Volume 2024 | No. 2
SURVEYOR
DMEPOS
SECTION 7: RISK MANAGEMENT: INFECTION AND SAFETY CONTROL DRX7-5B Overview of the requirement: The organization has a fire safety plan and emergency power system. Comment on deficiencies: Evidence of compliance includes review of policies and procedures and direct observation. Surveyors frequently noted a failure to conduct annual fire drills or inspect fire extinguishers.
DRX7-12D Overview of the requirement:
Equipment used in the provision of care/service must be cleaned, stored, transported, delivered, and set up according to the organization’s policies and procedures. Evidence of compliance includes direct observation, interviews, and personnel file review. Most deficiencies were related to improper equipment storage and cleaning procedures in warehouses and delivery vehicles.
Comment on deficiencies:
Frequency of citation:
42%
Frequency of citation:
21%
Examples of surveyor findings:
n Improper storage practices: Company does not have a method of tracking of products with lot and/or serial numbers for manufacturer recalls. Expired suction catheters were found in areas housing patient-ready product. Inoperable equipment and batteries to be disposed of were not properly segregated. Several oxygen cylinders of varying sizes were observed standing upright with no method utilized to secure them and prevent them from falling over. Oxygen cylinders were full but were stored in the designated empty 02 cylinder storage area. n Insufficient cleaning/disinfection practices: Clean and ready oxygen regulators were not protected from dust/dirt on delivery vehicles and in the warehouse. Upon interview, a warehouse staff member could not describe the process for cleaning returned equipment, specifically how long the chemical disinfectant used to clean/disinfect equipment was to remain “wet” on the equipment. The disinfectant being used (Lysol wipes, bedding license solution) is not effective against all infectious pathogens. Returned dirty CPAP equipment is processed, cleaned and tested on the same surface and in the same area as patients are instructed and setup with new CPAP equipment. n Delivery vehicle maintenance/documentation: The delivery vehicle was missing a valid vehicle registration. Delivery van front windshield glass is fractured and needs replacement. SDS sheets or access to SDS information wase not found in the delivery vehicle(s) and no eye wash was present.
Examples of surveyor findings:
n There was no evidence of any smoke detectors in the facility. n Annual fire drills and emergency power drills have not been completed. n Front exit light, rear exit light, rear warehouse exit light, and front warehouse exit light were all defective, and not illuminated on test button per fire code. n There was no evidence that fire extinguishers in the delivery vehicle received annual maintenance. n Facility inspections are done monthly but not documented in accordance with company’s process. n Test emergency power sources and items with a battery backup such as exit lights, smoke detectors, server batteries, etc., on an annual basis. n Ensure that fire extinguishers are maintained on an annual basis, and that there is documentation that it was completed. n Post evacuation diagrams into all back rooms and areas where exit signs are not visible.
Tips for compliance:
Document employee participation in the fire safety plan by implementing an attendance log.
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