Volume 2025 | No. 2
SURVEYOR
PHYSICAL ENVIRONMENT AND LIFE SAFETY FROM THE PROGRAM DIRECTOR
Physical environment and life safety standards always produce a large number of deficiencies. As the hospital’s largest and, arguably, most complex piece of medical equipment, this is not surprising. The relevant chapters are 03 and 14 for critical access hospitals and 11 and 13 for acute care hospitals.
CHAPTERS 03 & 11: PHYSICAL ENVIRONMENT 03.01.10 (CAH) 11.01.06* *For surveys that took place between June 1, 2024, and April 6, 2025, this standard was numbered 11.01.10. Eyewash stations and emergency showers
14.04.07/13.04.07 Fire-rated door assemblies – Ensure latching mechanisms are working.
Seven frequently-cited standards were common for surveys in hospitals of all sizes. For each of these standards, attention to one detail would significantly reduce deficiencies:
14.04.09/13.04.09 Ceilings – Seal penetrations.
Frequency of the citation: 03.01.10 67%, 11.01.06 35%
03.01.10/11.01.06 Eyewash stations and emergency showers – Ensure a mixing valve provides tepid water.
14.05.10/13.05.10 Utility systems – Cover all junction boxes.
Overview of the requirement: In locations where corrosive materials exist, an ANSI-compliant eyewash station or emergency shower is provided or there is a documented risk assessment that effectively demonstrates that the need is otherwise managed. Where eyewash stations/emergency showers exist, they are activated weekly and inspected/tested annually.
I also recommend collaborating with your clinical and administrative colleagues for regular environmental rounding. More eyes on (and better awareness of) the building and its systems will support a safer environment for patients, visitors, and staff.
03.07.03/11.06.05 Ventilation, light, and temperature controls – Improve monitoring and management of air pressure relationships 14.03.01 & 02/13.03.01 & 02 Water-based fire protection system: Installation and maintenance & Inspection and testing – Inventory all components and schedule testing on the required cadence.
Comment on deficiencies: Compliance is assessed through observation and document review. Surveyors noted:
Richard L. Parker, MBA, CHFM Associate Director, Life Safety & Physical Environment
■ Absence of required eyewash stations. ■ Noncompliant equipment installation. ■ Inspection and maintenance deficiencies. ■ Use of eyewash bottles instead of stations. ■ Lack of a consistent risk assessment process.
FREQUENT DEFICIENCIES IN PHYSICAL ENVIRONMENT AND LIFE SAFETY STANDARDS
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Examples of ACHC Sur veyor findings: ■ The laundry mechanical room stores corrosive materials. There is no eyewash station, and no risk assessment was available to indicate consideration of an eyewash station. ■ The eyewash station in the central processing area was not compliant with the ANSI Z358.1-2014 standard. The station did not to have a mixing valve and would require adjusting the hot and cold water to maintain a tepid temperature between 60-100 o F. ■ There was no eyewash station installed in the dirty side of the sterile processing department where caustic chemicals are used. ■ Based on document review, an annual eyewash station inspection report was unavailable. ■ The main laboratory eyewash station was plumbed with a cold water source. A tepid water supply as required under the ANSI Z358.1-2014 standard. ■ The receiving department eyewash station required more than a single action to operate.
Life Safety
Physical Environment
ACH- 3/14
CAH- 11/13
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