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Preparation for the DOH Environment of Care Survey Semi-Annual Report Randy Benson

Preparation for the DOH Environment of Care Survey Semi-Annual Report Randy Benson Executive Director, RHQN. Eight Areas of Concern: Air Flow Tamper Resistant Electrical Outlets Wheelchair Maintenance and Sanitation Food and Medication Temperatures Fire Drills Back Flow Valves

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Preparation for the DOH Environment of Care Survey Semi-Annual Report Randy Benson

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  1. Preparation for the DOH Environment of Care Survey Semi-Annual Report Randy Benson Executive Director, RHQN

  2. Eight Areas of Concern: • Air Flow • Tamper Resistant Electrical Outlets • Wheelchair Maintenance and Sanitation • Food and Medication Temperatures • Fire Drills • Back Flow Valves • Management of the EOC • Staff Competency

  3. Air FlowWAC 246-320-405 (9)(c)(ii) • Areas of Mandated Negative Air Flow: • Dirty Utility Rooms • Procedural Suites (Endoscopy) • Specific Types of Isolation • Areas of Mandated Positive Air Flow: • Surgical Services • ORs - - Sub Sterile - - Post OP - - Cath Lab • Clean Utility Rooms • Patient Rooms

  4. Air Flow: Problem Areas • Open Windows • Closing or Altering Doorways • Altering/Repairing Ventilation Systems • Failure to Maintain Proper Isolation Room Air Flow

  5. Tamper Proof Electrical Outlets • WAC 246-320-405 (9)(e)(ii) • Outlets Designed to Prevent Death or Injury From Insertion of Paper Clips, Pins, Other Sharp Objects • Required In: • Pediatric Patient Rooms • Alcohol and Substance Abuse Units • Psych Units • All Exam Rooms • All Waiting Areas

  6. Tamper Proof Electrical Outlets (con’t) • Issues: • Plastic Caps Are Not Acceptable • Age or Mental Condition of Patient or Visitor • Any Room That May House a Peds Patient • All Exam Rooms (ER, Clinic, PT, RT, Lab) • All Waiting Areas (Nursing Units, ER, Clinic) • Very Specific Standards

  7. Wheelchair Maintenance and Sanitation • WAC 246-320-176 and 246-320-296 • Policy for Routine Maintenance and Cleaning • Proof of Compliance With Policy • Identification of Clean Wheelchairs • Location of Clean Wheelchairs • Appropriate Procedure for Cleaning Wheelchairs

  8. Food and Medication Temperatures • WAC 246-320-211, 246-873, 246-320-305 (6),246-320-201 • The Safety of All Medications and Food is Mandated (see also WAC 246-215, the Food Service Code) • No Outdated Pharmaceutical of Food • Daily Log of Temperatures of All Refrigerators and Freezers Housing Patient Food Items or Pharmaceuticals.

  9. Food and Medication Temps(con’t) • Issues • Temperatures Not Taken Every Day • Automated Temperature Recording • Alarms • No Process for Reporting Temperatures Outside of Normal Range • Normal Range Not Identified

  10. Fire Drills (NFPA 2000, WAC 246-320-296 (7) • Establish and Implement a Plan • Investigate and Correct Fire Plan Deficiencies • Orient and Educate Staff and Conduct Drills On a Regular Basis

  11. Fire Drills (con’t) • Issues • Use Of An Object Representing Fire • A Card, A Flashlight, A Strobe Light • Frequency of Fire Drills • One Per Shift Per Quarter • Process For Conducting Fire Drills • Process For Evaluating Fire Drills • Process For Remedial Training • Posting of Fire Evacuation Routes

  12. Back Flow Valves • WAC 246-320-405 (9)(b)(iii) • Ensure a Safe Potable Water Supply by attaching backflow valves to certain types of equipment • Beverage Carbonators • Commercial Laundry Machines • Dialysis Units • Dish Washers • Ice Machines

  13. Back Flow Valves (con’t) • Food Prep Sinks • Chemical Feeders (Kitchen or Housekeeping) • Must Have a Policy In Place For Preventing Backflow Into the Potable Water System • Must Have An Annual Evaluation and Assessment of the Effectiveness of the Backflow Valves (Annual PM)

  14. Management of the Environment of Care (EOC):WAC 246-320-296 • Manage Environmental Risks and hazards, • Prevent Accidents and Injuries, • Maintain Safe Conditions For Patients, Visitors and Staff

  15. Management Plan Must Cover the Eight Areas of the EOC • General Safety • Security • Hazardous Materials and Waste • Emergency Preparedness • Fire Safety • Medical Equipment • Utility Systems • Physical Environment

  16. General Safety • Maintain Environment Free of Hazards • Investigate and Report Injuries (RCAs) • Maintain Policies Related to Safety (e.g. Wheelchairs) • Educate Staff on Safety Related Issues • Security • Maintain Policies Related to Security • Educate Staff About Security Issues • Maintain a Secure Environment (for Staff, Patients, Visitors)

  17. Hazardous Material and Waste • Establish and Implement a Program to Safely Handle Hazardous Materials According to Local, State and Federal Regulations • Provide Safe Storage Space for Hazardous Materials (O2, Shredable paper, Lab Chemicals, etc) • Investigate All Spills (RCAs), Clean Up Spills (as appropriate), Report All Spills • Educate Staff About the “Worker Right to Know” Program

  18. Emergency Preparedness • Disaster Plan • Disaster Drills • Emergency Preparedness Risk Assessment • Staff Education About Emergency/Disaster Response • Fire Safety • Maintain Fire Detection System • Maintain Policies • Conduct Fire Drills (Supervise Drills) • Educate Staff

  19. Medical Equipment • Policies • Preventive Maintenance System • Inventory • Documentation • Assure Quality of Service by Outside Vendors • Develop and Maintain a Quality Control Program • Investigate All Equipment Failures (RCAs) • Educate Staff On Proper Operation of Equipment

  20. Utility Systems • Maintain a Safe and Comfortable Environment • Ensure Operational Reliability of Utilities (HVAC, Elevators, Water, Electrical Grid, etc.) • Investigate All Utility Failures (RCAs) • Conduct and Document Preventive Maintenance • Physical Environment • Storage Areas Safe, Fire Protected, Secure • Plumbing (e.g. Hot Water Temp of 126oF)

  21. Physical Environment (con’t) • Ventilation (Proper Air Flow In All Areas) • Clean Interior Surfaces and Finishes • Windows • Functional Patient Call System • Outside Environment Is Safe (e.g. Grounds, Snow Removal, Sidewalks, Lighting)

  22. Staff Competency • Safety, Job Specific, Mandated By Admin. • Generic and Department Specific • Orientation and Ongoing • Access To Experts • Documentation • Review By DOH Surveyors • Current Job Description (3 years) • Current Evaluation

  23. Review By DOH Surveyors (con’t) • Proof of Current License • Current Certifications (e.g. CRNA, PT, Food Handler Green Card) • Documentation of Competency • Education Transcript • Everything in One Location • Skills and Knowledge • Department Specific Competencies • Outside Education/Professional Organizations (e.g. IP, Clinical Dietitian, PT, Pharmacy)

  24. Randy Benson RHQN Executive Director randyb@wsha.org 206 577-1821

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