Life Safety/EOC Survey - Pre-TJC Audit

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Follow Up by Surveyor to be performed before:

  Date

• Name of person conducting survey:

  Sign

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

• LS.01.01.01 EP 1. The hospital assigns an individual(s) to assess compliance with the Life Safety Code, complete the eSOC and manage the resolution of deficiencies.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

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

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.01.01 EP3 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>

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.01.01 EP 4 For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital maintains documentation of any inspection and approvals made by state or local fire control agencies.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

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

• LS. 01.02.01 EP 1 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 (NFPA 101-2000: 9.6.1.8 and 9.7.6.1)<br>

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.02.01 EP 2 The hospital posts signage identifying the location of alternative exits to everyone affected.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.02.01 EP 3 The hospital has a written interim life safety measure (ILSM) policy that covers situations when Life Safety Code deficiencies cannot be immediately corrected or during periods of construction. The policy includes criteria for evaluating when and to what extent the hospital follows special measures to compensate for increased life safety risk. <br>

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

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

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

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

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.02.01 EP6 Provides additional firefighting equipment. The need for this equipment is based on criteria in the hospital's interim life safety measure (ILSM) policy.<br>

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.01.02.01 EP7 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>

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

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

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• 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>

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

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

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

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

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

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

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

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

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

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

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

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 ".

  Compliant

  Non-Compliant

  PFI

  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.

  Compliant

  Non-Compliant

  PFI

  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>

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The hospital maintains the integrity of egress.

• LS.02.01.20 EP 1 Doors in the means of egress are unlocked in the direction of egress

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.20 EP 2 Doors in a means of egress swing in the direction of egress in hospitals whose occupancy is 50 or more.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.20 EP 3 Walls containing horizontal exits are fire rated for 2 or more hours, extend from the lowest floor slab to the floor or roof slab above, and extend continuously from exterior wall to exterior wall

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.20 EP 4 Outside exit stairs are separated from the interior of the building by walls with the same fire rating required for enclosed stairs. The wall extends vertically from the ground to a point 10 feet or more above the top landing of the stairs or roofline (whichever is lower) and extends 10 feet or more horizontally.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.20 EP 5 Doors in new buildings that are a part of horizontal exits have approved vision panels and are installed without a center mullion.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.20 EP 6 When horizontal exit walls in new buildings terminate at outside walls at an angle of less than 180 degrees, the outside walls are fire - rated for 1 hour for a distance of 10 or more feet. Openings in the walls in the 10-foot span are fire-rated for 34 hr.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.20 EP 7 Stairs and ramps serving as a required means of egress have handrails and guards on both sides in new buildings and

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.20 EP 8 Exits discharge to the outside at grade level or through an approved exit passageway that is continuous and terminates at a public way or at an exterior exit discharge

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.20 EP 9 When stair doors are held open and the sprinkler or fire alarm system activates the release of one door in a stairway, all doors serving that stairway close.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.20 EP 10 Doors to new boiler rooms, new heater rooms, and new mechanical rooms located in a means of egress are not held open by an automatic release device.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.20 EP 11 In new buildings, exit corridors are at least 8 feet wide; in existing building, exit corridors are at least 4 feet wide. If modifying existing buildings with exit corridors that exceed 8 feet, the exit corridors cannot be reduced to less than 8 feet.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.20 EP 12 The corridor width is not obstructed by wall partitions.<br><br>(Note: When corridors are 6 feet wide or more, TJC permits certain objects to project into the corridor, such as hand rub dispensers or computer desks that are retractable. They must be no more than 36 inches wide, and cannot project more than 6 inches into the corridor. These items must be installed at least 48 inches apart and above the handrail height. NFPA 101-2000:18/19.2.3.3)

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.20 EP 13 Exits, exits accesses, and exit discharges are clear of obstructions or impediments to the public way, such as clutter (for example, equipment, carts, furniture), construction material, and snow and ice.<br><br>* Cannot exit through a suite - NO EXIT SIGNS directing a path through them

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.20 EP 14 Exit access doors and exit doors are free of mirrors, hangings, or draperies that might conceal, obscure, or confuse the direction of exit.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.20 EP 15 Floors or compartments in a building have two or more approved exits arranged and constructed to be located remotely from each other

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.20 EP 16 Patient sleeping rooms or suites of patient sleeping rooms larger than 1000 sq. ft. are provided with at least 2 exit access doors remotely located from each other.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.20 EP 17 Rooms or suites (not used as patient sleeping rooms) larger than 2,500 sq. ft. must have at least 2 exit access doors remotely located from each other.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.20 EP 18 Suites of patient sleeping rooms are limited to 5,000 sq ft and suites used for other purposes are limited to 10,000 sq. ft. These suites are arranged so that no intervening rooms are hazardous areas.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.20 EP 19 In suites of patient sleeping rooms, the travel distance to an exit access door from any point in the suite is 100 ft or less

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.20 EP 20 In suites not used as patient sleeping rooms that have up to one intervening room, the travel distance to an exit access door from any point in the suite is 100 feet or less, and in suites containing 2 intervening rooms is 50 ft or less.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.20 EP 21. Patient sleeping rooms open directly onto an exit access corridor.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.20 EP 22 Doors to patient sleeping rooms are not locked.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.20 EP 23 The travel distance to a room door from any point in a patient sleeping room is 50 ft or less.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.20 EP 24 In existing buildings, the travel distance between any room door and an exit is 100 ft or less (or 150 ft or less when equipped with an approved automatic sprinkler system). In new buildings, the travel distance between any rom door and an exit is 150 ft.or less.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.20 EP 25 In existing buildings, the travel distance between any point in a room and an exit is 150 ft. or less (or 200 ft or less when equipped with an approved automatic sprinkler system). In new buildings, the travel distance between any point in a room and an exit is 200 ft. or less.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.20 EP 26 In new buildings, no dead-end corridor is longer than 30 feet.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.20 EP 27 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.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.20 EP 28 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.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.20 EP 29 Stairs serving 5 or more stories have signs on each floor landing in a stairwell that identify the story, the stairwell, the top and the bottom, and the direction to and story of exit discharge. The signs are placed 5 ft. above the flor landing in a position that is easily visible when the door is open or closed.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.20 EP 30 Signs reading "No Exit" are posted on any door, passage, or stairway that is neither an exit nor an access to an exit but may be mistaken for an exit.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.20 EP 31 Exit signs are visible when the path to the exit is not readily apparent. Signs are adequately lit and have letters that are 4 or more inches high (or 6 inches high if externally lit)

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.20 EP 32 The hospital meets all other Life Safety Code means of egress requirements related to NFPA 101-2000:1819.2<br><br>* "Exit" from roof clearly identified and not locked.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

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

• LS.02.01.30 EP 2 All hazardous areas are protected by walls and doors in accordance with NFPA 101-2000:18/19.3.2.1 Food storage areas (Dry/Wet/Refrigerated/Frozen) - must be sprinkled by an AASS<br><br>* Must have self closers and be self latching

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.30 EP 3 Gift shops storing or displaying combustibles in quantities considered to be hazardous are separated by a 1 hour fire-rated walls and 3/4 hour fire rated doors.In existing buildings, a combination of walls and doors to limit the passage of smoke and an approved automatic sprinkler system may be used for gift shops storing or displaying combustibles in quantities considered hazardous<br><br>* No storage in mechanical rooms<br><br>* Emergency generator spaces - clean and neat, no storage of any type. Genset on"Auto" Lighting of space must be on emergency power

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.30 EP 11 Corridor doors are fitted with positive latching hardware, are arranged to restrict the movement of smoke, and are hinged so that they swing. The gap between meeting edges of doors is no wider than 18" and undercuts are no larger than 1 inch. Roller latches are not accepted.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• 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>

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.30 EP 23 Doors in smoke barriers are self-closing or automatic-closing, constructed of 1 3/4 inch or thicker solid bonded wood core or equivalent, and fitted to resist the passage of smoke. The gap between meeting edges of door pairs is no wider than 1/8", and undercuts are no larger than 3/4". Doors do not have non-rated protective plates more than 48" above the bottom of the door.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.30 EP 24 In buildings, exit stairs connecting 3 or fewer floors have a fire rating of 1-hour; exit stairs connecting 4 or more floors have a fire rating of 2 hours.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.30 EP 25 the hospital meets all other Life Safety Code fire and smoke protection requirements related to NFPA 101-2000: 1819.3<br><br>* Placement of ABHR dispensers<br><br>* Greater than 10 gallons of ABHR in a smoke compartment

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The hospital 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>

  Compliant

  Non-Compliant

  PFI

  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

  Compliant

  Non-Compliant

  PFI

  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.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.34 EP 4 Pull stations are unobstructed

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The hospital 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.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• 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.

  Compliant

  Non-Compliant

  PFI

  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.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.35 EP 9 Class K - type portable fire extinguishers are located within 30 feet of grease-producing cooking devices.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.35 EP 11, 12, and 13 The automatic fire extinguishing system for grease producing devices : <br> EP 11 Activates the building fire alarm system<br> EP 12 Deactivates the fuel source<br> EP 13 Controls the exhaust fans as designed

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The hospital provides and maintains operating features that conform to fire and smoke prevention requirements.

• LS.02.01.70 EP 1 The hospital prohibits all combustible decorations that are not flame retardant.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.70 EP 2 Soiled linen and trash receptacles larger than 32 gallons (including recycling containers) are located in a room protected as a hazardous area. No more than 32 gallons are allowable in a 64 sq. ft. area.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• LS.02.01.70 EP 3 The hospital prohibits portable space heaters within smoke compartments containing patient sleeping areas and treatment areas.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The hospital 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 hospital's facilities.

  Yes

  No

• 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 hospital's facilities.

  Yes

  No

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.01.01.01 EP 5 Hazardous materials and waste

  Yes

  No

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.01.01.01. EP 6 Fire Safety

  Yes

  No

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.01.01.01 EP 7 Medical Equipment

  Yes

  No

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.01.01.01 EP 8 Utility Systems

  Yes

  No

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The hospital manages safety and security risks

• EC.02.01.01 EP 1 The hospital 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

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.01.01 EP 9 The hospital has written procedures to follow in the event of a security incident, including an infant or pediatric abduction.

  Yes

  No

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The hospital prohibits smoking except in specific circumstances (Line in the Sand)

• EC.02.01.03 EP 1 The hospital has a no smoking policy<br>

  Yes

  No

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.01.03 EP 6 The hospital takes action to maintain compliance with its smoking policy

  Yes

  No

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The hospital manages risks related to hazardous materials and waste

• EC.02.02.01 EP 3 The hospital 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

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.02.01 EP 4 The hospital 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

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.02.01 EP 5 The hospital 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

• 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 hospital has the permits, licenses, manifests, and MSDS required by law and regulation.

  Yes

  No

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The hospital manages fire risks

• EC.02.03.01 EP 1 The hospital 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

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.01 EP 9 and EP 10 The hospital 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

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The hospital conducts fire drills.

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

  Yes

  No

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

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

  Yes

  No

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

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

• EC.02.03.05 EP 1 At least quarterly, the hospital tests supervisory signal devices (except valve tamper switches). <br>

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

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

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 3 Every 12 months, the hospital tests duct detectors, electromechanical releasing devices, heat detectors, manual fire alarm boxes, and smoke detectors. <br>

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

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

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

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

  Compliant

  Non-Compliant

  PFI

  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 hospital tests fire pumps under no-flow conditions. <br>

  Compliant

  Non-Compliant

  PFI

  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 hospital tests water-storage tank high-and low-water level alarms. The completion date is documented

  Compliant

  Non-Compliant

  PFI

  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 hospital test water - storage tank temperature alarms. The completion date of the test is documented

  Compliant

  Non-Compliant

  PFI

  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 hospital tests main drains at system low point or at all system risers. <br>

  Compliant

  Non-Compliant

  PFI

  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 hospital inspects all fire department water supply connections. <br>

  Compliant

  Non-Compliant

  PFI

  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 hospital tests fire pumps under flow. <br>

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

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

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

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

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 14 Every 12 months, the hospital tests carbon dioxide and other gaseous automatic fire-extinguishing systems. The completion date of the test is documented.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

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

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

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

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 17 The hospital conducts hydrostatic tests on standpipe occupant hoses 5 years after installation and 3 years thereafter. Completion date is documented

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP18 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>

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

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

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP20 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>

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.03.05 EP 25:Documentation of maintenance, testing, and inspection activities for fire alarm and water-based fire protection systems includes the following:<br><br>* Name of the activity<br>* Date of the activity<br>* Required frequency of activity<br>* Name and contact information, including affiliation of the person who performed the activity<br>* NFPA Standard (s) referenced for the activity (This information must be on ALL reports reflected in the Elements of Performance for EC.02.03.05<br>* Results of the activity <br><br>NOTE: Additional guidance on documenting activities, see NFPA 25, 1998 edition (Section 2.13) and NFPA 72, 1999 edition (Sectin 7-5.2).

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The hospital inspects, tests, and maintains medical equipment

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

  Yes

  No

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The hospital manages risks associated with its utility systems.

• EC.02.05.01 EP 5 The hospital 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

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

  Yes

  No

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

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

  Yes

  No

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

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

  Yes

  No

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The hospital has a reliable emergency electrical power source.

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

  Yes

  No

• 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

• 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

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

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

  Yes

  No

• 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

• 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

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The hospital inspects, tests, and maintains utility systems

• EC.02.05.05 EP 1 The hospital 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

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.05.05 EP 3 Life support utility system components on the inventory. Activities are documented<br>* Line isolation monitor inspections per manufacturer recommendations S/A.

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.05.05 EP 4 Infection control utility system components on the inventory. Activities are documented.<br>* Temperature logs on refrigerators<br>* Temperature logs on refrigerator/freezer/dishwashing

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.05.05 EP 5 Non-life support utility system components on the inventory. Activities are documented.<br>* Lightening protection inspection<br>* Exhaust hood cleaning/inspection certification sticker. Every 6 months

  Compliant

  Non-Compliant

  PFI

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The hospital 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

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.05.07 EP 6 Twelve times a year, at intervals of not less than 20 days and not more than 40 days, the hospital tests all automatic transfer switches.

  Yes

  No

  N/A

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The hospital establishes and maintains a safe, functional environment.

• EC.02.06.01 EP 1 Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment, and services provided.<br><br>* Compressed gas cylinders are secured properly<br>* Evacuation routes are posted and up to date<br>* Bulk O2 storge - free of debris,no storage of anything other than low level reserve tank/cylinders. Properly secured and out of direct sunlight.

  Yes

  No

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.02.06.01 EP 13 (CLD) The hospital maintains ventilation, temperature, and humidity levels suitable for the care, treatment, and services provided.

  Yes

  No

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

The hospital collects information to monitor conditions in the environment (EC Committee)

• EC.04.01.01 EP 1 The hospital 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

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.04.01.01 EP 12 The hospital conducts environmental tours every 6 months in patient care areas to evaluate the effectiveness of previously implemented activities intended to minimize or eliminate environment of care risks

  Yes

  No

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.04.01.01 EP 13 The hospital conducts annual environmental tours in non-patient care areas to evaluate the effectiveness of previously implemented activities intended to minimize or eliminate risks in the environment.

  Yes

  No

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion:

• EC.04.01.01. EP 15 Every 12 months, the hospital evaluates each environment of care management plan, including a review of the plan's objectives, scope, performance, and effectiveness.

  Yes

  No

• Isolated/Facility Wide:

• Corrective Action Plan:

• Responsible Party:

• Expected Date of Completion: