceptacle(othersanitarymeanstodryhandsarepermissibleintoiletrooms,i.e.handdryers).(29CFR1910.1030(d)(2)(iii),CPL2‐2.69(4)(b),HICPACPartII.Recommendations:hand‐hygienepracticesofHCW’sandWHOGuidelines,FGI3.1‐8.4.3.2).

C. InClinicswithoutrunningwater,acceptablealternativesforhandhygieneshallstillbeprovided.Thisincludesthefollowingtwoexamples:


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1. Handwashingstations:Describedasaninsulatedcontainerwithafaucettypespigotwhichcanbesecuredintheopenposition,providingacontinuousflowofhandwashingwater(seeAppendix20).Acontainershouldbeplacedbelowthespigottocatchwastewaterfromhandwashingoperations(BMP).“Thehandwashingstationshouldbeplacedinanareaoftheclinicwhereunattendedchildrenarenotallowed.Infantsandtoddlerscandrowninsmallamountsofwaterleftina5‐gallonbucket(http://www.cpsc.gov/cpscpub/pubs/5006.html).”

2. Antimicrobial‐impregnatedwipes(i.e.,towelettes):Arenotconsideredasubstituteforwashinghandswithsoapandcleanwater.However,theymaybeusedtocleanvisiblysoiledhands.Aftercleaninghands,alcohol‐basedhandrubshouldbeusedpriortopatientcontact.

6.4. InsectandRodentControl

Clinicsshouldbemaintainedsoastopreventtheentranceorpresenceofinsectsandrodents(29CFR1910.141(a)(5)).AlthoughawrittenIntegratedPestManagement(IPM)planisnotrequiredintheclinics,IPMtechniquesshouldbepracticed(APICCH100).Appendix5containsmoreinformationonIPM,someitemsallclinicsshouldhaveinplaceinclude:

A. FacilityDesign‐Facilitydesignandmaintenanceshouldhelptoexcludepests,minimizepesthabitatandpromotepropersanitation.Thisincludes

1. Screenswithatleast16meshperinchshouldbeprovidedonallopenablewindows(IPMC304.14,FGI7.28.A9).

2. Self‐closingdoordevicesshouldbeusedonallexteriordoors(IPMC304.14).

B. Monitoring‐Monitoringshouldbeusedinplaceofpreventivepesticidaltreatments.Thoughaformalmonitoringprogramcouldbeestablished(trapsandfrequentvisualinspections),staffshouldbeaskedaboutthepresenceofpestsduringenvironmentalhealthsurveys.ThepresenceofpestsshouldtriggeramoreestablishedIPMprogram.

C. SanitationandFacilityMaintenance‐Clutterandotherharborageareasshouldbereduced.Foodshouldnotbeleftout.Allcracksorseamsontheoutsideofthebuildingthatcouldallowinsectsorrodentstoentershouldbesealed.

D. PestControlwithPesticidesshouldbelimitedtoareasofpestactivityandshouldonlyusetheleasttoxicproductthatwouldbeeffective.Baitstations(keptoutofthereachofchildren)shouldbeconsideredinthesecircumstances.AnyapplicationsusinganEPArestrictedusepesticidemustbedonebyacertifiedpesticideapplicator(18AAC90.300).TheStateofAlaskamaintainsalistofcertifiedapplicatorsat:http://www.dec.state.ak.us/eh/pest/AdherencetoOSHAregulationsdealingwithPersonalProtectiveEquipmentandtheHazardCommunicationStandardmustbefollowed.ThiswouldincludeallowingstaffaccesstotheMaterialSafetyDataSheetsforthepesticidesused(29CFR1910.1200(g)(8)).

AcertifiedpestcontrolapplicatormayalsoassistwiththeimplementationofacompleteIPMprogram.ContactANTHC/DEHEforadditionalassistance.


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6.5. Patient‐careMedicalDevices,DisinfectingandSterilizing

TheCentersforDiseaseControlandPrevention(CDC)HealthcareInfectionControlPracticesAdvisoryCommittee(HICPAC)issuedtheGuidelineforDisinfectionandSterilizationinHealthcareFacilities(2008)andisthemainreferenceusedinthissection.AdditionalreferencesincludetheGuidetotheGuidelines:FromPolicytoPracticepublishedbytheOrganizationforSafety&AsepsisProcedures(OSAP)andtheAssociationforProfessionalsinInfectionControlandEpidemiology(APIC)2011Text.

Allhealthcareworkers(HCWs)andstaffsurveyingclinicswithsterilizationprocessesmustbefamiliarwiththerecommendationsoutlinedintheCDCguidelineforsuccessfulcleaning,disinfection,andsterilizationpractices.Athoroughreviewoftheguidelineisstronglyadvisedpriortoreviewingprocessesandrecommendingimprovementsforclinicssterilizingpatient‐caredevicesandequipment.

Forconsiderationduringthesurvey,thedeliveryofsterileproductsforuseinpatientcaredependsnotonlyontheeffectivenessofthesterilizationprocessbutalsoonthefollowing:

Physicalfacilities

- whichincludedecontamination,sterilization,packagingandstorage

OperatorcompetencyincludingPPEselection

Workflow(standardizationofprocess)

- receiving,holding,cleaning,preparing,packaging,sterilization,andstorage

Propercleaninganddecontamination

Packaging,storage,andrecall(event‐relatedshelf‐lifepractice,expirationdates)

Properloadingofsterilizer

Monitoringentireprocess;QualityAssurance(QA)

- sterilantqualityandquantity(logbook)

Appropriatenessofcycleforcontents(equipment,instruments)

Otheraspectsofdevicereprocessing(manufacturers’recommendations)

Duetorequirementsforhigh‐leveldisinfection/sterilization,manyclinicsmaydecidetousedisposablemedicalequipmentforitemsrequiringhigh‐leveldisinfection/sterilization.Aninfectioncontrolriskassessmentshouldhavebeencompletedtodeterminewhetheritisnecessarytosterilizepatient‐caremedicaldevicesatthecliniclevel.

Ifitisdeterminedthatclinicstaffwillsterilizepatient‐caremedicaldevices,theymustadherestrictlytoboththecleaning,disinfection,andsterilizationrecommendationsoutlinedbytheCDCandtoinstructionsonproductlabels.Theactualsterilizationprocessshouldbeevaluatedtoensureitisperformedcorrectly.Thisincludesdentaloperationsthatsterilizepatientcaredevicesandequipment.

Ensuringconsistencyofsterilizationpracticesrequiresacomprehensiveprogram.Staffwhoperformhigh‐leveldisinfection/sterilizationforpatientcaredevicesandequipmentshouldhavereceivedtrainingintheseprocesses.Thetrainingshouldincludeoccupationalsafetyandhealthissues.Thistrainingshouldbedocumentedandanannualassessmentshouldbeperformedtoensurecompetencyisretained(TJC:HR.01.02.05).Thissectionwillsummarizethesterilizationprocessandpointoutissuesthatshouldbereviewed.


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A. PhysicalFacilities:Itemsreceivingsterilizationorhigh‐leveldisinfectionshouldflowinaprocessfromdirtytoclean.Ideally,thereshouldbephysicalseparationbetweendirtyandcleanareas,butminimally,theflowofitemsmustnotallowforcrosscontamination.Itemsshouldnotbeallowedtobacktrack.

Staffshouldperformmostcleaning,disinfecting,andsterilizingofpatient‐caresuppliesinacentralprocessingdepartmentinordertomoreeasilycontrolquality.Theaimofcentralprocessingistheorderlypreparationofmedicalandsurgicalinstrumentstoprotectpatientsfrominfectionswhileminimizingriskstostaffandpreservingthevalueoftheitemsbeingreprocessed.Iftheprocessbeingevaluatedisnotdonecorrectlyorisnotfeasibleinthefacility,surveyorrecommendationsmightincludediscontinuingsterilizationatthecliniclevel,usingdisposableproducts,orsendingitemsoutforsterilization.

B. Decontamination:Foritemsreceivinghigh‐leveldisinfection/sterilization,decontaminationwillconsistofthefollowing:

1. Transportation:Afteruse,itemsshouldbeplacedinbio‐hazardousmarkedreceptaclesfortransportationtothedecontaminationarea.Thesereceptaclesshouldbeusedevenifitemsaretransportedwithintheclinic.Itemsshouldeitherberinsedorkeptmoistuntilcleaned.Thiswillpreventorganicmaterialfromdryingontheitems.

2. Cleaning:Itemsmustbecleanedbeforehigh‐leveldisinfection/sterilization.Cleaningremovesforeignmatter(organicmatter,soil,etc).Withoutcleaning,thehigh‐leveldisinfection/sterilizationprocessmaybeineffective.Self‐enclosedcleanerssuchasultrasoniccleanersorwashersarepreferredfromanoccupationalhealthandsafetypointofviewsincetheylimitexposuretotheprocess.Ifmanualcleaningisperformed,theemployeeshouldwearappropriatepersonalprotectiveequipmentincluding;eyeprotection,fluidresistantfacemask,haircover,imperviousgownandutilitygloves.

C. Packaging:Manyitemsarepackagedbeforethesterilizationprocess.Thefacilityshoulddevelopandfollowtheirownpolicyformarkingpackages.Asystemshouldbeinplacetoallowtrackingofpackagessterilizedineachbatch.Adatingsystemwouldsufficeforlowvolumefacilities.Ifthefacilityhasapolicyonexpirationdatesfortheirpackages,itshouldbefollowed.SomefacilitiesmayuseEventRelatedSterility,wherethesterilizedpackageisconsideredsterileunlessthepackagehasbeencompromised(torn,etc.),asaresult,expirationdatesarenotneeded.

D. Sterilization/HighLevelDisinfection:

1. TheSterilization/HighLevelDisinfectionfigurefoundinAppendix14shouldbeusedtohelpdeterminetheappropriatelevelofdisinfectionorsterilization.(APICCH21,Table21‐1).

2. Processmonitoring:Thesterilizationprocessshouldbemonitoredusingchemical,mechanical,andbiologicalmonitoring.Themanufacturer’srecommendationsformonitoringshouldbefollowed.Iftheyarenotavailable,thefollowinginformationcanbeused.Thefollowingtableisaguideofitemsthatshouldbemonitored:


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Process Mechanical Chemical Indicator Color change indicates item exposed to sterilization, but not proof of sterilization.

Biological

Steam Physical Monitoring (time, temperature, and pressure)

Place indicators on inside and outside of each pack on every load.

Geobacillus stearothermophilus at least weekly. Placed in most challenging location of sterilizer

Dry Heat Review recording charts for each load

Check with spores of Bacillus atropheus at least weekly.

Chemiclave (Dental may use a formaldehyde/ethanol sterilizer)

As indicated by manufacturer

Place indicators on inside and outside of each pack on every load.

Check with spores of Bacillus stearothermophilus at least weekly.

Parametersarespecifiedbythemanufacturer.Apositivecontrolsporetestshouldbeconductedaccordingtothemanufacturer'sdirections(typicallythisisconductedwitheverybiologicalindicatorsporetest,toensureviablesporesinthetestpack).Ifrecordedparametersarebeyondthemanufacturer’srecommendations,actionsmustbetakentocorrecttheproblem.Writtenrecordsshouldbekeptofallprocessmonitoringparameters.

3. Whenstaffremovepackagesfromsterilizer,thepackagesshouldbedry.Hotpacksareabletowickmoisturewhichcanintroducebacteriafromhands.Ifpackagesarewetuponcompletionofthesterilizationprocess,thismayindicateoverfillingofthesterilizer(CDC‐ICDHSp.22,OSAPp.52).

E. StorageofSterilizedPackagesandotherPatientCareItems

1. Patientcareitemsshouldberotatedtoensurefirstinfirstout(FIFO).

2. Theintegrityofsterilizedpackagesshouldbechecked.Thecontentsoftornpackagesshouldbereprocessed.

3. Sterilizeditemsandotherpatientcareitemsshouldnotbestoredundersinksandshouldbestoredupoffthefloor(CDC‐DSp.75,CDC‐ICDHSp.25).

F. Recall:Theclinicshouldfollowapolicyonhowandwhentorecallitemsfromasterilizationbatchwhereoneoftheprocessindicatorshasfailed.


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6.6 PersonalProtectiveEquipment(PPE)

PPEmustbeprovidedtoemployees.ThissectiondescribesPPEtypicallyusedtocomplywiththeBloodbornePathogen(BBP)standard.PPEmayberequiredforothertasks.AllPPEshouldbeselectedbytheemployerafterconductingawrittenworkplacehazardassessment(29CFR1910.132(d)(2)).ANTHC,DEHEstaffcanprovideresourcesforthisassessment.

PersonalprotectiveequipmentforcompliancewiththeBBPstandardwillbeconsidered"appropriate"onlyifitdoesnotpermitbloodorotherpotentiallyinfectiousmaterialstopassthroughtoorreachtheemployee'sworkclothes,streetclothes,undergarments,skin,eyes,mouth,orothermucousmembranesundernormalconditionsofuseandforthedurationoftimewhichtheprotectiveequipmentwillbeused.ExamplesofPPEthatmayberequiredinclude:gloves,gowns,laboratorycoats,faceshieldsormasksandeyeprotection,andmouthpieces,resuscitationbags,pocketmasks,orotherventilationdevices(29CFR1910.1030(d)(3)(i)).SpecificPPEandwhenitshouldbeworn,include:

1. Gloves:Glovesshouldbewornwhenitcanbereasonablyanticipatedthattheemployeemayhavehandcontactwithblood,otherpotentiallyinfectiousmaterials,mucousmembranes,andnon‐intactskin;whenperformingvascularaccessprocedures,andwhenhandlingortouchingcontaminateditemsorsurfaces(29CFR1910.1030(d)(3)(ix)).

a. Disposable(singleuse)glovessuchassurgicalorexaminationgloves,shouldbereplacedassoonaspracticalwhencontaminatedorassoonasfeasibleiftheyaretorn,punctured,orwhentheirabilitytofunctionasabarrieriscompromised(29CFR1910.1030(d)(3)(ix)(A)).

b. Latexallergyconsideration–theuseoflatexglovesshouldbelimitedasmuchaspossible.Ifstaffpreferlatex,ariskassessmentshouldbecompleted,includingaskingnewstaffandpatientsaboutlatexsensitivities.

2. Masks,EyeProtection,andFaceShields:Masksincombinationwitheyeprotectiondevices,suchasgogglesorglasseswithsolidsideshields,orchin‐lengthfaceshields,shouldbewornwheneversplashes,spray,spatter,ordropletsofbloodorotherpotentiallyinfectiousmaterialsmaybegeneratedandeye,nose,ormouthcontaminationcanbereasonablyanticipated(29CFR1910.1030(d)(3)(x)).Typicalprescriptionglassesdonotofferadequatesplashprotection,thoughsplashresistantgogglesmaybepurchasedwithprescriptionlens.

3. Gowns,Aprons,andOtherProtectiveBodyClothing:Appropriateprotectiveclothingsuchas,butnotlimitedto,gowns,aprons,labcoats,clinicjackets,orsimilaroutergarmentsshouldbeworninoccupationalexposuresituations(29CFR1910.1030(d)(3)(xi)).Theoccupationsandexposuresituationsshouldbedelineatedintheclinic'sBloodbornePathogenProgram.

Note:Staffclothingcommonlyreferredtoas“scrubs”havebecomerecognizedasanacceptablehealthcareworkeruniformorgeneralworkclothes.Scrubs,orgeneralworkclothes/uniforms,arenottypicallyintendedtofunctionas“protectionfromahazard”.AppropriatePPE,includingbutnotlimitedtogownsandlaboratorycoats,areusedoverthescrubswhenPPEisrequired.Inmostcases,scrubsarenotconsideredPPE.Anypersonalclothingshouldbechangedifitbecomessoiled(APICCH101‐5)


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6.7 Thermometers,Disinfection

APICreferencesthermometersasbeing“implicatedinthespreadoforganismssuchasClostridiumdifficileandmethicillin‐resistantStaphylococcusaureus(MRSA)”.Bothorganismssurvivewelloninanimateobjects(APICCH56‐4).

A. Disposableplasticsleevesshouldbeusedwithdigitalthermometers.Theprobebodyshouldbewipedwithadisinfectantclothafteruse(APICCH56‐5).

Note:forotherthandigitalthermometers

PerCDCGuidelines,soakingoralandrectalthermometersinethylorisopropylalcoholat70%to90%concentrationfor>1min(alwaysfollowmanufacturer’srecommendations)isadequate.Oralandrectalthermometersshouldnotbemixedatanytimeduringhandlingorprocessing(CDC‐DS).

6.8 Toys,Disinfection

A. Whentoysaremadeavailable,onlytoysthatcanbewashedanddisinfectedshouldbeprovided.Machinewashableclothtoysmaybeusedonlyifusedbyoneindividualatatimeandcleanedbetweenuses.

B. Cleaningcriteriaincludes:

1. Setasideorcleanedaftereachuse:

(a) Alltoysthatgointothemouth(contactwithsaliva)

(b) Contactwithanyotherbodyfluids

2. Visiblycontaminated

3. Allotherusedtoysshouldbecleanedattheendoftheday

C. Toysshouldberinsedafterdisinfection.Adisinfectantappropriateforenvironmentalsurfacesshouldbeusedandshouldbecompatiblewiththetoy.

D. Smalltoyswithhardsurfacescanbesetasideforcleaningbyputtingthemintoadishpanlabeled“soiledtoys”.Thisdishpancancontainsoapywatertobeginremovalofsoil,oritcanbeadrycontainerusedtobringthesoiledtoystoatoycleaningarealaterintheday.Thiscontainermustbekeptoutofreachofchildren.

E. Usingamechanicaldishwasherisanacceptablelabor‐savingapproachforplastictoysaslongasthedishwashercanwashandsanitizethesurfacesanddishwashingisapprovedbythetoymanufacturer.(CaringforOurChildren3.3.0.2).


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VII. JOINT COMMISSION (TJC) ACCREDITATION

ParticipationinTJCaccreditationprogramisvoluntary.Althoughsomeclinicsdonotactivelyparticipate,theintentoftheEnvironmentofCare(EC),EmergencyManagement(EM),andLifeSafety(LS)standards,asdescribedinElementsofPerformance(EPs),arestillrelevantasbestmanagementpractices(BMPs).IfaclinicisaccreditedorisapplyingforaccreditationeitherthroughtheirTHOorasastand‐aloneclinicthesurveyormayusethemostrecentapplicablestandardstocompleteareviewoftheEC,EMandLSprograms.Whenreviewingaclinicforaccreditationcompliance,pleasenotethereareotherTJCstandardstoconsiderthatarenotthoroughlydiscussedinthisdocument,suchasInfectionControl(IC).TheappropriateTJCmanualshouldbetheguideforacomprehensiveaccreditationprogramreview.

OutlinesfortheEC,EM,andLSchapters,providedbythe2011EnvironmentofCareEssentialsforHealthCarepublishedbyJointCommissionresources,representalloftheaspectsrequiredtosuccessfullycomplywithTJCrequirementsforaccreditationinrespecttoEC,EM,andLSchapters.TheoutlinescanbefoundinAppendix9.StandardsareappliedrelativetothetypeofaccreditationrecognizedbyTJCforeachfacility.MultipleEPsspecifyactivitiesthatareeithertimesensitiveand/oridentifiedascritical.AcomparisonoftimesensitiveandcriticalrequirementsforAmbulatoryHealthCarestandards(AHC),CriticalAccessHospital(CAH),andHospital(HAP)isprovidedintheAppendix8.ActivitiesrequiredbyacodeorstandardadoptedbyTJCarelistedintherespectiveheading,suchasfiredrillrequirementsarelistedunderFireSafetybecauseallclinicsshouldcomplyregardlessofaccreditationstatus.

Note:Previously,theECchapteraddressedsevenaspectsoftheenvironment.Inthe2011edition,SafetyandSecuritywerecombinedandEmergencyManagementandLifeSafetyarenowlocatedinseparatechapters.

VIII. SAFETY AND HEALTH

8.1. Asbestos

Theintentofthissectionisnottodescribeallpertinentasbestosregulations,buttolegallyensureappropriateclinicstaffareawareofpotentialasbestosexposures.Thisawarenesswillhelpensurecomplianceofotherasbestosregulationswhennecessary.

A. ThefollowingshouldbemanagedasPresumedAsbestosContainingMaterial(PACM)ifinabuildingconstructedbefore1980(29CFR1910.1001(j)(1)):

1. ThermalSystemInsulation:insulationappliedtopipes,fittings,boilers,tanks,ductsorotherstructuralcomponentstopreventheatlossorgain.

2. Sprayedonandtrowledsurfacingmaterials.

3. Asphaltorvinylflooring.


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B. ThePACMmaybeprovenasbestosfreeunderthefollowingscenarios(29CFR1910.1001(j)(8)(ii)):

1. AcompleteAsbestosHazardEmergencyResponseAct(AHERA)inspectionconductedper40CFR763SubpartEdeclaresnoACMispresent.

2. AnaccreditedinspectororCertifiedIndustrialHygienist(CIH)conductsaninspectionofthematerialper40CFR763.86anddeclaresthematerialasbestosfree.

C. EmployeeswhoperformhousekeepingormaintenanceoperationsinacliniccontainingACMorPACMshouldreceiveannualasbestosawarenesstraining(29CFR1910.1001(j)(7)(iv)).

8.2. BloodbornePathogenProgram(BPP)

ManyoftheitemsrequiredinaBBPprogramarementionedthroughouttheseguidelines.AclinicshouldalsohaveawrittenprogramthataddressesitemsrequiredintheOSHAStandard29CFR1910.1030andtheNeedleStickSafetyandPreventionAct.AclinicmaybeincludedintheTHOBBPprogram.Theexposurecontrolplanshouldbeavailable,andshouldaddress:

1. Identificationofhighexposureriskjobsortasks

2. Employeetraining

3. Safeworkprocedures

4. Engineeringcontrols

5. Personalprotectiveequipment(providedandavailabletoemployees).Note:OSHAStandard,29CFR1910.1030(d)(3)(iii),requiresthatappropriatepersonalprotectiveequipmentintheappropriatesizesisreadilyaccessibleattheworksiteorisissuedtoemployees.Hypoallergenicgloves,gloveliners,powderlessgloves,orothersimilarnon‐latexalternativesshallbereadilyaccessibletothoseemployeeswhoareallergictotheglovesnormallyprovided.

6. Labelinganddisposalpractices

7. Evaluationandmonitoringofexposedemployees

8. Medicalrecordsandtrainingrecordsmaintenance

9. Confidentialityandrightsofemployees

8.3. CompressedGases

Compressedgascylinders,whichincludeoxygenbottles,presentseveralsafetyhazards.Properprecautionsmustbetakentoensurethesafetyofpatientsandstaff(NFPA99:4‐3.5.2.1,4‐3.5.2.2;IFC3006(citesNFPA99).AnexcerptoftheNFPA99guidelinesforoxygencylindersisintheappendix.SeeIFC4001‐4005foradditionalinformation.

A. Compressedgascylinders,specificallyoxygenbottles,mustbesecuredatalltimesincludingwhennotinuse.Thisistopreventcylindersfromfallingortipping.Cylindersshouldalwaysbesecuredinastand,inacart,orattachedtoanimmovableobject.

B. Topreventcombustion,allcomponentsoftheoxygensupplysystemmustbekeptfreeofpetroleumproducts,suchasgreaseoroil.


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C. Cylinder‐valveprotectioncaps,whereprovided,shouldbekeptinplaceandbehandtightened,exceptwhencylindersareinuseorconnectedforuse.

D. Manufacturerswhofillcompressedoxygencylindersarenotrequiredtoplaceexpirationlabelsonthecylinderforthecontents,butifthereisanexpirationlabelfortheoxygenitmustbefollowed.AnattachedexpirationlabelshouldnotbeconfusedwiththeDepartmentofTransportation(DOT)stamponthecylinder.

E. TheDOTdatestampedonthecylinderistodeterminewhenthecylindermustberequalifiedforshippingpurposes.Theoxygeninthecylindermaybeusedafterthedatehaspassed.Therefillerofthecylinderhastheresponsibilitytoretestandstampthecylindereveryfiveyears.Thedateoftheretestshouldbestampedonthecylinder.Aretestisdueevery10yearsifthedatehasafive‐pointstarbyit.Itisagainstthelawtodefacethisdate(49CFR180.205,49CFR180.209and49CFR180.213).

F. Verycoldcylindersorcontainersshouldbehandledwithcaretoavoidinjury(NFPA994‐3.5.2.1(30).

8.4. HazardCommunication

A. AHazardCommunicationProgramasrequiredbyOSHAStandard29CFR1910.1200shouldbeinplace.Awrittenhazardcommunicationprogramshouldbeavailable,andshouldaddress:

1. Awrittenhazardcommunicationplan

2. Aninventoryofallhazardoussubstancesused

3. MaterialSafetyDataSheets(MSDS)

4. Productlabelingandotherformsofwarning

5. Employeeinformationandtrainingandrecordkeeping

6. Appropriatedisposalofhazardouswastes

B. MSDSshouldbemaintainedforallhazardousmaterialsintheclinic,andshouldbeavailableandaccessibletoemployeesatalltimes.Allrequireditems,suchaspersonalprotectiveequipment,shouldbeprovidedandavailabletoemployeesatalltimes(29CFR1910.1200).

C. PhysicalAgentDataSheets(PADS)shouldbemaintainedintheclinicsforphysicalhazardsthatexceedthethresholdestablishedinthe1995‐1996editionof“ThresholdLimitValues(TLVs)forChemicalSubstancesandPhysicalAgentsandBiologicalExposureIndicesintheWorkEnvironment”publishedbytheAmericanConferenceofGovernmentalIndustrialHygienists(ACGIH).Thismayincludecoldstress,hand‐arm(segmental)vibration,ionizingradiation,andnoise(8AAC61.1110).AlaskaOccupationalSafetyandHealthhassamplePADSontheirwebsiteat:http://www.labor.state.ak.us/lss/pads/pads.htm.


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D. Thefollowingmandatorypostersshouldbepostedinacommonareathatallowsallemployeestoreviewthem:

1. EqualEmploymentOpportunityAct

2. AlaskaandFederalMinimumWage

3. EmployeePolygraphProtectionAction

4. AlaskaHumanRightsLawasitpertainstothepreventionofsexualharassment

5. UnemploymentCompensation

6. ChildLaborLaws

7. Anti‐discriminationnotice

8. Paydaynotice

9. Emergencycontactinformation

10. IRSWithholdingNotice

11. WorkersCompensation

12. UniformedServicesEmploymentandReemploymentRightsAct

13. FamilyandMedicalLeaveAct

14. OSHASummaryofOccupationalSafetyandHealthActandRighttoKnowAct

15. AlaskaOccupationalSafetyandHealthLaws(AS18.60.010to.105)

8.5. InjuryControl

Asurveyoftheclinicshouldtakeintoaccountthehazardstowhichanunsupervisedchildcouldbeexposed.Childspecifichazardsshouldbeengineeredoutwhenpossible.Thoughclinicsarenotchildcarecenters,theguidelinesusedforchildcarecentersareusefulwhendesigningandmaintainingachildsafefacility,accordingly,thissectionreferencestheAmericanPublicHealthAssociationandtheAmericanAcademyofPediatrics,CaringforOurChildren,NationalHealthandSafetyPerformanceStandards:GuidelinesforOut‐of‐HomeChildCare,2011(CFOC).

A. Theclinicfacilityshouldbemaintainedtominimizepotentialinjuryhazards.Injuryhazardsidentifiedshouldbecorrectedinareasonableamountoftime(TJC:EC.01.01.01).

B. Unlessaroomiskeptlockedduringbusinesshours,itshouldbeassumedachildcouldenterthatroom.Allunlockedroomsshouldbesurveyedforpotentialhazards.Itemstoconsiderinclude:

1. Hazardouschemicalsandsharps(contaminatedorclean)shouldbeinlockedcabinetsoroutofthereachofchildren,separatefromstoredmedicationsandfood(CFOC5.2.9.1).

2. Anyapprovedspaceheatersshouldbemadeinaccessibletochildrenandstable(CFOC5.2.1.11and5.2.1.13).Waterpipesorbaseboardheatersthatexceed1100Fshouldbeinaccessibletochildrenbybarrierssuchasguardsorotherdevices(CFOC5.2.1.13).Hotwatertemperaturesatsinksusedforhandwashing,oratplumbingfixtureswherethehotwaterwillbeindirectcontactwithchildren,shouldbeatatemperaturenotexceeding1200F(CFOC5.2.1.14).


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3. Asmuchaspractical,electriccordsshouldbeplacedbeyondchildren'sreach(CFOC5.2.4.5and5.2.4.6).Ensurechildrencannotpulloncordsattachedtohotequipment(coffeepots)orheavyequipmenttotheextentwheretheequipmentcouldfallonthem.

4. Tables,chairs,andotherfurnishingsorplayequipmentinthewaitingroomshouldbesturdyandfreeofsharppointsorcorners,splinters,protrudingnailsorbolts,orhazardoussmallparts(CFOC5.3.1.1).

5. Poisonousorpotentiallyharmfulplantsshouldbeinaccessibletochildren(CFOC5.2.9.10).Unlesstheclinichasevidenceofthesafetyoftheplant,itshouldbeassumedtobepoisonousorpotentiallyharmful.

6. Childrenshouldnotbeallowedtoplaywithorblowuplatexgloves.Thiswilllimitexposuretolatexandreducepossibilityoflatexsensitization(BMP).

7. Stringsandcordslongenoughtoencircleachild'sneck(6inchesormore)shouldnotbeaccessibletochildren(CFOC5.160).Ensurewindowshadecordswithinchildren'sreachdonotcontainloopsunlessequippedwithabreak‐awaytassel(moreinfoatwww.cpsc.gov).

8. Staffshouldbeabletounlockbathroomdoorsorotherdoorsinwhichachildorincapacitatedpersonmaylockthemselves.Thisistoallowimmediateaccessincaseofamedicalemergencyorfire(NFPA101:17.2.2.2.5).

C. Snowandiceremovalfromstairwaysshouldbeprovidedasafunctionofroutinemaintenanceorjanitorialservices.Buildingoverhangsshouldbeconsideredforallnewclinicconstructionwhenstairwaysleadingtothebuildingwillbesubjecttosnowandiceaccumulation,thisisespeciallyimportantforexitdoorsnotusedasameansofaccess(29CFR1910.37(a)(3)).

D. Fallortriphazardsshouldbeeliminatedthroughtheuseofrailingsonsteps,stairwaysorramps(NFPA101:7.2.2.4.2)andnon‐slipsurfacesonstairs,ramps,tubs,etc.(NFPA101:7.1.6.4andBMP).

8.6. Lead

Theuseofleadinpaintwasbannedin1978(16CFR1303)forconsumerpurposes.ClinicsbuiltaroundthistimeorearliermayhaveLeadBasedPaint(LBP).Activitiesthatcoulddisturbthispaint(includingdemolitionofdrywall,sanding,scraping,heatgunuse)shouldnotbeconducteduntiloneofthefollowinghavebeenmet:

1. Competentsamplingandaccreditedlaboratoryanalysisdeterminesthepainthasnodetectablelevelsoflead.

2. Ifsamplingwasnotdone,thepaintshouldbepresumedtocontainleadandworkersshouldtakenecessaryprecautionstoprotectthemselvesandtheclinicworkers(29CFR1926.62and29CFR1910.1025).

ThoughclinicstaffwillprobablynotbeengagedinactivitiestodisturbLBP,theymaybeinapositiontoensureothersdonotdisturbLBPbeforenecessaryprecautionsaretaken.


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8.7. MedicineandPoisonControl

Pharmacyisoftenresponsibleforcheckingtheitemsinthissection.Theenvironmentalhealthspecialistshouldcheckwiththepharmacyprovidertocoordinateroles.Unlesstheenvironmentalhealthspecialisthasreceivedspecializedtraining,theirroleformedicineandpoisoncontrolshouldbelimitedtotherealmdescribedinthissection.

A. Drugs,medicinesandotherpharmaceuticalsshouldbestoredinalockedroomorcabinet.Controlledsubstancesshouldbestoredinasecurelylockedsubstantiallyconstructedcabinet.Wherefeasible,drugstoragecabinetsshouldbesecured(bolted)tothewallorfloortopreventremovalbyunauthorizedpersonnel(21CFR1301.75andTJC:MM.03.01.01).

B. Outdatedorexpiredmedicinesshouldberemovedfromthepatientmedicinestorageareaandshouldbereturnedtotheregionalhospital/healthcenterorvendorforproperdisposal(TJC:MM.05.01.19).

C. Multiple‐dosecontainerswithantimicrobialpreservativesshouldnotbeusedbeyond28daysafteritisinitiallyopenedorentered(e.g.,needle‐punctured),unlessotherwisespecifiedbythemanufacturer(USP797page41).

D. Single‐useitems,suchassodiumchlorideirrigationbottles,shouldbediscardedandnotreusedasperthemanufacturers’guidelines.

E. Toxicproductsorhazardousmaterialsshouldbestoredseparatelyawayfromfoodormedicines(29CFR1910.141(g)(4);TJC:EC.02.02.01).

F. Refrigerators,andwhereneeded,freezersofadequatesizeshouldbeprovidedforthesafestorageoftemperaturesensitivemedicines.Ameansmustbeprovidedtomonitorthetemperaturecontinuouslytoensurethetemperaturerangefortherefrigeratorstaysbetween2°Cand8°C(36°Fand46°F).Therangeformedicinesrequiringfreezertemperaturesshouldbebetween‐15°Cand‐25°C(5°Fand‐14°F).Themeanstomonitorthetemperatureshouldbesensitivetopoweroutagesthatmayoccurafterhours.Arecordingthermometerthatchartstemperatureovertimeisonemeanstoaccomplishthis.TheStateofAlaskaprovidesandrequires“dataloggers”foruseinmonitoringtemperatureinyourmain(bulk)storagerefrigeratorsandfreezersusedforvaccines(http://www.epi.hss.state.ak.us/id/iz/vaxpacket/default.htm).Asabackupmonitor,iftherefrigeratorispartofafreezer,thenacoinmaybeplacedontopofafrozencupofwaterinthefreezer.Ifthecoinsinks,therehasbeenaninterruptionintemperaturemaintenance.Theuseoftemperaturelogsmightbeacceptable,ifthecliniccandemonstratehowthesystemwouldbesensitivetoafter‐hoursituations(poweroutages,unintentionalunpluggingofthecord).Theclinicshouldhaveandfollowapolicyonthedispositionofdrugswherethetemperaturerangehasbeenexceeded(USP23NF18,page11,APICCH61‐5).

G. Laboratoryspecimens,suchascultures,throatswabsorothercontaminateditems,shouldbephysicallyseparatedandstoredawayfrompharmaceuticals(APICCH61‐5).

H. Thelocalpoisoncontrolnumbershouldbepostedandavailabletoemployeesatalltimes.Thisnumberis1‐800‐222‐1222forthestateofAlaskahttp://www.hss.state.ak.us/dph/chronic/injury_prevention/poison.htm.


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8.8. RadiationProtection

ANTHC/DEHERadiationProtectionSurveyorsperformradiologicalhealthsurveysatclinicswithmedicalanddentalx‐rayproducingequipment.Thesesurveysareconducted,inpart,toevaluatecompliancewith18AAC85,AS08.36.075andTJC.ANTHC/DEHERadiationProtectionSurveyorsmaybecontactedformoreinformation.

Ifarenovatedornewlyconstructedclinicwillhavex‐rayproducingequipment,plansfortheclinicshouldbeevaluatedbyANTHC/DEHERadiationProtectionSurveyorsorotherqualifiedentitiestoensureappropriatex‐rayshielding.

8.9. Tuberculosis(TB)Precautions

A. TheclinicshouldhavewrittenpoliciesdetailinginfectioncontrolproceduresasrecommendedbytheCDCGuidelinesforPreventingtheTransmissionofMycobacteriumtuberculosisinHealth‐CareSettings,2005and29CFR1910.134tobeusedinthecareofsuspectedcasesorpatientswithactiveTBcases.Ataminimumthesepoliciesshouldinclude:

1. ProcedurestoidentifypatientswithactiveTB.

2. ProceduresthatdescribesymptomsandactionstobetakenwhendealingwithapatientsuspectedofactiveTB.

3. ProceduresdescribingisolationprecautionsforpatientswithactiveTB.

4. ProcedurestoprotectemployeesfromexposuretoTB.

B. TheclinicshouldconductinitialandongoingevaluationsoftheriskfortransmissionofM.tuberculosis,regardlessofwhetherornotpatientswithsuspectedorconfirmedTBdiseaseareexpectedtobeencounteredinthesetting.TheTBriskassessmentdeterminesthetypesofadministrative,environmental,andrespiratory‐protectioncontrolsneededforasettingandservesasanongoingevaluationtoolofthequalityofTBinfectioncontrolandfortheidentificationofneededimprovementsininfection‐controlmeasures.TheTBRiskAssessmentWorksheet(AppendixBoftheCDCGuidelines)canbeusedasaguideforconductingariskassessment.

C. IftheriskassessmentdeterminesthateveryoneneedstodonN‐95respirators,thenplansforenvironmentalcontrolsthatincludetechnologiesfortheremovalorinactivationofairborneM.tuberculosisshouldbeestablished.Thesetechnologiesincludeairborneinfectionisolationrooms(a.k.a.negativepressureisolationrooms),localexhaustventilation,HEPAfiltrationorUVGI.AsummaryofenvironmentalcontrolsandtheiruseinpreventionoftransmissionofM.tuberculosisisprovidedintheCDCGuidelines(visitCDConlineforsupplement,EnvironmentalControls),includingdetailedinformationconcerningtheapplicationofenvironmentalcontrols.

D. PriortodonningN‐95respirators,therequirementsof29CFR1910.134mustbemet,includingcompletionoftherespiratoryprotectionmedicalquestionnaire,medicalclearance,properrespiratorselectionandannualfittestingandtraining.Seethe“RespiratoryProtection”sectionoftheCDCGuidelinesand29CFR1910.134.


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IX. SANITATION

9.1. Refuse

A. ClassificationsandPractices

1. Refuse(orsolidwaste)includesallputrescibleandnon‐putresciblewaste,excepthumanbodywaste.Propersolidwastemanagementpracticesareessentialforthecontrolofdisease‐carryingvectors,eliminationofinjuryhazardsandpreventionofthespreadofinfectiousdisease(BMP).

B. CollectionFrequency

1. SolidWasteandRegulatedMedicalWaste(exceptforSharpsContainers)shouldbecollectedfrompatientcareareasdaily(APICCH100‐5).

2. Sharpscontainersshouldbereplacedbeforetheyoverfill(29CFR1910.1030(d)(4)(iii)(2)(iii)).Mostsharpscontainershaveanoverfilllinethatshouldbevisibleandusedtodeterminewhentoreplacethecontainer(NIOSHPublicationNo.97‐111,p.25).

3. Storageandfrequencyoftransportforthesolidwasteshouldbedesignedsoasnottoattractdomesticanimals,wildlife,ordiseasevectors.Thesolidwasteshouldnotcreateahealthhazardorpolluterun‐offwater(18AAC60.010(a)).

C. InsideStorage

1. Allnon‐infectiousrefuseshouldbestoredindurable,watertight,nonabsorbentandeasilycleanablecontainersmadeofrustresistantandcorrosionresistantmetalorequivalentheavydutyplastic.Asufficientnumberofcontainersshouldbeprovidedtoholdallputresciblewastematerialsthataccumulatebetweendailycollections.Allcontainersshouldbekeptcleanandmaintainedinasanitarymanner(BMP).

2. Containersthatarebrokenorotherwisefailtoprovidesafe,sanitarystorageofsolidwasteshouldbediscardedandreplacedwithacceptablecontainers(BMP,TJC:EC.02.06.01).

D. OutsideStorageAreas

1. Allsolidwastestoragecansshouldhavelidsandshouldbestoredonracksorplatforms.Theseshouldbeconstructedinsuchamannerastopreventspillagebydogsorotheranimals.Storagecanlidsshouldbesecuredtothecansinwindyareas(18AAC60.010(a)).

2. Bulkstoragecontainers(dumpsters)maybeusedforthestorageofnon‐infectiouswastematerialswhencompatiblewithlocalcollectionvehicles.Thesecontainersshouldbeconstructedandmaintainedinasanitarymanner(BMP).

3. Rubbish,abandonedvehicles,appliances,oildrums,scrapmetal,constructionwasteorotherwastematerialsshouldnotbeallowedtoaccumulateinoraroundtheclinic(18AAC60.010(a)).


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E. RegulatedMedicalWaste(RMW)

1. Definitions,ForthepurposesofruralhealthclinicsinAlaska:

a. Regulatedmedicalwaste(RMW)includes:

- contaminateditemsthatwouldreleasebloodorotherpotentiallyinfectiousmaterialsinaliquidorsemi‐liquidstateifcompressed

- itemsthatarecakedwithdriedbloodorotherpotentiallyinfectiousmaterialsandarecapableofreleasingthesematerialsduringhandling

- liquidorsemi‐liquidbloodorotherpotentiallyinfectiousmaterials

- discardedcultures

- usedandunuseddiscardedsharps

- pathologicalwaste‐humanbodytissue,organsorotherparts

(18AAC60.990(78);29CFR1910.1030(b))

b. Otherpotentiallyinfectiousmaterials(OPIM)includeshumanbodyfluids.Semen,vaginalsecretions,cerebrospinalfluid,synovialfluid,pleuralfluid,pericardialfluid,peritonealfluid,amnioticfluid,salivaindentalprocedures,anybodyfluidthatisvisiblycontaminatedwithblood,andallbodyfluidsinsituationswhereitisdifficultorimpossibletodifferentiatebetweenbodyfluids(18AAC60.990(78);29CFR1910.1030(b)).

c. Non‐regulatedmedicalwasteincludes:wastesnotdescribedintheabovedefinitions.

2. Policy:AclinicshouldhaveawrittenpolicylocallyorthroughtheirTHOdefiningmedicalwasteandidentifyingproceduresforhandlingwaste(29CFR1910.1030(d)(4)(i)).

3. Accessibility:Regulatedmedicalwaste,includingsharps,shouldbestoredinawaytolimitaccessbychildren.Instorageareas(insideoroutside),regulatedmedicalwasteshouldbestoredinareasthatareinaccessibletothepublicandwildlife(18AAC60.030(a);APICCH102‐5).

4. Storage:Foreconomicreasons,non‐regulatedmedicalwasteshouldbediscardedseparatelyfromregulatedmedicalwaste.Toavoidconfusionbetweennon‐regulatedmedicalwasteandinfectiouswaste,redbagsshouldnotbeusedfornon‐regulatedmedicalwaste.Redbagsareanindicatorthatthecontentsareinfectiouswasteandifnotseparated,allwastewouldbetreatedasregulatedmedicalwaste.

Regulatedmedicalwastecontainersshouldbe:

- closable.Containerswithfootoperatedlidsarerecommendedforexamrooms(29CFR1910.1030(d)(4)(iii)(B)(1)(i)).Kickbucketsmaybeallowedinurgentcareroomswherepatientcareneedsnecessitatequickaccesstothecontainer.Thebagliningthekickbucketshouldbeclosedanddisposedaftereverypatientencounter.

- closedpriortoremoval.Closedpriortoremovaltopreventspillageorprotrusionofcontentsduringhandling,storage,transport,orshipping(29CFR1910.1030(d)(4)(iii)(B)(1)(iv)).


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- constructedtocontainallcontentsandpreventleakageoffluidsduringhandling,storage,transportorshipping;(29CFR1910.1030(d)(4)(iii)(B)(1)(ii))

- labeledwiththebiohazardlabel(seebelow)orstoredinredbagsorredcontainers.Biohazardlabelsarenotrequiredforuseinclinics(iftheregulatedmedicalwasteisinredbagsorcontainers).However,labelsarerequiredforshippingcontainers(seebelow:F.Shipping)(29CFR1910.1030(g)(1)(i)(A‐E)).

FIGURE 1: BIOHAZARD LABEL EXAMPLE

Labelshouldbefluorescentorangeororange‐redorpredominantlyso,withletteringandsymbolsinacontrastingcolor(29CFR1910.1030(g)(1)(i)(C))

5. Shipping:Onceanitemisconsideredtoberegulatedmedicalwaste,itmustbeappropriatelydisposed.TheStateofAlaskadoesnotallowdisposaluntilthemedicalwastehasbeentreatedaccordingtothemanufacturer’sinstructions:

- inanautoclave,

- byadecontaminationprocessotherthananautoclave,or

- inamedicalwasteincinerator(18AAC60.030).

Consideringmostclinicsdonothavethecapacitytotreatregulatedmedicalwaste,itisassumedmostwillshipormailtheirregulatedmedicalwastetoaplacewherethiscanbeaccomplished.

Asthepackagingrequirementstoshipuntreatedregulatedmedicalwasteareveryspecificandnoteasilyattainedatthecliniclevel,mostclinicswilllikelyuseapprovedpackagingprovidedbythefacilitytreatingthewaste.Thisispreferred.Theapprovedpackagingshouldcomeasanassemblywithinstructions.Thepackaginginstructionsshouldbefollowed(49CFR173.197(b)).

StaffattheclinicwhoprepareuntreatedregulatedmedicalwasteforshippingshouldhavedocumentationtheyhavereceivedtrainingtoconformtoDepartmentofTransportation(DOT)trainingrequirements.Ataminimum,trainingshouldoccureverythreeyears.Furtherinformationcanbefoundinthefederalregulations45CFR173.

Iftheclinicwantstopursuepurchaseanduseofapprovedpackaging,theANTHCInstitutionalEnvironmentalHealthprogrammaybecontactedformoreinformation.


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6. Unlessregulatedbythelocalwastewaterauthority,wastebloodandbodyfluidsmaybepoureddownthedrain.Ifthisprocedureisdone,watershouldnotberunningwhilepouringthebodilyfluid.Afterdisposingofthebodilyfluid,largeamountsofwatershouldbeallowedtogodownthedrain.(CDC‐HICPCGuidelinesforEnvironmentalInfectionControl,p.116;APICCH60‐5).

F. StorageandDisposal

1. Theclinicshouldhavesafeandsanitarystorageofallsolidwastematerialsgeneratedatthefacility.AllsolidwasteshouldbedisposedofinaccordancewithADEC18AAC60Regulations.

G. Sharps

1. Needlesshouldnotberecapped.ThoughtheBloodbornePathogenStandardallowsexceptionsforrecappingneedles,thesecircumstancesdonotexistinmostclinics(29CFR1910.1030(d)(2)(vii)).Anexceptiontothismightbeindentalwherethedentistshouldusearecappingdevicethatallowsforone‐handedoperation.

2. Usedsharpobjectssuchasscalpelsorneedlesandsyringesshouldbeplacedinapprovedpunctureresistantcontainers(29CFR1910.1030(d)(2)(viii)).

3. Approvedcontainersshouldbe:

- Closable.

- Punctureresistant.

- Leak‐proofonsidesandbottom.

- Easilyaccessibletopersonnelandlocatedascloseasisfeasibletotheimmediateareawheresharpsareusedorcanbereasonablyanticipatedtobefound(e.g.,laundries)(29CFR1910.1030(d)(4)(iii)(A)).

- Withinhorizontalreachofpersonnelusingthecontainer.Themountingheightfortheinletopeningofthesharpscontainerdependsiftheproviderissittingorstanding(NIOSHPublicationNo.97‐111,p.4):

Sitting:38inchesto42inchesStanding:53inchesto56inches

(Thesearerecommendedheights.Judgmentmayhavetobeused.Theintentisfortheinletopeningtobebelowtheeyelevelof95%offemaleworkers.)

- Equippedwithguardstopreventhandsorfingersfromentering(especiallyinexamroomswherechildrenmaybeleftunattendedorunsupervised)(NIOSHPublicationNo.97‐111,p.3).

- Securedwhileensuringaccessibility.Thereisnorequirementforsharpscontainerstobemounted,butmountingisoftenthemosteffectivemeanstoensuretheyareaccessible,outofreachofchildrenandreasonablysecure(BMP).

TheNIOSHdocumentonSharps(NIOSHPublicationNo.97‐111,referencedinAppendix4)containsusefulinformationforevaluationandplacementofsharpscontainers.

4. Shippingconcernsaresimilartothoseforregulatedmedicalwaste.


37

9.2. SewageDisposal

A. CommunitySewageSystem

1. Whereavailable,thehealthclinicshouldbeconnectedtoanapprovedcommunitysewersystem(UPC305).

B. DisposalMethods

1. LiquidwasteshouldbedisposedofinaccordancewiththeUPCandADEC18AAC72regulations.Liquidwastesystemsshouldbeoperatedasdesignedandbeproperlymaintained(UPC101.5.5).

C. IndividualSewageSystems

1. Whereacommunitysewersystemisnotavailable,andanindividualseptictanksystemisused,thelocationofthetank(s)shouldbeidentifiedtoallowsludgedepthmeasurementandtheentiresystemshouldbeprotectedwithfencesorothermeanstopreventdamagebyheavyvehicles(IPSC802.6;GMP).Inaddition,thelocationofsaidsystemshouldbeatleast100feetfromthemeanannualhighwaterlevelofanysurfacewatersourceandshouldbeatleast100feetfromtheclinic’sdrinkingwatersource,unlessotherwisecodified(18AAC72.020(c)).

2. Septictanksludgelevelsshouldbemeasuredandpumpedannually,orasspecifiedbythesystem’soperationandmaintenancemanual(IPSC506.1/2).

3. Sludgefromseptictanks,chemical,orbox‐and‐pailtoiletsystemsshouldbedisposedofonlyatasiteorfacilityholdinganADECpermitforthattypeofdisposal(ADEC18AAC72.055).

4. Honeybucketsshouldbeemptiedaminimumofonceperday(BMPforaclinic).

5. Pitprivies,whereused,shouldbewellconstructed,flytight,ventilatedandshouldbemaintainedinasafeandsanitarymanner(UPC101.5.5).

9.3. WaterSupply

A. Distribution

1. Provisionsshouldbemadeforconvenientlyaccessibledrinkingwatertobothstaffandpatients.Thismayincludeadrinkingfountain,bottledwaterorsingleservicecupsinasanitarydispenser(FGI3.1‐6.1.6).


38

B. Source

1. Potablewatershouldbeprovidedinallclinics(29CFR1910.141(b)(1)(i)).PotablewatershouldmeetADECDrinkingWaterregulations(18AAC80).

2. Ifapiped,publicwatersystemmeetingADECDrinkingWaterregulationsisavailable,thehealthclinicshouldbeconnected(FGI1.3‐2.4;UPC601.1).

C. StorageandDisinfection

1. Iftheclinicisnotplumbedtoacommunitywatersystembutisequippedwithaclosedhaul‐typesystem,watershouldbedeliveredtotheclinicfromthepublicwatersysteminanapprovedvehicle(18AAC80.220).Duringasurvey,theresidualchlorineshouldbetested.Thefreeresidualchlorineshouldbeatleast0.2mg/lifthewatercomesfromachlorinatedsource(guidancefrom18AAC80.035(c)(1)).Ifthesourceofthewaterisnotchlorinated,theInfectionControlCommitteefortheclinicortheenvironmentalhealthspecialistshouldconductariskassessmenttodetermineiflocalchlorinationorotheracceptablemeansofdisinfectionofthestoredwatershouldbeimplemented(TJC:IC.01.03.01).

2. Ifwaterishauledandtheclinicdoesnothaveaclosedsystem,potabledrinkingwaterdispensersshouldbeprovided.Theseshouldbedesigned,constructed,andservicedsothatsanitaryconditionsaremaintained,shouldbecapableofbeingclosed,andshouldbeequippedwithatap.Opencontainerswherethewatermustbedippedorpouredshouldnotbeusedfordrinkingorhandwashing(29CFR1910.141(b)(1)(iii,v)).Thewatercontainersshouldbecleanedandsanitizedwhenthewaterischangedorrefilled.

3. Iftheclinicdoesnotreceivewaterfromacommunitywatersourceorfromanothertestedsource,thenthewatershouldbetreatedattheclinic.

Ifthesourceofwaterissurfacewaterorasourceundertheinfluenceofsurfacewater,thenthetreatmentshouldbecapableofreducingatleast99percentofgiardia‐sizedparticles.AfilterlistedwithNationalSanitationFoundation(NSFStandard53)forCystreductionwillfitthisrequirement,aswilldeviceslistedbyADEC.

Ifthesourceofwaterisfromawellwithanintactsanitarysealbutnottestedorapproved,thentreatmentshouldbeappliedtoinsuredisinfectiontoalevelmeetingtheintentof18AAC80.035(c).Thisincludesafreechlorineresidualof0.2mg/l.

Thoughtherearenotstandardsspecifyingthistreatment,manyguidesrecognizedbyTJCassumeaclinicwillprovidepotablewater.Thetreatmentofwaterfromanunapprovedsourcebringsaclinicclosertothisrequirement.AnInfectionControlCommitteeforaclinicorenvironmentalhealthspecialistmayapproveanothermethodologytoensuresafe,potablewater.


39

4. Duringemergencyoperations(temporaryinterruptionofpotablewatersupplyoraboilwaternoticefromthecommunitywatersystem)aclinicmayneedtodisinfecttheirsupply.Thismaybedonebyoneoftwomeans(seeAppendix3:ADECflyer).

a. Waterfordrinkingmaybedisinfectedbyboiling(fullrollingboil)foraminimumofoneminute(afterboiling,theflavorofthewatermaybeimprovedbypouringthewaterfromonecleancontainertoanotherseveraltimes).

b. Waterfordrinkingmayalsobedisinfectedbyaddingcommonhouseholdunscentedbleachcontaining5¼percentchlorine.Toachieveadequatedisinfection,thechlorinetreatedwatermustbemixedthoroughlyaccordingtoTable1belowandallowedtostandfor30minutesbeforeuse.

TABLE 1: BLEACH DISINFECTION TABLE

AmountofWater BleachtoAdd(ClearWater) BleachtoAdd(CloudyWater)

1 Quart 2 Drops 3 Drops

5 Gallons 1.25 ml (cc) 2.5 ml (cc)

D. Testing

1. Iftheclinichasitsownwellsource,thesystemshouldbeprotected,maintained,andhavethewatertestedasdeterminedbyitsclassification(18AAC80(Article3)).Recordsofsampleresultsshouldbemaintainedattheclinicandshouldbeavailabletoclinicstaffandenvironmentalhealthspecialists.SanitarysurveysshouldbeconductedperADECregulations(ADEC18AAC80.430).IftheADECregulationsdonotstipulateanytesting,theInfectionControlCommitteethatcoverstheclinicshoulddoariskassessmenttomaketestingrecommendations(TJC:IC.01.03.01).Lackinganinfectioncontrolcommittee,theenvironmentalhealthspecialistshouldmakeaprofessionaljudgmentregardingtestingbasedonsource,treatmentandlevelofserviceprovidedattheclinic.Thegoalistoachievealevelofassurancethatpotablewaterisbeingprovided.


APPENDICESAppendix1 REFERENCESEXPLANATIONS(FGI,TJC)

THE FACILITY GUIDELINES INSTITUTE

The2010GuidelinesforDesignandConstructionofHealthCareFacilitiespublishedbytheFGIarespecifictodesignandconstruction.TheGuidelineshaveroutinelybeencitedbyTheJointCommissionasoneofthestandardsorguidelinesthatshouldbeusedwhenplanningrenovationornewfacilities(TJC:EC.02.06.05EP1).TheGuidelinesgoback63yearsandoriginallyappearedintheFederalRegisterin1947.TheGuidelineswereremovedfromregulationsin1984.

ThecontentofsomeoftheGuidelinecitationsusedinthisdocumenthavenotchangedovertheyears.AnexistingclinicshouldhavecompliedwiththeGuidelinesinexistenceatthetimetheclinicwasdesignedorrenovated.ThecurrentGuidelineswerecitedforseveralreasons.

Thecurrentguidelinesreflectthemostcurrentthinkinginthedesignandconstructionofhealthcarefacilities.IfanexistingclinicmettheGuidelineswhenitwasdesignedbutdoesnotmeetthecurrentGuideline,thenitwouldstillbeusefultocitethecurrentGuideline.ThisdocumentationcanbeusedwhenfundingbecomesavailabletohelpensurerenovationsmeetcurrentGuidelines.

ThisdocumentwouldbetoolongandcumbersometogobackandcitetheyearswhencertainportionsoftheGuidelinescameineffect.IfdoubtexistsonwhetherornottheGuidelinecitationappliedwhentheclinicwasbuilt,theenvironmentalhealthspecialistcangobackandresearchtheGuidelinedocumentorfederalregulationineffectwhentheclinicwasdesignedorwentundersubstantialrenovation.

Thoughitsuseonexistingclinicscouldbedebated,theGuidelinecanbereferencedtoexistingclinicsasagoodmanagementpractice.Ifclinicscanreasonablyattainthesestandards,theywouldprovidethecurrentstandardofcareintheseareas.Ataminimum,theenvironmentalhealthspecialistshouldcitestandardsbasedontheGuidelinewithanexplanationthatfutureconstructionorrenovationshouldincorporatethestandards.

THE JOINT COMMISSION

TheJointCommission(TJC)isanot‐for‐profitorganizationthatsetsperformanceexpectationsforsafetyandqualityofcareinhealthcarefacilities.Thesestandardsaimtoimproveoutcomesbutarenotintendedtoemphasizehowanorganizationmightachievetheseoutcomes.FacilitiesaccreditedbyTJCaredeemedtomeettherequirementsoftheMedicareConditionsofParticipation(CoPs).MeetingthesestandardsarerequiredtoreceiveMedicarefunds.Otherpublicandprivatethirdpartypayersrequirethisoranothersimilaraccreditationtoreceivepayment.


REFERENCES APPLIED (IN DEVELOPMENT, INTENTIONALLY BLANK)

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Appendix4 NIOSHPUBLICATIONS,PREVENTINGNEEDLESTICKINJURIES

http://www.cdc.gov/niosh/docs/2000‐108/


Appendix5 INTEGRATEDPESTMANAGEMENT(IPM)INFORMATION

CDCApproach toIntegrated PestManagement inaResearchFacility

IPMisanimportantpartofmanagingaresearchfacility.Manypests,suchasfliesandcockroaches,canmechanicallytransmitdiseasepathogensandcompromisetheresearchenvironment.Eventhepresenceofinnocuousinsectscancontributetotheperceptionofunsanitaryconditions.

Themostcommonapproachtopestcontrolhasbeentheapplicationofpesticides,eitherasapreventiveorremedialmeasure.Pesticidescanbeeffectiveandmaybenecessaryasacorrectivemeasure,buttheyhavelimitedlong‐termeffectwhenusedalone.Pesticidesalsocancontaminatetheresearchenvironmentthroughpesticidedriftandvolatilization.

Tocontrolpestsandminimizetheuseofpesticides,itisnecessarytoemployacomprehensiveprogramapproachthatintegrateshousekeeping,maintenance,andpestcontrolservices.ThismethodofpestcontrolisoftenreferredtoasIPM.TheprimarygoalofanIPMprogramistopreventpestproblemsbymanagingthefacilityenvironmenttomakeitlessconducivetopestinfestation.Alongwithlimitedapplicationsofpesticides,pestcontrolisachievedthroughproactiveoperationalandadministrativeinterventionstrategiestocorrectconditionsthatfosterpestproblems.

PriortodevelopinganytypeofIPMprogram,itisimportanttodefineanoperationalframeworkforIPMservicesthathelpspromotecollaborationbetweenIPMspecialistsandfacilitypersonnel.ThisframeworkshouldincorporatefacilityrestrictionsandoperationalandproceduralissuesintotheIPMprogram.AneffectiveIPMprogramisanintegralpartofthefacility’smanagement.AnIPMpolicystatementshouldbeincludedinthefacility’sstandardoperatingprocedurestoincreaseawarenessoftheprogram.

Trainingsourcesfortheprinciplesandpracticesofstructural(indoor)IPMprogramsareavailablethroughuniversityentomologydepartments,countyextensionoffices,theEntomologicalSocietyofAmerica,statedepartmentsofagriculture,statepestcontrolassociations,theNationalPestControlAssociation,suppliersofpestcontrolequipment,andIPMconsultantsandfirms.Severaluniversitiesoffercorrespondencecourses,shortcourses,andtrainingconferencesonstructuralpestmanagement.

IPMisastrategy‐basedservicethatconsidersnotonlythecostoftheservices,butalsotheeffectivenessoftheprogram’scomponents.EachIPMprogramissite‐specific,tailoredtotheenvironmentwhereapplied.

LaboratoryIPMserviceswillbedifferentfromthoseinanofficebuildingorananimalcarefacility.Interrelatedcomponentsof“Environmentalpestmanagement”follow.

FACILITY DESIGN

IPMissuesandrequirementsshouldbeaddressedinaresearchfacility’splanning,design,andconstruction.Thisprovidesanopportunitytoincorporatefeaturesthathelpexcludepests,minimizepesthabitat,andpromotepropersanitationinordertoreducefuturecorrectionsthatcandisruptresearchoperations.

MONITORING

MonitoringisthecentralactivityofanIPMprogramandisusedtominimizepesticideuse.Traps,visualinspections,andstaffinterviewsidentifyareasandconditionsthatmayfosterpestactivity.

SANITATION AND FACILITY MAINTENANCE

Manypestproblemscanbepreventedorcorrectedbyensuringpropersanitation,reducingclutterandpesthabitat,andbyperformingrepairsthatexcludepests.Recordsofstructuraldeficienciesandhousekeepingconditionsshouldbemaintainedtotrackproblemsanddetermineifcorrectiveactionswerecompletedandinatimelymanner.

COMMUNICATION

AstaffmembershouldbedesignatedtomeetwithIPMpersonneltoassistinresolvingfacilityissuesthatimpactonpestmanagement.Reportscommunicatedverballyandinwritingconcerningpestactivityandimprovementrecommendationsforpersonnel,practicesandfacilityconditionsshouldbeprovidedtothedesignatedpersonnel.Facilitypersonnelshouldreceivetrainingonpestidentification,biology,andsanitation,whichcanpromoteunderstandingandcooperationwiththegoalsoftheIPMprogram.


RECORDKEEPING

AlogbookshouldbeusedtorecordpestactivityandconditionspertinenttotheIPMprogram.ItmaycontainprotocolsandproceduresforIPMservicesinthatfacility,MaterialSafetyDataSheetsonpesticides,pesticidelabels,treatmentrecords,floorplans,surveyreports,etc.

NON‐PESTICIDE PEST CONTROL

Pestcontrolmethodssuchastrapping,exclusion,caulking,washing,andfreezingcanbeappliedsafelyandeffectivelywhenusedinconjunctionwithpropersanitationandstructuralrepair.

PEST CONTROL WITH PESTICIDES

Preventiveapplicationsofpesticidesshouldbediscouraged,andtreatmentsshouldberestrictedtoareasofknownpestactivity.Whenpesticidesareapplied,theleasttoxicproduct(s)availableshouldbeusedandappliedinthemosteffectiveandsafemanner.

PROGRAM EVALUATION AND QUALITY ASSURANCE

Qualityassuranceandprogramreviewshouldbeperformedtoprovideanobjective,ongoingevaluationofIPMactivitiesandeffectivenesstoensurethattheprogramdoes,infact,controlpestsandmeetthespecificneedsofthefacilityprogram(s)anditsoccupants.Baseduponthisreview,currentIPMprotocolscanbemodifiedandnewproceduresimplemented.

TECHNICAL EXPERTISE

AqualifiedentomologistcanprovidehelpfultechnicalguidancetodevelopandimplementanIPMprogram.Pestmanagementpersonnelshouldbelicensedandcertifiedbytheappropriateregulatoryagency.

SAFETY

IPMminimizesthepotentialofpesticideexposuretotheresearchenvironmentandthestaffbylimitingthescopeofpesticidetreatments.

REFERENCES

RobinsonWH.Urbanentomology:insectandmitepestsinthehumanenvironment.NewYork:ChapmanandHall;1996.

BennettGW,OwensJM,editors.Advancesinurbanpestmanagement.NewYork:VanNostrandReinholdCompany;1986.

OlkowskiW,DaarS,OlkowskiH.Commonsensepestcontrol:least‐toxicsolutionsforyourhome,garden,pestsandcommunity.Newton(CT):TheTauntonPress,Inc.;1991.

NationalPestControlAssociation[http://www.pestworld.org].Fairfax(VA):TheAssociation;[cited2006Sept25].Availablefrom:http://www.pestworld.org.

BiocontrolNetwork[http://www.biconet.com].Brentwood(TN):BiocontrolNetwork;c1995‐2006[updated2006Sept;cited2006Sept25].Availablefrom:http://www.biconet.com

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A.7.3.2

Theannualmaintenanceofafireextinguisherrequirestheservicesofatrainedandcertifiedtechnicianwhohasthepropertools,listedparts,andappropriatemanufacturer’sservicemanual.Maintenanceoffireextinguishersshouldnotbeconfusedwithinspection,whichisaquickcheckoftheextinguishersthatisperformedatleastevery30days.Becausethedetailedmaintenanceproceduresforvariousextinguishertypesandmodelsdiffer,thespecificproceduresspecifiedwithinservicemanualsneedtobefollowed.

Thefollowinglistisasampleofmaintenanceproceduresandchecksthatarecommonlyassociatedwithrechargeable,stored‐pressuredrychemicalhandportablefireextinguishers:

(1)Removetheextinguisherfromhanger,bracket,orcabinetandvisuallyexamineitfordamage.

(2)Verifythatthehanger,bracket,orcabinetistheproperonefortheextinguisher.

(3)Ensurethatthehanger,bracket,orcabinetissecure,undamaged,andproperlymounted.

(4)Ensurethatthenameplateoperatinginstructionsarelegibleandfacingoutward.

(5)Confirmthattheextinguishermodelisnotsubjecttorecallandisnotobsolete.

(6)Checkextinguisherrecordstodetermineinternalexaminationandhydrostatictestintervals.

(7)Thoroughlyexaminecylinderfordents,damage,repairs,orcorrosion.

(8)Removethepullpintoensurethatitfunctionsproperlyandisnotdamagedorcorroded.

(9)Examinethehandleandleverstoensurethattheyareundamagedandoperable.

(10)Ensurethatthevalvestemiscorrectlyextendedandnotcorrodedordamaged.

(11)Verifythatthepressuregaugeorindicatorisintheoperablerange.

(12)Examinethepressuregaugetoensurethatitisnotdamaged,bent,orcracked.

(13)Verifythatthegauge‐operatingpressurecorrespondswiththenameplateinstructions.

(14)Verifythatthegaugefacecorrespondswiththeproperagenttype.

(15)Verifythatthegaugethreadsarecompatiblewiththevalvebodymaterial.

(16)Removethenozzleorhoseassemblyorbothandensurethattheyareunobstructed.

(17)Confirmthatthenozzleandhoseassemblyarecorrectforthemodelofextinguisher.

(18)Examineexposedthreadareasforcorrosion,wear,ordamage.

(19)Ensurethatthehoseandcouplingsarenotcut,cracked,damaged,ordeformed.

(20)Examineinternalvalveportsurfacesandthreadsforsignsofleakageorcorrosion.

(21)Reinstallthenozzleandhoseassemblysecurely.

(22)Ensurethatthehoseretentionbandissecureandproperlyadjusted.

(23)Weightheextinguishertoverifythatitcorrespondstotheweightlistedonthenameplate.

(24)Reinstalltheringpinandinstallanewtamperinspectionseal.

(25)Cleanexposedextinguishersurfacestoremoveanyforeignmaterial.

(26)Recordthemaintenanceontheextinguishertagorlabel.

(27)Returntheextinguishertothehanger,bracket,orcabinet.


Appendix7 NFPA99:HEALTHCAREFACILITIES,SPECIALPRECAUTIONSFOROXYGENCYLINDERS

COPIED FROM NFPA 99, 1999 STANDARD FOR HEALTH CARE FACILITIES

4‐3.5.2GasSystemsPolicies–Level1

4‐3.5.2.1GasesinCylindersandLiquefiedGasesinContainers—Level1.

(a) HandlingofGases.Administrativeauthoritiesshallprovideregulationstoensurethatstandardsforsafepracticeinthespecificationsforcylinders;markingofcylinders,regulators,andvalves;andcylinderconnectionshavebeenmetbyvendorsofcylinderscontainingcompressedgasessuppliedtothefacility.

(b) SpecialPrecautions—OxygenCylindersandManifolds.Greatcareshallbeexercisedinhandlingoxygentopreventcontactofoxygenunderpressurewithoils,greases,organiclubricants,rubber,orothermaterialsofanorganicnature.Thefollowingregulations,basedonthoseoftheCGAPamphletG‐4,Oxygen,shallbeobserved:

(c) Oil,grease,orreadilyflammablematerialsshallneverbepermittedtocomeincontactwithoxygencylinders,valves,regulators,gauges,orfittings.

(d) Regulators,fittings,orgaugesshallneverbelubricatedwithoiloranyotherflammablesubstance.

(e) Oxygencylindersorapparatusshallneverbehandledwithoilyorgreasyhands,gloves,orrags.(f) Particlesofdustanddirtshallbeclearedfromcylindervalveopeningsbyslightlyopeningandclosingthevalvebefore

applyinganyfittingtothecylinder.(g) Thehigh‐pressurevalveontheoxygencylindershallbeopenedbeforebringingtheapparatustothepatientorthe

patienttotheapparatus.(h) Thecylindervalveshallbeopenedslowly,withthefaceofthegaugeontheregulatorpointedawayfromallpersons.(i) Anoxygencylindershallneverbedrapedwithanymaterialssuchashospitalgowns,masks,orcaps.(j) Oxygenfittings,valves,regulators,orgaugesshallneverbeusedforanyserviceotherthanthatofoxygen.(k) Gasesofanytypeshallneverbemixedinanoxygencylinderoranyothercylinder.(l) Oxygenshallalwaysbedispensedfromacylinderthroughapressureregulator.(m) Regulatorsthatareinneedofrepairorcylindershavingvalvesthatdonotoperateproperlyshallneverbeused.(n) .Oxygenequipmentthatisdefectiveshallnotbeuseduntilithasbeenrepairedbycompetentpersonnel.Ifcompetent

in‐houserepairscannotbemade,suchequipmentshallberepairedbythemanufacturerorhisorherauthorizedagent;oritshallbereplaced.

(o) Oxygencylindersshallbeprotectedfromabnormalmechanicalshock,whichisliabletodamagethecylinder,valve,orsafetydevice.Suchcylindersshallnotbestorednearelevators,gangways,orinlocationswhereheavymovingobjectswillstrikethemorfallonthem.

(p) Cylinder‐valveprotectioncaps,whereprovided,shallbekeptinplaceandbehandtightened,exceptwhencylindersareinuseorconnectedforuse.

(q) Cylindersshallbeprotectedfromthetamperingofunauthorizedindividuals.(r) Valvesshallbeclosedonallemptycylindersinstorage.(s) Oxygenshallbereferredtobyitspropername,oxygen,notair.Liquidoxygenshallbereferredtobyitspropername,

notliquidair.(t) Oxygenshallneverbeusedasasubstituteforcompressedair.(u) Cylindersorcylindervalvesshallnotberepaired,painted,oraltered.


(v) Safetyreliefdevicesinvalvesorcylindersshallneverbetamperedwith.Sparksandflameshallbekeptawayfromcylinders;atorchflameshallneverbepermittedunderanycircumstancestocomeincontactwithcylindervalvesorsafetydevices.Valveoutletscloggedwithiceshallbethawedwithwarm—notboiling—water.

(w) Themarkingsstampedoncylindersshallnotbetamperedwith.ItisagainstfederalstatutestochangethesemarkingswithoutwrittenauthorityfromtheBureauofExplosives.

(x) Markingsusedfortheidentificationofcontentsofcylindersshallnotbedefacedorremoved,includingdecals,tags,stenciledmarks,andupperhalfofshippingtag.

(y) Theownerofthecylindershallbenotifiedifanyconditionhasoccurredthatmightpermitanyforeignsubstancetoenteracylinderorvalve,givingdetailsandcylindernumber.

(z) Eveniftheyareconsideredtobeempty,cylindersshallneverbeusedasrollers,supports,orforanypurposeotherthanthatforwhichtheyareintendedbythesupplier.

(aa) Whensmall‐size(A,B,D,orE)cylindersareinuse,theyshallbeattachedtoacylinderstandortotherapyapparatusofsufficientsizetorendertheentireassemblystable.Individualcylinderstorageassociatedwithpatientcareareasarenotrequiredtobestoredinenclosures.

(bb) Cylindersandcontainersshallnotbedropped,dragged,orrolled.

(cc) Freestandingcylindersshallbeproperlychainedorsupportedinapropercylinderstandorcart.(dd) Cylindersshallnotbechainedtoportableormovableapparatussuchasbedsandoxygentents.(ee) Cylindersshallnotbesupportedby,andneithercylindersnorcontainersshallbeplacedinproximityof,radiators,

steampipes,orheatducts.(ff) Verycoldcylindersorcontainersshallbehandledwithcaretoavoidinjury.(gg) Cylindersandcontainersshallnotbehandledwithhands,gloves,orothermaterialscontaminatedwithoilorgrease.(hh) MakingCylinderandContainerConnections.(ii) Wrenchesusedtoconnectrespiratorytherapyequipmentshallbemanufacturedofsteelorothersuitablematerialof

adequatestrength.(jj) Cylindervalvesshallbeopenedandconnectedinaccordancewiththefollowingprocedure:(kk) Makecertainthatapparatusandcylindervalveconnectionsandcylinderwrenchesarefreeofforeignmaterials.(ll) Turnthecylindervalveoutletawayfrompersonnel.Standtotheside—notinfrontandnotinback.Before

connectingtheapparatustocylindervalve,momentarilyopencylindervalvetoeliminatedust.(mm) Makeconnectionofapparatustocylindervalve.Tightenconnectionnutsecurelywithanappropriatewrench[see

4‐3.5.2.1(c)1].(nn) Releasethelow‐pressureadjustmentscrewoftheregulatorcompletely.(oo) Slowlyopencylindervalvetofullopenposition.(pp) Slowlyturninthelow‐pressureadjustmentscrewontheregulatoruntiltheproperworkingpressureisobtained.(qq) Openthevalvetotheutilizationapparatus.(rr) Connectionsforcontainersshallbemadeinaccordancewiththecontainermanufacturer’soperatinginstructions.(ss) CareofSafetyMechanisms.(tt) PersonnelusingcylindersandcontainersandotherequipmentcoveredinthischaptershallbefamiliarwiththePin‐

IndexSafetySystem(see8‐3.1.2)andtheDiameter‐IndexSafetySystem(see8‐3.1.3),bothdesignedtopreventutilizationofthewronggas.

(uu) Safetyreliefmechanisms,noninterchangeableconnectors,andothersafetyfeaturesshallnotberemoved,altered,orreplaced.


Appendix8 COMPARINGTJCACCREDITATIONSTANDARDS–AHC,CAH,ANDHAP(DEVELOPING)

ThecomparisonofstandardsforAHC,CAH,andHAPaccreditationprogramsprovidedbelowisonlyasnapshotofactivitieswithtimerestrictionstocomplywiththeEC,EM,andLSstandards.ForcompletedetailsforallstandardsandEPspleasereviewtheappropriateTJCaccreditationmanual.ContacttheANTHC/DEHEofficeat907‐729‐3600foradditionalassistance.(adaptedfromthe2011EnvironmentofCare,EssentialsforHealthCarepublishedbytheJointCommissionResources)

EC.01.01.01: The organization plans activities to minimize risks in the environment of care. AHC CAH HAP

(3‐8):Theorganizationhasawrittenplanformanagingthefollowing:Safety,Security,HazardousMaterialsandWaste,FireSafety,MedicalEquipment,UtilitySystems.Note:Theplansmayallbecontainedinasingledocument,separateplansarenotrequired.ClinicsaffiliatedwithaTHOmaybeincludedintheorganizationalmanagementplansandwouldnotneedtodeveloptheirownclinicspecificmanagementplans

X X X

EC.02.03.03: The organization conducts fire drills. AHC CAH HAP

(1):TheorganizationconductsquarterlyfiredrillsineachbuildingdefinedasanambulatoryhealthcareoccupancybytheLifeSafetyCode.Note:Evacuationofpatientsduringadrillisnotrequired.Inleasedorrentedfacilities,drillsneedbeconductedonlyintheareasofthebuildingthattheorganizationoccupies.

X X X

(2):Theorganizationconductsfiredrillsevery12monthsfromthedateofthelastdrillineachareathatisdefinedasbusinessoccupancybytheLifeSafetyCode.

X X X

EC.02.03.05: The organization maintains fire safety equipment and fire safety building features. AHC CAH HAP

(1):Atleastquarterly,theorganizationtestssupervisorysignaldevices.Thecompletiondateofthetestsisdocumented.

X X X

(2):Every6months,theorganizationtestsvalvetamperswitchesandwater‐flowdevices.Thecompletionofthedateofthetestsisdocumented.

X X X

(3):Every12months,theorganizationtestsductdetectors,electromechanicalreleasingdevices,heatdetectors,manualfirealarmboxes,andsmokedetectors.Thecompletionofthedateofthetestsisdocumented.

X X X

(4):Every12months,theorganizationtestsvisualandaudiblefirealarms,includingspeakers.Thecompletionofthedateofthetestsisdocumented.

X X X

(5):Everyquarter,theorganizationtestsfirealarmequipmentfornotifyingoff‐sitefireresponders.Thecompletionofthedateofthetestsisdocumented.

X X X

(6):Forautomaticsprinklersystems:Everyweek,theorganizationtestsfirepumpsunderno‐flowconditions.Thecompletionofthedateofthetestsisdocumented.

X X X

(7):Forautomaticsprinklersystems:Every6months,theorganizationtestswaterstoragetankhighandlowwaterlevelalarms.Thecompletionofthedateofthetestsisdocumented.

X X X

(8):Forautomaticsprinklersystems:Everymonthduringcoldweather,theorganizationtestswaterstoragetemperaturealarms.Thecompletionofthedateofthetestsisdocumented.

X X X

(9):Forautomaticsprinklersystems:Every12months,theorganizationtestsmaindrainatsystemlowpointoratallsystemrisers.Thecompletionofthedateofthetestsisdocumented.

X X X

(10):Forautomaticsprinklersystems:Everyquarter,theorganizationinspectsallfiredepartmentwatersupplyconnections.Thecompletionofthedateofthetestsisdocumented.

X X X

(11):Forautomaticsprinklersystems:Every12months,theorganizationtestsfirepumpsunderflowconditions.Thecompletionofthedateofthetestsisdocumented.

X X X

(12):Everyfiveyears,theorganizationconductswater‐flowtestsforstandpipesystems.Thecompletionofthedateofthetestsisdocumented.

X X X

(15):Atleastmonthly,theorganizationinspectsportablefireextinguishers.Thecompletionofthedateofthetestsisdocumented.Note:Therearemanywaystodocumenttheinspections,suchasusingbar‐codingequipment,usingcheckmarksonthetag,orusinganinventory.Inspectionsinvolveavisualcheckforthepresenceandcorrecttypeofextinguisher,brokenparts,fullcharge,andeaseofaccess.(ReferenceNFPA10formoreinformation.SeeAlaskaFireExtinguisherChecklistforexample.)

X X X

(16):Every12months,theorganizationperformsmaintenanceonportablefireextinguishers.Thecompletionofthedateofthetestsisdocumented.(SeeAlaskaFireExtinguishersheetformoreinformation)

X X X

(17):Theorganizationconductshydrostatictestsonstandpipeoccupanthoses5yearsafterinstallationandevery3yearsthereafter.Thecompletionofthedateofthetestsisdocumented.

X X X

(18):Theorganizationoperatesfireandsmokedampersatleastevery4yearstoverifythattheyfullyclose.Thecompletionofthedateofthetestsisdocumented.

X X X

(19):Every12months,theorganizationtestsautomaticsmoke‐detectionshutdowndevicesforair‐handlingequipment.Thecompletionofthedateofthetestsisdocumented.

X X X


(20):Every12months,theorganizationtestsslidingandrollingfiredoorsforproperoperationandfullclosure.Thecompletionofthedateofthetestsisdocumented.

X X X

EC.02.04.01: The organization manages medical equipment risks. AHC CAH HAP

(3):Theorganizationidentifiestheactivitiesformaintaining,inspecting,andtestingforallmedicalequipmentontheinventory

X X X

(4):Theorganizationidentifiesfrequenciesforinspecting,testingandmaintainingmedicalequipmentontheinventorybasedoncriteriasuchasmanufacturers’recommendations,risklevel,orcurrentorganizationexperience.

X X X

EC.02.05.07: The organization inspects, tests, and maintains emergency power systems. AHC CAH HAP

(1):At30dayintervals,theorganizationperformsafunctionaltestofbattery‐poweredlightsrequiredforegressforaminimumdurationof30seconds.Thecompletiondateofthetestsisdocumented.

X X X

(2):Every12months,theorganizationeitherperformsafunctionaltestofthebatter‐poweredlightsrequiredforegressforadurationof1½hours;ortheorganizationreplacesallbatteriesevery12monthsand,duringreplacement,performsarandomtestof10%ofallbatteriesfor1½hours.Thecompletiondateofthetestsisdocumented.

X X X

EC.04.01.01: The organization collects information to monitor conditions in the environment. AHC CAH HAP

(12):Theorganizationconductsenvironmentaltoursevery6monthsinpatientcareareastoevaluatetheeffectivenessofpreviouslyimplementedactivitiesintendedtominimizeoreliminateenvironmentofcarerisks.

X X

(13):Theorganizationconductsannualenvironmentaltoursinnonpatientcareareastoevaluatetheeffectivenessofpreviouslyimplementedactivitiesintendedtominimizeoreliminaterisksintheenvironment.

X X

(15):Every12months,theorganizationevaluateseachenvironmentofcaremanagementplan,includingareviewoftheplan’sobjectives,scope,performance,andeffectiveness.

X X X

EM.03.01.03: The organization evaluates the effectiveness of its Emergency Management Plan. AHC CAH HAP

(1):Asanemergencyresponseexercise,theorganizationactivatesitsEmergencyManagementPlantwiceayearateachsiteincludedintheplan.Note1:IftheorganizationactivatesitsEmergencyManagementPlaninresponsetooneormoreactualemergencies,theseemergenciescanserveinplaceofemergencyresponseexercise.Note2:Staffinfreestandingbuildingsclassifiedasabusinessoccupancy,asdefinedbytheLifeSafetyCode),thatdonotofferemergencyservicesnorarecommunitydesignatedasdisasterreceivingstationsneedtoconductonlyoneemergencymanagementexerciseannually.

X X X

(2)Foreachsiteoftheorganizationthatoffersemergencyservicesorisacommunitydesignateddisasterreceivingstation,atleastoneoftheorganization’stwoemergencyresponseexercisesincludesaninfluxofpatients.Note:Tabletopsession,thoughuseful,cannotserveforthisportionoftheexercise.

X X X

LS.01.02.01: The organization protects occupants during periods when the Life Safety Code is not met or during periods of construction. Note: This standard applies to sites of care where four or more patients at the same time are provided either anesthesia or outpatient services that render the patients incapable of saving themselves in the event of an emergency in the organization. Lodging situations should also be taken into consideration.

AHC CAH HAP

(1):Theorganizationnotifiesthefiredepartment(orotheremergencyresponsegroup)andinitiatesafirewatchwhenafirealarmorsprinklersystemisoutofservicemorethan4hoursina24‐hourperiodinaanoccupiedbuilding.Notificationandfirewatchtimesaredocumented.

X X X


Appendix9 TJCEC,EM,LSCHAPTEROUTLINES

Adaptedfromthe2011Environment ofCare,EssentialsforHealthCarepublishedbytheJointCommission Resources

EC CHAPTER OUTLINE

I. Plan(EC.01.01.01)II. ImplementA. SafetyandSecurity(EC.02.01.01,EC.02.01.03,EC.02.01.05)B. HazardousMaterialsandWaste(EC.02.02.01)C. FireSafety(EC.02.03.01,EC.02.03.03,EC.02.03.05)D. MedicalEquipment(EC.02.04.01,EC.02.04.03)E. Utilities(EC.02.05.01,EC.02.05.03,EC.02.05.05,EC.02.05.07,EC.02.05.09)F. OtherPhysicalEnvironmentRequirements(EC.02.06.01,EC.02.06.05)

III. StaffDemonstrateCompetence(EC.03.01.01)IV. MonitorandImprove(EC.04.01.01,EC.04.01.03,

EC.04.01.05)

EM CHAPTER OUTLINE

I. FoundationfortheEmergencyOperationsPlan(EM.01.01.01)

II. ThePlanforEmergencyResponseA. GeneralRequirements(EM.02.01.01)B. SpecificRequirements

1. Communications(EM.02.02.01)2. ResourcesandAssets(EM.02.02.03)3. SecurityandSafety(EM.02.02.05)4. Staff(EM.02.02.07)5. Utilities(EM.02.02.09)6. Patients(EM.02.02.11)7. DisasterVolunteers

a. VolunteerLicensedIndependentPractitioners(EM.02.02.13)

b. VolunteerPractitioners(EM.02.02.15)III. Evaluation(EM.03.01.01,EM.03.01.03)A. EvaluatingthePlanningActivities(EM.03.01.01)B. EvaluatingthePlanThroughExercises

(EM.03.01.03)

LS CHAPTER OUTLINE

I. AdministrativeActivities

A. StatementofConditions(LS.01.01.01)

B. InterimLifeSafetyMeasures(LS.01.02.01)

II. HealthCareOccupancy

A. AllHealthCareOccupancyBuildings

1. GeneralBuildingRequirements(LS.02.01.10)

2. MeansofEgressRequirements(LS.02.01.20)

3. Protection(LS.02.01.30)

a. FireAlarm(LS.02.01.34)

b. Extinguishment(LS.02.01.35)

4. SpecialProvisions(LS.02.01.40)

5. BuildingServices(LS.02.01.50)

6. OperatingFeatures(LS.02.01.70)

III. AmbulatoryHealthCareOccupancy

A. AllAmbulatoryHealthCareOccupancyBuildings

1. GeneralBuildingRequirements(LS.03.01.10)

2. MeansofEgressRequirements(LS.03.01.20)

3. Protection(LS.03.01.30)

a. FireAlarm(LS.03.01.34)

b. Extinguishment(LS.03.01.35)

4. SpecialProvisions(LS.03.01.40)

5. BuildingServices(LS.03.01.50)

6. OperatingFeatures(LS.03.01.70)


Appendix10 COMPARINGNFPAANDINTERNATIONALCODESFORLODGING(UNDERREVIEW)

Issue NFPA Codes International Code

Occupancy Classification for sleeping portion

Lodging or rooming house (LSC 26.1.1.1) Residential Group R‐1 (IBC 310.1)

Mixed use occupancy According to the Life Safety Code, if sleeping accommodations are provided the whole building should comply with the most restrictive requirements among the occupancies (LSC 26.1.2.1, 6.1.14.2).

If a designated bunk room or other designated sleeping room exceeds 10% of the total floor area of the clinic, then the sleeping area should be separated from the clinic by a two‐hour fire rated barrier (IBC 302.2, Table 302.3.3). Otherwise construction requirements and fire protection system requirements should be met by the most restrictive of the R‐1 or B provisions, other requirements are based on the use of the portion of the building (IBC 302.3.2).

Separation of Sleeping Rooms

Sleeping rooms should be separated from escape route corridors by walls and doors that are smoke resistant. Air passages should not penetrate the wall unless they are properly installed heating and utility installations (LSC26.3.4).

Smoke Detectors: placement and numbers

Single‐station smoke alarms in each sleeping room. Do not have to be interconnected (LSC 26.3.3.5).

A single or multiple station smoke alarm in the sleeping area (907.2.10.1.1). This section specifies installation not maintenance.

Smoke Detector Maintenance

A schedule for smoke detector inspection should be established. This should include a six‐month visual inspection (NFPA 72 7‐3.1) and a sensitivity test one year after installation and every two years thereafter (NFPA 72 7‐3.2). The sensitivity test should ensure smoke entry into the sensing chamber and an alarm response. Testing with smoke or listed aerosol approved by the manufacturer is permitted (NFPA 72 7‐2.2).

In accordance with IFC and Chapter 7 or NFPA 72 (IFC 907.20) IFC requirements same as NFPA 72 for items of concern.

Approved Automatic Sprinkler (new)

New lodging or rooming houses shall be protected throughoutby an approved automatic sprinkler system (LSC 26.3.5.2). Sprinkler systems complying with NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including four stories in Height shall be permitted (LSC 26.3.5.1) Exception: If the sleeping room has a door opening directly to the outside a sprinkler system is not required (LSC 26.3.5.2).

The IBC has essentially the same requirement (with reference to NFPA 13R) for sprinklers as NFPA (IBC 903.2.7). Exception: If the sleeping room has a door opening directly to the outside a sprinkler system is not required (IBC 903.2.7).

Fire Alarm System (new) Should be provided (LSC 26.3.3.1): Initiation ‐ by manual mean (LSC 26.3.3.2), a manual fire alarm box in the natural exit access path near each required exit (LSC 9.6.2.3). Notification ‐ automatically ((LSC 26.3.3.3) with both audible and visible signals (LSC 9.6.3.2) operated throughout the building (LSC 9.6.3.7).

A manual fire alarm system and an automatic fire detection system (IFC 907.2.8). System smoke detectors are not required if the single‐station smoke detector in the sleeping room are connected to the emergency electrical system and are annunciated by the guestroom at a constantly attended location from which the fire alarm system is capable of being manually activated (IFC 907.2.8.1)

Fire Alarm System (existing) Don't need a "Fire Alarm System" if existing clinic has a single‐station smoke alarm with at least one manual fire alarm box arranged to initiate the smoke detection alarm (LSC 26.3.3.1). Otherwise, comply with "new" Fire Alarm System.

IFC 907.3.1.7 ‐ same as for NFPA for existing.

Exits Every sleeping room should have a primary means of escape and a second means of escape (LSC 926.2.1.1, 2). The secondary means of escape can be a window if meeting requirements of LSC 24.2.2.3.

Two exits, unless occupant load is less than 10 and travel distance less than 75 (IBC Table 1005.2.2)

Bathroom Doors Should be designed to allow opening from outside during an emergency when locked (LSC 26.2.5).


Appendix11 VILLAGEHEALTHCLINICSURVEYTOOLEXAMPLE

Electroniccopyofchecklistavailableat:http://www.anthc.org/cs/dehe/envhlth/ieh/vhc‐guidelines.cfm


Appendix12 HANDHYGIENEEXCERPTSFROMCDCANDWHOGUIDELINES

Thefollowingrecommendationsaredesignedtoimprovehandhygienepracticesofhealthcareworkersandtoreducetransmissionofpathogenicmicroorganismstopatientsandpersonnelinhealth‐caresettings:

1. Indicationsforhandhygiene:

Washhandswithsoapandwaterwhenvisiblydirtyorvisiblysoiledwithbloodorotherbodyfluidsorafterusingthetoilet.

Ifhandsarenotvisiblysoiled,useanalcohol‐basedwaterlessantisepticagentforroutinelydecontaminatinghandsinthefollowingclinicalsituations:

beforeoraftertouchingthepatient(takingapulseorbloodpressure,orliftingapatient)

beforehandlinganinvasivedeviceforpatientcare

aftercontactwithbodyfluidsorexcretions,mucousmembranes,non‐intactskin,orwounddressings,aslongashandsarenotvisiblysoiled

ifmovingfromacontaminatedbodysitetoacleanbodysiteduringpatientcare

aftercontactwithinanimateobjects(includingmedicalequipment)intheimmediatevicinityofthepatient

afterremovingsterileornon‐sterilegloves

Beforehandlingmedicationperformhandhygieneusinganalcohol‐basedhandruborwashhandswitheitherplainorantimicrobialsoapandwater.

Antimicrobial‐impregnatedwipes(i.e.,towelettes)maybeconsideredasanalternativetowashinghandswithnon‐antimicrobialsoapandwater.Becausetheyarenotaseffectiveasalcohol‐basedhandrubsorwashinghandswithanantimicrobialsoapandwaterforreducingbacterialcountsonthehandsofHCWs,theyarenotasubstituteforusinganalcohol‐basedhandruborantimicrobialsoap

2. HandhygieneTechnique:

Applyapalmfulofalcohol‐basedhandrubandcoverallsurfacesofthehands.Rubhandsuntildry.Followmanufacturer’srecommendationsregardingthevolumeofproducttouse.(ThetechniqueforhandrubbingisillustratedinFigureII.1)

Whenwashinghandswithsoapandwater,wethandswithwaterandapplytheamountofproductnecessarytocoverallsurfaces.Rinsehandswithwateranddrythoroughlywithasingle‐usetowel.Useclean,runningwaterwheneverpossible.Avoidusinghotwater,asrepeatedexposuretohotwatermayincreasetheriskofdermatitis.Usetoweltoturnofftap/faucet.Dryhandsthoroughlyusingamethodthatdoesnotrecontaminatehands.Makesuretowelsarenotusedmultipletimesorbymultiplepeople(ThetechniqueforhandwashingisillustratedinFigureII.2).

Liquid,bar,leaforpowderedformsofsoapareacceptableWhenbarsoapisused;smallbarsofsoapinracksthatfacilitatedrainageshouldbeusedtoallowthebarstodry.

3. Recommendationsforsurgicalhandpreparation:

Removerings,wrist‐watch,andbraceletsbeforebeginningsurgicalhandpreparation.

Priortoperformingminorsurgicalproceduressuchassuturinguseeitheranalcohol‐basedhandruboranantimicrobialsoap,preferablywithaproductensuringsustainedactivity,beforedonningsterilegloves.

Brushesarenotrecommendedforsurgicalhandpreparation.


4. Selection,handling,andplacementofhandhygieneagents:

ifalcohol‐basedwaterlessantisepticagentsareusedthenensuredispensersareaccessibleatthepointofcare(theentrancetopatientcareroomsoratthebedsideandinotherconvenientlocations)

wall‐mounteddispenserscontainingalcohol‐basedhandrubsshallnotbeinstalleddirectlyadjacentto,directlyaboveorbelowandelectricalreceptacle,switch,appliance,deviceorotherignitionsource.Thewallspacebetweenthedispenserandthefloorshallremainclearandunobstructed(IFC3405.5(3)).

wall‐mounteddispensersshallbemountedsothatthebottomofthedispenserisaminimumof42inchesandamaximumof48inchesabovethefinishedfloor(IFC3405.5(4)).

ensuredispensersystemforthealcohol‐basedhandrubsisapprovedforflammablematerials

ensurethatdispensersfunctionadequatelyandreliablyanddeliveranappropriatevolumeoftheproduct

donotaddsoaporalcohol‐basedformulationstoapartiallyemptysoapdispenser.Ifsoapdispensersarereused,followrecommendedproceduresforcleansing.Thispracticeof“toppingoff”dispenserscanleadtoabacterialcontaminationofthesoap.Theuseofrefillablesoapdispensersthattakepre‐packagedrefillsarepreferabletorefillablecontainersthattakebulkliquidsoap.

5. Skincare:

Whenalcohol‐basedhandrubisavailableinthehealth‐carefacilityforhygienehandantisepsis,theuseofantimicrobialsoapisnotrecommended.

Soapandalcohol‐basedhandrubshouldnotbeusedatthesametime.

6. Useofgloves:

Theuseofglovesdoesnotreplacetheneedforhandhygiene.

Weargloveswhenitcanbereasonablyanticipatedthatcontactwithbloodorotherpotentiallyinfectiousmaterials,mucousmembranes,ornon‐intactskinwilloccur.

Removeglovesaftercaringforapatient.Donotwearthesamepairofglovesforthecareofmorethanonepatient.

Whenwearinggloves,changeorremovetheglovesduringpatientcareifmovingfromacontaminatedbodysitetoeitheranotherbodysite(includingnon‐intactskin,mucousmembraneormedicaldevice)withinthesamepatientortheenvironment.

7. Otherconsiderations:

MonitorHCWs’adherencetorecommendedhandhygienepracticesandprovidethemwithperformancefeedback.

Encouragepartnershipsbetweenpatients,theirfamilies,andHCWstopromotehandhygieneinhealthcaresettings.

ProvideHCWswithaccesstoasafe,continuouswatersupplyatalloutletsandaccesstothenecessaryfacilitiestoperformhandwashing.

ProvideHCWswithareadilyaccessiblealcohol‐basedhandrubatthepointofpatientcare.

EnsureHCWshavededicatedtimeforinfectioncontroltraining,includingsessionsonhandhygiene.

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Appendix17 LIGHTING:DETERMINATIONOFILLUMINANCECATEGORIES

Determination of Illuminance Categories (ANSI/IESNA RP‐29‐06), page 44, Table 3A

Orientation and simple tasks. Visual performance is largely unimportant. These tasks are found in spaces where reading and visual inspection are only occasionally performed. Higher levels are recommended for tasks where visual performance is occasionally important. Measured in footcandles (fc)

A Public Spaces 3 fc

B Simple Orientation for short visits 5 fc

C Working spaces where simple visual tasks are performed 10 fc

Common visual tasks. Visual performance is important. Recommended Illuminance levels differ because of the characteristic of the visual task being illuminated. Higher levels are recommended for visual tasks with critical elements of low contrast or small size.

D Performance of visual tasks of high contrast and large size 30 fc

E Performance of visual tasks of high contrast and small size, or visual tasks of low contrast and large size

50 fc

F Performance of visual tasks of low contrast and small size 100 fc

TABLE 2: DETERMINATION OF ILLUMINANCE CATEGORIES

Lighting Design Guide for Health Care Facilities (ANSI/IESNA RP‐29‐06), excerpt from page 45‐49, Table 3B

IlluminanceHorizontal(fc)

Generalexamandtreatmentroom,local 100Generalexamandtreatmentroom,general 50Specimencollecting 50Medicationstation 50Lobby 30Pharmacy,general 30Toilets 30Utilityroom 30Waitingareas,reading 30

FIGURE 4: MINIMUM AVERAGE ILLUMINANCE


Appendix18 NFPASECONDARYMEANSFORESCAPECRITERIA‐WINDOWS

(c)*Itshallbeanoutsidewindowordooroperablefromtheinsidewithouttheuseoftools,keys,orspecialeffortandshallprovideaclearopeningofnotlessthan5.7ft2(0.53m2).Thewidthshallbenotlessthan20in.(51cm),andtheheightshallbenotlessthan24in.(61cm).Thebottomoftheopeningshallbenotmorethan44in.(112cm)abovethefloor.Suchmeansofescapeshallbeacceptablewhereoneofthefollowingcriteriaaremet:

(1)Thewindowshallbewithin20ft(6.1m)ofgrade.(2)Thewindowshallbedirectlyaccessibletofiredepartmentrescueapparatusasapprovedbytheauthorityhavingjurisdiction.(3)Thewindowordoorshallopenontoanexteriorbalcony.(4)Thewindowshallhaveasillheightbelowtheadjacentgroundlevelandshallbeprovidedwithawindowwellmeetingthefollowingcriteria:

a.Thewindowwellshallhavehorizontaldimensionsthatallowthewindowtobefullyopened.b.Thewindowwellshallhaveanaccessiblenetclearopeningofnotlessthan9ft2(0.82m2)withalengthandwidthofnotlessthan36in.(91.4cm).c.Awindowwellwithaverticaldepthofmorethan44in.(112cm)shallbeequippedwithanapprovedpermanentlyaffixedladderorwithstepsmeetingthefollowingcriteria:1.Theladderorstepsshallnotencroachmorethan6in.(15.2cm)intotherequireddimensionsofthewindowwell.2.Theladderorstepsshallnotbeobstructedbythewindow.

Laddersorstepsthatcomplywiththerequirementsof24.2.2.3(c)(4)shallbeexemptfromtherequirementsof7.2.2.Exception:Existingapprovedmeansofescape.

Above*denotes:ANNEXAEXPLANATORYMATERIAL

A.24.2.2.3

Foruseofemergencyescapedevices,refertoA.7.1.1.

*A.7.1.1

A.7.1.1Portableladders,ropefireescapes,andsimilaremergencyescapedevicescanhaveausefulfunctioninfacilitatingescapefromburningbuildingslackingadequateexitsofthestairorotherstandardtype,buttheyarenottheequivalentofstandardexits,andtheiruseisnotinanywayrecognizedbythisCodeassatisfyingtherequirementsformeansofegress.Furthermore,manysuchdevicesareoftypesunsuitableforusebyagedorinfirmpersonsorbysmallchildren.Therefore,suchdevicescanprovideafalsesenseofsecurityandshouldnotbeusedasanexcusefornotprovidingstandardexitfacilities

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APPENDIX20HANDWASHINGSTATIONEXAMPLE(WITHOUTRUNNINGWATER)

Handwashingstations,ataminimum,shouldinclude:

Aninsulatedcontainerwithafaucettypespigotwhichcanbesecuredintheopenposition,providingacontinuousflowofhandwashingwater

Acontainershouldbeplacedbelowthespigottocatchwastewaterfromhandwashingoperations.

o “Thehandwashingstationshouldbeplacedinanareaoftheclinicwhereunattendedchildrenarenotallowed.Infantsandtoddlerscandrowninsmallamountsofwaterleftina5‐gallonbucket(http://www.cpsc.gov/cpscpub/pubs/5006.html).”

Handsoap

Papertowelsoracceptablemeanstodryhands

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