Amendment_03_-_TJC_Inspections_-_23FEB2016.pdf

Documentation required by the Hospital Accreditation program Life Safety (LS) and selected Environment of

Care (EC) standards is presented in the following pages. These documents will be reviewed by the Life

Safety surveyor upon their arrival for the on-site survey.

This tool is provided to organizations for use in their continuous compliance and survey readiness efforts.

Other EC and LS documents may be requested by surveyors their, as needed, throughout the survey.

Life Safety and Environment of Care - Document List and Review Tool

STANDARD

LS.01.01.01 C NC NA IOU Buildings serving patients comply with NFPA 101 (2000 edition)

EP 1 Individual assigned to assess LSC compliance

EP 2 Current e-SOC maintained

EP 3 Timely completion of PFIs

EP4 Documentation of inspections and approvals made by state or local AHJs

YES NO YES NO

EP 1

Alarms / sprinklers out of service 4 or more hrs in 24 hrs - Fire watch / Fire Dept.

notification

EP 2 Signs for alternate exits posted

EP 3 ILSM policy identifying when and to what extent ILSM implemented

EP 4 Daily inspection of routes of egress (See also 19.7.9.2 RE: daily inspections)

EP 5 Temporary but equivalent systems while system is impaired

EP 6 Additional fire fighting equipment provided

EP 7 Smoke tight non-combustible temporary barriers

EP 8 Increased surveillance implemented

EP 9 Storage and debris removal

EP 10 Additional training on fire fighting equipment

EP 11 Additional fire drill per shift per quarter

EP 12 Temporary systems tested and inspected monthly

EP 13 Additional training on bldg deficiencies, construction hazards, temp measures

EP 14 Training for impaired structural or impaired compartment fire safety features

COMMENTS:

Legend: C=Compliant; NC=Not compliant; NA=Not applicable; IOU=Surveyor awaiting documentation

YES NO

DOCUMENT

Legend: C=Compliant; NC=Not compliant; NA=Not applicable; IOU=Surveyor awaiting documentation

See Legend

NCCLS.01.02.01

COMMENTS:

Addressed in Policy? Implemt. as required?

Interim Life Safety Measures (ILSM)IOUNA

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EC.02.03.01 C NC NA IOU Hospital Manages Fire Risk - Fire Response Plan

EP 9 The hospital has a written fire response plan.

EP 10 The plan describes the specific roles of staff and LIPs at and away from fire.

*when and how to sound and report fire alarms,

* how to contain smoke and fire

*how to use a fire extinguisher, *how to evacuate to areas of refuge

COMMENTS:

EC.02.03.03 C NC NA IOU Fire Drills FREQUENCY 1st QTR 2nd QTR 3rd QTR 4th QTR/

Ann.

EP 1

Fire drills once per shift per quarter: Health Care and Ambulatory Health Care (If available, please provide five quarters of fire drill data) Quarterly

EP 2 Fire drills every 12 months from date of last drill: Business Occupancies Annually

EP 3 When quarterly fire drills are required, at least 50% unannounced. Quarterly

EP 4 Staff participate in the drills according to the hospital's fire response plan.

EP 5 Critiques include fire safety equipment & building features and staff response.

COMMENTS:

DOCUMENT

YES NO

See Legend

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EC.02.03.05 C NC NA IOU Fire Protection and Suppression Testing and Inspection FREQUENCY 1st QTR/

Semi 2nd QTR

3rd QTR/

Semi

4th QTR/

Ann.

EP 1 Supervisory Signals-"fire pump running & fire pump failure" trouble signals Quarterly

Water flow devices -- Deemed Hosptials and CAHs Quarterly

Water flow devices -- Non-Deemed Hospitals Semiannually

Tamper switches Semiannually

EP 3 Duct, heat, smoke detectors, pull boxes, elect. releasing devices Annually

EP 4 Notification devices (audible & visual) Annually

EP 5 Emergency services notification transmission equipment Quarterly

EP 6 Fire pump(s) tested - under no flow Weekly

EP 7 Water storage tank high & low level alarms Semiannually

EP 8 Water storage tank low water temp alarms (cold weather only) Monthly

EP 9 Sprinkler systems main drain tests on all risers Annually

EP 10 Fire department connections inspected (Fire hose connections N/A) Quarterly

EP 11 Fire pump(s) tested - underflow Annually

EP 12 Standpipe flow test every 5 years 5 years

EP 13 Kitchen suppression semi-annual testing Semiannually

EP 14 Gaseous extinguishing systems inspected (no discharge req) Annually

EP 15 Portable fire extinguishers inspected monthly Monthly

EP 16 Portable fire extinguishers maintained annually Annually

EP 17 Fire hoses hydro tested 5 yrs after install, every 3 yrs thereafter 5 yrs / 3yrs

EP 18 Smoke & fire dampers tested (fusible links removed when applicable) 4-6 years

EP 19 Smoke detection shutdown devices for HVAC tested Annually

EP 20 All horizontal & vertical roller & slider doors tested Annually

DOCUMENTSee Legend

COMMENTS:

EP 2

Legend: C=Compliant; NC=Not compliant; NA=Not applicable; IOU=Surveyor awaiting documentation

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EC.02.05.07 C NC NA IOU Emergency Power Systems are Maintained and Tested FREQUENCY

EP 1 Battery powered egress lights tested monthly - 30 seconds Monthly

EP 2 Battery powered egress lights tested annually - 90 minutes Annually

EP 3

Quarterly functional test of SEPSS for 5 min/class and

60% full duration of class annually Qtrly/Ann.

Note 1: Non-SEPSS tested per manufacturer's specifications. Per Mfg.

Note 2: SEPSS for critical areas and equipment tested monthly Monthly

Note 3: Class defines minimum time which SEPSS is designed to operate

EP 4 Generator load test monthly for 30 min under load (plus cool-down) Monthly

EP 5 Monthly load test 30% or exhaust gas temp or annual load bank 25/50/75% Monthly/Ann.

EP 6 All Transfer switches monthly/12 times per Yr. Monthly

EP 7 Generator load test once every 36 months for 4 hours 36 Months

EP 8 Generator 4 hour test @ at least 30% nameplate 36 Months

EP 9 If generator testing fails, review contingency & implement protective measures Per occurrence

EP 10 If load test fails retest after making repairs Per occurrence

EP 1

Test, inspect & maintain: master panels, area alarms, automatic pressure switches, shut-off valves, flexible connectors and outlets.

No prescribed frequency; recommend risk assessment if < annual.

EP 2

Review med gas installation/modification/breech certification results for:

cross-connection, purity and pressure As applicable

EP 3 Med gas supply and zone valves are accessible and clearly labeled On Bldg Tour

COMMENTS:

NO

YES NO / Missing Date

COMMENTS:

Legend: C=Compliant; NC=Not compliant; NA=Not applicable; IOU=Surveyor awaiting documentation

THIS MAY BE SCORED AS CONDITIONAL OR STD

Per Policy

IOUNANCCEC.02.05.09 Medical Gas and Vacuum Systems are Inspected and Tested

YES

See Legend DOCUMENT REVIEW

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