28.1 Facilities
1. The healthcare organization shall maintain safe and adequate facilities in accordance with national and local laws, regulations, and guidelines that reflect the scope and complexity of the services offered in accordance with recognized standards of practice.
2. The healthcare organization facilities shall be constructed, arranged, and maintained to ensure the safety of all persons. It shall be designed to provide facilities for diagnosis and treatment within the intended scope of services.
3. Pertinent information and data regarding the safe management of the physical environment shall be distributed regularly for the healthcare organization management oversight.
4. The healthcare organization shall have written policies and procedures address and control the following six processes: Life Safety, Security, Emergency Management, Hazardous Materials (HAZMAT), Medical Equipment, and Utility Systems.
5. The complexity of facilities shall be determined by the scope of services offered.
NOTE 1 "Adequate facilities" means the healthcare organization has facilities that:
a) allow safe access for all persons including those with disabilities and special needs;
b) designed and maintained in accordance with regulatory requirements and healthcare organization policy;
c) designed and maintained to reflect the scope and complexity of the services it offers in accordance with recognized standards of practice.
d) provides clear signage, direction boards and/or adequate parking space. Certain areas of the healthcare organization may be required to have external sources responsible for maintaining treatment areas and the healthcare organization will ensure that these services are providing a safe environment for all staff, patient, and visitors.
28.2 Life and Fire Safety Process
28.2.1 Life Safety
1. The healthcare organization shall develop, monitor, and maintain a Life Safety process that provides a healthy, safe, and hazard-free physical environment.
2. The healthcare organization shall conduct periodic surveillance of the facility and grounds to identify life safety issues and concerns in order to take corrective actions as needed.
3. The healthcare organization shall develop and enforce a tobacco-free policy in all facilities and other areas under the organization’s responsibility. This shall include all recreational inhalants (vapor). Substantial progress toward complete conformity shall be demonstrated.
4. The healthcare organization’s management shall receive documented information with respect to life safety issues that affect the organization’s processes.
5. The healthcare organization shall have a written policy that addresses safety recalls and alerts.
6. The healthcare organization shall assess, document, and minimize the impact of construction, repairs, or improvement operations upon occupied area(s). The assessment shall include provisions for infection prevention and control, utility requirements, noise, vibration, and alternative life safety measures. These measures shall be undertaken with the supervision and oversight of infection prevention and control, including any national law or regulatory requirements relating to life safety.
28.2.2 Fire Safety
1. The healthcare organization shall develop and follow a Fire Safety Process to ensure that all fire safety requirements of National law or other regulatory agencies are met.
2. The healthcare organization shall have written fire management plans that contain provisions for:
a) reduction of fire risks;
b) prompt reporting of fires;
c) protection of patients, personnel, and visitors;
d) detection of fire and smoke by use of alarms including their transmission to fire department, as well as response to alarms;
e) extinguishing fires;
f) cooperation with firefighting authorities;
g) isolation, abatement of fire and smoke containment;
h) evacuation procedures of personnel from proximate and smoke compartment areas;
i) safe and unobstructed exit from the healthcare organization when fire emergencies occur.
3. The healthcare organization shall ensure buildings are designed and constructed with suitable fire compartmentation to prevent fire and smoke spread, particularly where there is a life safety risk to patients are receiving overnight care. Where improvement works, and penetrations are undertaken to existing buildings and fire compartmentation integrity is compromised the healthcare organization shall have adequate procedures to ensure appropriate fire stopping is completed, documented and inspected.
4. The healthcare organization shall maintain written evidence of regular inspections and approval by all applicable fire control agencies and applicable national and local law and legislation. This evidence shall be maintained as documented information.
5. Fire drills and evacuations shall be conducted regularly according to healthcare organization policy. The healthcare organization shall oversee and evaluate the effectiveness of the fire drills.
28.3 Security Management Process
1. The healthcare organization shall develop and maintain a Security Management Process that provides a secure physical environment, including the identification and monitoring of security issues within the healthcare organization.
2. The healthcare organization shall implement a written policy that prohibits harassment/mobbing in the workplace. The policy shall address employee awareness, on-going training, and investigation of harassment issues, as well as management of a violence prevention program. It shall also ensure a confidential grievance procedure for all employees. (See STANDARD 3.2.)
3. The Security management process shall ensure that all patients, staff, visitors, and others are identified as stated below:
a) all patients shall be identified by using 2 patient identifiers for have wrist band or similar identification;
b) all internal staff shall be identified by visible ID badge;
c) all external providers shall register and display an appropriate ID badge;
d) all visitors shall register if required by the healthcare organization policy.
NOTE 1 Unidentified persons should be assumed to be visitors.
28.4 Emergency Management Process
1. The healthcare organization shall develop and utilize an Emergency Management Process to address the safety and wellbeing of all persons in emergency situations.
2. The healthcare organization in conjunction with the community shall conduct a hazard vulnerability analysis (HVA) to identify any potential emergencies.
3. The Emergency management processes shall address alternative means to support and maintain all essential building functions including electricity, water, ventilation, fuel, medical gas and vacuum systems, and other identified utilities (see STANDARD 28.8). This process shall include relevant required maintenance procedures and inspection logs.
4. There shall be emergency power and lighting in at least the operating suites, recovery, intensive care, and emergency rooms, and all fire evacuation routes including stairwells. In all other areas not serviced by the emergency supply source, battery lamps and flashlights shall be available.
5. The Emergency Management Process shall include memorandums of understanding for utilization of resources (space, personnel, and equipment) with local and regional healthcare facilities and public health agencies in cases of organizational, community, or regional crisis.
6. Emergency management exercises shall be based upon the most probable emergencies or other circumstances that may impact the healthcare organization and the community. A report shall be created after each exercise and distributed for healthcare organization management oversight. This report shall document excellence and opportunities for improvement. (See STANDARD 10)
7. The healthcare organization’s emergency management process shall be revised as necessary and in accordance with changing circumstances and any identified opportunities for improvement.
NOTE 1 The "community" represents local, regional, national public safety forces and/or public health agencies and officials.
28.5 Hazardous Materials (HAZMAT) Process
1. The healthcare organization shall develop and maintain a HAZMAT process within its environment of care that addresses the risk from materials and substances that includes:
a) management and utilization;
b) selection;
c) labeling and documentation;
d) storing;
e) security;
f) handling;
g) transportation;
h) disposition of hazardous materials and waste.
The HAZMAT process shall be consistent with national and local law, regulation and STANDARD 2.6.
2. The healthcare organization shall maintain a hazardous materials and waste inventory.
3. The healthcare organization shall ensure investigation and reporting of spills, exposures, and other incidents.
4. All healthcare facilities and their associated agencies shall not introduce hazardous waste pharmaceuticals into the sewer systems or other channels leading to environmental waterways by flushing or similar action. Alternate plans for the management of hazardous waste pharmaceuticals shall be developed and put into use.
5. The healthcare organization shall ensure the provision and use of personal protective equipment for all personnel when at risk of exposure to hazardous materials and waste.
6. HAZMAT exposure levels shall be monitored, measured, and addressed as needed for all persons as indicated by the appropriate MSDS (Manufacturer’s Safety Data Sheet).
7. The healthcare organization shall meet the following requirements for the installation and use of alcohol-based hand rub dispensers:
a) dispensers shall be permitted in carpeted floor locations only in sprinkled smoke compartment environments;
b) dispensers shall be permitted as allowed by law and other associated regulations.
8. Alcohol-based prep solutions used in anesthetizing areas are a potential fire hazard and shall be used in accordance with the manufacturer’s recommendations. Details of use and compliance with this standard shall be recorded in the medical records.
9. The healthcare organization shall establish processes to ensure that contaminated and potentially contaminated bio hazard waste is identified, handled, recorded and stored effectively in order to prevent contamination of other areas.
10. When transporting and storing waste, the healthcare organization shall take measures to prevent and mitigate any hazard related to the following by:
a) providing adequate facilities and procedures for the short and long-term storage of waste;
b) ensuring that appropriate containers and other materials are used during storage and transportation (e.g. carts, bags, sharps containers);
c) adequately segregating waste to minimize risk of contamination;
d) addressing the potential of drug diversion.
NOTE 1 The organization should categorize HAZMAT sources of waste and their means of disposal including but not limited to:
a) clinical waste including body fluids as circumstances indicate;
b) medical equipment;
c) needles, syringes and sharps;
d) clothing and PPE;
e) paper and plastic waste;
f) waste water, including that from sinks and showers;
g) air filters and air handling systems;
h) discarded equipment used in the healthcare facility;
i) pharmaceutical waste.
28.6 Medical Equipment Process
1. The healthcare organization shall develop and maintain a medical equipment process that provides for selection, safe use, inspection, testing, and maintenance of equipment to ensure an acceptable level of safety and quality. A qualified individual shall monitor, test, calibrate, and maintain the equipment periodically. These requirements shall be based on risk assessment, in accordance with the manufacturer’s recommendations, risk-based industry practices and/or healthcare organization experience, applicable laws, or regulations.
2. This process shall also address medical equipment inventory and identification, as well as an equipment alert/recall system in use. The process shall also provide for initial service inspections, proper training, and demonstration of use for rental and physician owned equipment, as well as the criteria for the selection of medical equipment.
NOTE 1 As a part of this risk assessment process to determine maintenance intervals that consider safety, equipment availability and service life the following should be considered:
a) consulting manufacturer recommendations;
b) applicable codes and standards or accreditation requirements;
c) health and safety information relevant to potential hazards;
d) appropriate training and education of staff regarding the use of equipment;
e) likelihood of an injury or illness occurring and the likely severity of any injury;
f) illness resulting from the use of equipment.
28.7 Utility Systems Process
1. The healthcare organization shall maintain an Utility Systems Process that ensures the safe and reliable access to all required utilities necessary for the scope of services provided. Memorandums of agreement shall be developed and maintained accordingly. These shall be in keeping with the life safety requirements of STANDARD 28.2.
2. The healthcare organization shall identify critical operating components for quality control and have methods for regular maintenance, inspections, and testing of all utility systems.
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