Volume 2024 | No. 2
SURVEYOR
PHYSICAL ENVIRONMENT AND LIFE SAFETY NOTES FOR THE FACILITIES DIRECTOR
Physical environment and life safety standards always produce a significant number of deficiencies. Combining regular environmental rounding in collaboration with department leaders on the clinical and administrative side of your CAH’s operations will be helpful in identifying problems early. Creating training on how your team looks at each space and construction element from a life safety perspective—the why of the standards—can help you gain buy-in from all staff. The goal here would be to avoid deficiencies that result from people trying to solve problems without realizing they are creating new ones. Managing the environment as an inventory with associated inspections and testing also may be helpful.
The physical environment is the hospital’s largest and most critical piece of medical equipment, playing a vital role in patient care. Many ACHC Standards in these chapters are based on guidelines adopted from NFPA, CDC, and other resources, and reflect the minimum required activity to create a safe environment. Your study of this list of most frequently cited standards will help you focus efforts on issues that many hospitals share.
CHAPTER 03: PHYSICAL ENVIRONMENT 03.01.10 Eyewash stations and emergency showers Overview of the requirement:
Approved eyewash stations and/or emergency showers must be provided in every area where a person may be exposed to hazardous corrosive materials. Compliance is assessed through observation and document review. Citations focused on eyewash stations that were not fully ANSI-compliant.
Comment on deficiencies:
Frequency of citation:
33%
Examples of surveyor findings:
n In the room housing Generator 1, the batteries that are being tested are not within the required distance (10 seconds or 55 feet) of an eyewash station. n In the lab, surgery center core, and endoscopy scope cleaning area, the eye wash stations did not meet the ANSI Z-358- 2014 standard because they were connected to cold water sources only. n The facility could not produce testing documents for the annual temperature and flow test of eye wash stations. n The eye wash station located near the dishwasher has no mixing valve installed to meet the required temperature range. This station is connected to the cold-water supply line.
Richard L. Parker Associate Director, Life Safety & Physical Environment
FREQUENT DEFICIENCIES IN PHYSICAL ENVIRONMENT AND LIFE SAFETY STANDARDS
Tips for complianc e:
A documented risk assessment can be used to demonstrate why an ANSI- compliant station is not needed in a particular location
n Eyewash stations often require a mixing valve to maintain tepid water temperature of 60-100⁰F. n Every eyewash station requires a documented weekly inspection. Maintain a log.
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
03.07.03 Ventilation, Light, and Temperature Controls Overview of the requirement:
The hospital must meet relevant guidelines for temperature, humidity, ventilation and air pressure relationships based on the function of the space. Compliance is evaluated through observation, interview, and document review. Most deficiencies were due to incorrect air pressure relationships or the adoption of low humidity levels without regard to the effect on equipment.
Comment on deficiencies:
Frequency of citation:
56%
Examples of surveyor findings:
n Review of the OR temperature and humidity logs showed that they are completed on a weekly basis and only the only day that surgery is scheduled. The logs are to be checked at a minimum of once a day. n The clean utility room was observed to have a negative pressure relationship to the corridor. A positive relationship is required.
03.01.10
03.07.03
14.02.01
14.04.01
14.01.07
14.04.09
14.05.05
14.05.09
Physical Environment
Life Safety
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