• Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

The hospital manages safety and security risks.

  • EC.02.01.01 EP5 <br>The hospital maintains all grounds and equipment. <br>

The hospital manages its environment during demolition, renovation, or new construction to reduce risk to those in the organization.

  • EC.02.06.05 EP2 <br>When planning for demolition, construction, or renovation, the hospital conducts a reconstruction risk assessment for air quality requirements, infection control, utility requirements, noise, vibration, and other hazards that affect care, treatment, and services. <br>

  • EC.02.06.05 EP3 <br>The hospital takes action based on its assessment to minimize risks during demolition, construction, or renovation. <br>

  • LS.01.02.01 EP4 <br>Inspects exits in affected areas on a daily basis. <br>

  • LS.01.02.01 EP5 <br>Provides temporary but equivalent fire alarm and detection systems for use when a fire system is impaired. <br>

  • LS.01.02.01 EP6 <br>Provides additional firefighting equipment. <br>

  • LS.01.02.01 EP7 <br>Uses temporary construction partitions that are smoke-tight, or made of noncombustible or limited-combustible material that will not contribute to the development or spread of fire. <br>

  • LS.01.02.01 EP8 <br>Increases surveillance of buildings, grounds, and equipment, giving special attention to construction areas and storage, excavation, and field offices. <br>

  • LS.01.02.01 EP9 <br>Enforces storage, housekeeping, and debris-removal practices that reduce the building’s flammable and combustible fire load to the lowest feasible level. <br>

  • LS.01.02.01 EP10 <br>Provides additional training to those who work in the hospital on the use of firefighting equipment. <br>

  • LS.01.02.01 EP11 <br>Conducts one additional fire drill per shift per quarter. <br>

  • LS.01.02.01 EP12 <br>Inspects and tests temporary systems monthly. <br>

  • LS.01.02.01 EP13 <br>The hospital conducts education to promote awareness of building deficiencies, construction hazards, and temporary measures implemented to maintain fire safety. <br>

  • LS.01.02.01 EP14 <br>The hospital trains those who work in the hospital to compensate for impaired structural or compartmental fire safety features. <br>

The hospital designs and manages the physical environment to comply with the Life Safety Code.

  • LS.01.01.01 EP2 <br>The hospital maintains a current electronic Statement of Conditions. <br>

  • LS.01.01.01 EP3 <br>When the hospital plans to resolve a deficiency through a Plan for Improvement (PFI), the hospital meets the time frames identified in the PFI accepted by The Joint Commission. <br>

The hospital conducts fire drills.

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

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

The hospital maintains fire safety equipment and fire safety building features.

  • EC.02.03.05 EP1 <br>At least quarterly, the hospital tests supervisory signal devices (except valve tamper switches). <br>

  • EC.02.03.05 EP2 <br>Every 3 months, the hospital tests valve tamper switches and water-flow devices. <br>

  • EC.02.03.05 EP3 <br>Every 12 months, the hospital tests duct detectors, electromechanical releasing devices, heat detectors, manual fire alarm boxes, and smoke detectors. <br>

  • EC.02.03.05 EP4 <br>Every 12 months, the hospital tests visual and audible fire alarms, including speakers. <br>

  • EC.02.03.05 EP5 <br>Every quarter, the hospital tests fire alarm equipment for notifying off-site fire responders. <br>

  • EC.02.03.05 EP6 <br>For automatic sprinkler systems: Every week, the hospital tests fire pumps under no-flow conditions. <br>

  • EC.02.03.05 EP9 <br>For automatic sprinkler systems: Every 12 months, the hospital tests main drains at system low point or at all system risers. <br>

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

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

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

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

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

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

  • EC.02.03.05 EP18 <br>The hospital 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>

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

  • EC.02.03.05 EP20 <br>Every 12 months, the hospital tests sliding and rolling fire doors for proper operation and full closure. The completion date of the tests is documented. <br>

The hospital designs and manages the physical environment to comply with the Life Safety Code.

  • LS.01.01.01 EP4 <br>For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital maintains documentation of any inspections and approvals made by state or local fire control agencies. <br>

The hospital protects occupants during periods when the Life Safety Code is not met or during periods of construction.

  • LS.01.02.01 EP1 <br>The hospital notifies the fire department (or other emergency response group) and initiates a fire watch when a fire alarm or sprinkler system is out of service more than 4 hours in a 24-hour period in an occupied building. Notification and fire watch times are documented. <br>

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

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

The hospital provides and maintains building features to protect individuals from the hazards of fire and smoke.

  • LS.02.01.30 EP20 <br>In existing buildings, ducts that penetrate smoke barriers are protected by approved smoke dampers that close when a smoke detector is activated. The detector is located either within the duct system or in the area serving the smoke compartment. <br>

The hospital provides and maintains fire alarm systems.

  • LS.02.01.34 EP1 <br>The fire alarm signal automatically transmits to a Central Monitoring station as described in NFPA 72-1999; 5-2 <br>

The hospital maintains the integrity of the means of egress.

  • LS.02.01.20 EP27 <br>Means of egress are adequately illuminated at all points, including angles and intersections of corridors and passageways, stairways, stairway landings, exit doors, and exit discharges. <br>

  • LS.02.01.20 EP28 <br>Illumination in the means of egress, including exit discharges, is arranged so that failure of any single light fixture or bulb will not leave the area in darkness. <br>

The hospital manages risks associated with its utility systems.

  • EC.02.05.01 EP7 <br>The hospital maps the distribution of its utility systems. <br>

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

The hospital has a reliable emergency electrical power source.

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

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

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

  • EC.02.05.03 EP4 <br>Elevators (at least one for nonambulatory patients). <br>

  • EC.02.05.03 EP5 <br>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>

  • EC.02.05.03 EP6 <br>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>

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