2014 EOC Clinics

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Follow Up to be performed before:

  Date

• Name of person conducting survey:

  Sign

Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.

• LS.02.01.10 EP 5 Doors are equipped with self closing and self latching devices. Gaps between meeting edges of door pairs are no more than 1/8" wide, and undercuts are no larger than 3/4 ".

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.10 EP 7 Doors requiring fire rating of 3/4 hour or longer are free of coverings, decorations, or other objects applied to the door face, with the exception of information signs.

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.10 EP8 Ducts that penetrate a 2-hour fire-rated separation are protected by dampers that are fire-rated for 1 1/2 hours. <br>

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

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 <br>

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• 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

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.34 EP 3 The remote ancillary annunciator panel is in a location approved by the local fire department or its equivalent.

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.34 EP 4 Pull stations are unobstructed

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

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.

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.35 EP 6 There are 18" or more of open space maintained below the sprinkler deflector to the top of storage.

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.35 EP 8 The travel distance from any point to the nearest fire extinguisher is 75 ft. or less.

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The Organization has a written plan for managing the following

• EC.01.01.01 EP 3 The environmental safety of patients and everyone else who enters the organization's facilities.

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.01.01.01 EP 4 The security of everyone who enters the organization's facilities.

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.01.01.01 EP 5 Hazardous materials and waste

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.01.01.01. EP 6 Fire Safety

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.01.01.01 EP 7 Medical Equipment

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.01.01.01 EP 8 Utility Systems

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The organization manages safety and security risks

• EC.02.01.01 EP 1 The organization identifies safety and security risks associated with the environment of care that could affect patients, staff, and other people coming to the hospitals facilities<br><br>* Fall protection plan

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The organization prohibits smoking.

• EC.02.01.03 EP 1 Smoking is not permitted in the organization. <br>

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The organization manages risks related to hazardous materials and waste

• EC.02.02.01 EP 3 The organization has written procedures, including the use of precautions and personal protective equipment, to follow in response to hazardous material and waste spills or exposures.

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.02.01 EP 4 The organization implements its procedures in response hazardous material and waste spills or exposures<br><br>* Sharps containers are not more than 3/4 full

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.02.01 EP 5 The organization minimizes risks associated with selecting, handling, storing, transporting, using, and disposing of hazardous chemicals.<br><br>* Biohazard waste is properly disposed of<br><br>* Eye wash stations inspections are documented and meet ANSI z358.1-2009, are accessible, clean and working<br><br>* No more than a single 5-gallon storage container of flammable solvents is stored in the lab outside of a flammable materials cabinet or fire-rated safety can

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.02.01 EP 11 For managing hazardous materials and waste, the organization has the permits, licenses, manifests, and MSDS required by law and regulation.

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

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.<br><br>* (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.<br>* Fire extinguishers are not obstructed<br>* Corridors are reduced to less than 3'

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.01 EP 9 and EP 10 The organization has a written fire response plan. The plan describes the specific roles of staff and licensed independent practitioners at and away from a fire's point of origin, including when and how to sound fire alarms, how to contain smoke and fire, how to use an extinguisher, and how to evacuate to areas of refuge.

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The organization conducts fire drills.

• EC.02.03.03. EP1 The organization conducts fire drills once per shift per quarter in each building defined as a health care occupancy. <br>

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.03 EP5 The organization critiques fire drills to evaluate fire safety equipment, fire safety building features, and staff response to fire. <br>

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

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). <br>

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 2 Every 3 months, the organization tests valve tamper switches and water-flow devices. <br>

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• 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. <br>

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 4 Every 12 months, the organization tests visual and audible fire alarms, including speakers. <br>

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 5 Every quarter, the organization tests fire alarm equipment for notifying off-site fire responders. <br>

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 6 For automatic sprinkler systems: Every week, the organization tests fire pumps under no-flow conditions. <br>

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• 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

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• 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.

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• 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. <br>

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP10 For automatic sprinkler systems: Every quarter, the organization inspects all fire department water supply connections. <br>

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP11 For automatic sprinkler systems: Every 12 months, the organization tests fire pumps under flow. <br>

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP12 Every 5 years, the organization conducts water-flow tests for standpipe systems. <br>

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP13 Every 6 months, the organization inspects any automatic fire-extinguishing systems in a kitchen. <br>

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• 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.

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP15 At least monthly, the organization inspects portable fire extinguishers. <br>

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP16 Every 12 months, the organization performs maintenance on portable fire extinguishers. <br>

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• 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

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• 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. <br>

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP19 Every 12 months, the organization tests automatic smoke-detection shutdown devices for air-handling equipment. <br>

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• 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. <br>

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The organization inspects, tests, and maintains medical equipment

• EC.02.04.03 EP 2 The organization inspects, tests and maintains all life-support equipment. Activities are documented<br><br>* Equipment within PM schedule

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The organization manages risks associated with its utility systems.

• EC.02.05.01 EP 5 The organization minimizes pathogenic biological agents in cooling towers, domestic hot and cold water systems, and other aerosolizing water systems.<br><br>* No standing H2O near air intakes.<br>* Exhaust vents are 30 or > from air intakes

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.05.01 EP 6 (CLD) In areas designed to control airborne contaminants, the ventilation system provides appropriate pressure relationships, air-exchange rates, and filtration efficiencies.

  Yes

  No

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.05.01 EP 8 The organization labels utility system controls to facilitate partial or complete emergency shutdowns.

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.05.01 EP10 The organization procedures address shutting off the malfunctioning system and notifying staff in affected areas. <br>

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The organization has a reliable emergency electrical power source.

• EC.02.05.03 EP1 Organization provides emergency power for the following utilities and systems: Alarm systems, as required by the Life Safety Code. <br>

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.05.03 EP2 Exit route and exit sign illumination, as required by the Life Safety Code. <br>

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.05.03 EP3 Emergency communication systems, as required by the Life Safety Code. <br>

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.05.03 EP5 Equipment that could cause patient harm when it fails, including life-support systems; blood, bone, and tissue storage systems; medical air compressors; and medical and surgical vacuum systems. <br>

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.05.03 EP6 Areas in which loss of power could result in patient harm, including operating rooms, recovery rooms, obstetrical delivery rooms, nurseries, and urgent care areas. <br>

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The organization inspects, tests, and maintains utility systems

• EC.02.05.05 EP 1 The organization tests utility system components on the inventory before initial use. The completion date of the test is documented<br>* Generator switch gear in "auto"

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

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.

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

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:<br><br>* injuries to patients or others within the hospital facilities<br>* Occupational illnesses and staff injuries<br>* Incidents of damage to its property or the property of others<br>* Security incidents involving patients, staff, or others within its facilities<br>* Hazardous materials and waste spills and exposures<br>* Fire safety management problems, deficiencies, and failures<br>* Medical or Lab equipment management problems, failures, and use errors<br>* Utility systems management problems, failures, or use errors

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• 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.

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion: