2014 EOC Clinics

Information

Audit Title
Client / Site
Conducted on
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Personnel

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The Organization provides and maintains fire alarm systems.

LS.02.01.34 EP1 The fire alarm signal automatically transmits to a Central Monitoring station as described in NFPA 72-1999; 5-2
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LS.02.01.34 EP 2 The master fire alarm control panel is located in a protected environment (an area enclosed with a 1-hour fire-rated walls and 3/4-hour fire-rated doors) that is continuously occupied or in an area with a smoke detector
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LS.02.01.34 EP 3 The remote ancillary annunciator panel is in a location approved by the local fire department or its equivalent.
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LS.02.01.34 EP 4 Pull stations are unobstructed
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The Clinic provides and maintains systems for extinguishing fires.

LS.02.01.35 EP 5 Sprinkler heads are not damaged and are free from corrosion, foreign materials and paint.
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LS.02.01.35 EP 6 There are 18" or more of open space maintained below the sprinkler deflector to the top of storage.
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LS.02.01.35 EP 8 The travel distance from any point to the nearest fire extinguisher is 75 ft. or less.
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The organization prohibits smoking.

EC.02.01.03 EP 1 Smoking is not permitted in the organization.
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The organization manages fire risks

EC.02.03.01 EP 1 The organization minimizes the potential for harm from fire, smoke, and other products of combustion. * (Electrical rooms locked at all times,should have "storeroom" type locksets. No storage allowed within 4' of transformers and breaker panels. No combustible materials in any room. * Fire extinguishers are not obstructed * Corridors are reduced to less than 3'
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EC.02.03.01 EP 4 The organization maintains free and unobstructed access to all exits. This requirement applies to all buildings classified as business occupancy,
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The organization conducts fire drills.

EC.02.03.03. EP2 The organization conducts fire drills every 12 months from the date of the last drill in each area that is defined as a business occupancy per year in each building defined as a business occupancy by the Life Safety code and in which care, treatment or services are provided. Note 1: IN leased or rented spaces, drills need to be conducted only in areas of the building the organization occupies.
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EC.02.03.03 EP5 The organization critiques fire drills to evaluate fire safety equipment, fire safety building features, and staff response to fire.
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The organization maintains fire safety equipment and fire safety building features.

EC.02.03.05 EP 1 At least quarterly, the organization tests supervisory signal devices (except valve tamper switches).
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EC.02.03.05 EP 2 Every 6 months
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EC.02.03.05 EP 3 Every 12 months, the organization tests duct detectors, electromechanical releasing devices, heat detectors, manual fire alarm boxes, and smoke detectors.
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EC.02.03.05 EP 4 Every 12 months, the organization tests visual and audible fire alarms, including speakers.
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EC.02.03.05 EP 5 Every quarter, the organization tests fire alarm equipment for notifying off-site fire responders.
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EC.02.03.05 EP 6 For automatic sprinkler systems: Every week, the organization tests fire pumps under no-flow conditions.
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EC.02.03.05 EP 7 For automatic sprinkler systems: Every 6 months the organization tests water-storage tank high-and low-water level alarms. The completion date is documented
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EC.02.03.05 EP 8 For automatic sprinkler systems: Every month during cold weather, the organization test water - storage tank temperature alarms. The completion date of the test is documented.
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EC.02.03.05 EP9 For automatic sprinkler systems: Every 12 months, the organization tests main drains at system low point or at all system risers.
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EC.02.03.05 EP10 For automatic sprinkler systems: Every quarter, the organization inspects all fire department water supply connections.
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EC.02.03.05 EP11 For automatic sprinkler systems: Every 12 months, the organization tests fire pumps under flow.
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EC.02.03.05 EP12 Every 5 years, the organization conducts water-flow tests for standpipe systems.
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EC.02.03.05 EP13 Every 6 months, the organization inspects any automatic fire-extinguishing systems in a kitchen.
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EC.02.03.05 EP 14 Every 12 months, the organization tests carbon dioxide and other gaseous automatic fire-extinguishing systems. The completion date of the test is documented.
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EC.02.03.05 EP15 At least monthly, the organization inspects portable fire extinguishers.
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EC.02.03.05 EP16 Every 12 months, the organization performs maintenance on portable fire extinguishers.
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EC.02.03.05 EP 17 The organization conducts hydrostatic tests on standpipe occupant hoses 5 years after installation and 3 years thereafter. Completion date is documented
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EC.02.03.05 EP18 The organization operates fire and smoke dampers 1 year after installation (commencing Jan 2010) and then at least every 6 years to verify that they fully close.
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EC.02.03.05 EP19 Every 12 months, the organization tests automatic smoke-detection shutdown devices for air-handling equipment.
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EC.02.03.05 EP20 Every 12 months, the organization tests sliding and rolling fire doors for proper operation and full closure. The completion date of the tests is documented.
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The organization inspects, tests, and maintains emergency power systems

EC.02.05.07 EP 4. Twelve times a year, at intervals of not less than 20 days and not more than 40 days, the hospital tests each emergency generator for at least 30 continuous minutes.
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The organization collects information to monitor conditions in the environment (EC Committee)

EC.04.01.01 EP 1 The organization establishes a process (es) for continually monitoring, internally reporting, and investigating the following: * injuries to patients or others within the hospital facilities * Occupational illnesses and staff injuries * Incidents of damage to its property or the property of others * Security incidents involving patients, staff, or others within its facilities * Hazardous materials and waste spills and exposures * Fire safety management problems, deficiencies, and failures * Medical or Lab equipment management problems, failures, and use errors * Utility systems management problems, failures, or use errors
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EC.04.01.01. EP 15 Every 12 months, the organization evaluates each environment of care management plan, including a review of the plan's objectives, scope, performance, and effectiveness.
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