October 29, 2012 | | Comments 2
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And where it’s going, no one knows

Continuing on our recap of survey adventures, we finish out the Top 10:
EC.02.06.01 – Establishment and maintenance of a safe, functional environment (#9, with 32% of hospitals having been cited)
A couple of somewhat disparate conditions are coalescing under this particular standard:

  • Safety and suitability of interior spaces – this apparently is where the unsecured compressed gas cylinders are ending up when they are found during survey. Not necessarily the place I would have picked (I’d run with EC.02.01.01 EP #3 – minimization of safety risk in the environment), but I can see where it would fit;
  • Management of ventilation, temperature and humidity in the care environment – this is one that will cause you so much heartache, it’s not funny. Temperature and humidity logs? You better have ‘em (and yes, I know that they are not specifically required in the regulatory verbiage, but that doesn’t mean a (insert descriptor of your choice) thing. Trust me on this, if on nothing else, ever!) Make sure that you have extremely reliable pressure relationships in every spot where you’ve got clean/soiled environments cheek-to-jowl; clean/sterile; sterile/soiled, etc. The air has got to flow from the good to the bad (euphemistically speaking), if it flows from the bad to the good, you are going to get lit up like a Roman candle during survey, likely resulting in a CMS visit to boot – none of us want that, none of us at all.
  • Finally, and I don’t know that this got a whole lot of play in the official version, but there is a universal opportunity relative to cleanliness in the patient environment. There are some that I’ve seen who do a pretty good job, but I also know that I’ve not encountered anything close to perfect. If you have a surveyor with a mind to find dust, etc. somewhere in the patient environment, it will be found and it will be cited. Tell me the EVS folks aren’t shoveling against the tide sometimes…

EC.02.02.01 – Management of Hazardous Materials Risks (#10, with 29% of hospitals having been cited)
Lots of funky conditions can reside here, to name just a couple:

  • Management of eyewash stations – weekly checks, temperature, obstructions, where they are installed, etc.
  • Labeling secondary containers – if the chemical leaves its home vessel and is placed in another vessel, the second vessel (spray bottle, basin, sink) needs to have the hazard identified, unless the second vessel is absolutely attended until it is used/properly disposed – and even then, I’d do the label;
  • Access to the Hot Lab in Nuclear Medicine – you’ve got to have a policy that makes sense about access, particularly for couriers delivering the materials – and remember, they’re already driving around with the stuff – if they want to swipe the stuff, they’ll just keep driving – so keep an eye on your stuff (George Carlin would want you to). That said, you should track down the July 2012 edition of Perspectives – there’s a lovely article on just this subject – can you say risk assessment? Thought so.

OK, we’ll do one more for this week, breaking into the next 10
EC.02.05.01 – Managing risks associated with Utility Systems (#11, with 28% of hospitals having been cited)

For those of you with older buildings and/or older utility system components, this one may keep you up at night. The sort of overarching way this is popping up during surveys (other than temperature, humidity, and ventilation, about which we’ve already spoken and will, no doubt, speak of again) is the inability of the system (whichever system it might happen to be) to achieve required results. Now, the sticking point here relates very much to what constitutes a “required result”. In case you hadn’t noticed, CMS is pretty much calling the shots when it comes to enforcement and, with increasing frequency, the practice of grandfathering older, lesser-performing systems is going by the wayside. If you (or someone you love) has a utility system that is not performing up to modern standards, then you had best get going on a risk assessment and identify mitigation strategies for appropriately managing the risks associated with the current performance level of the systems (and, perhaps, a plan for how you’re going to get to where you need to be).

The other condition that has been popping up is the identification, in writing, of inspection and maintenance activities (and the appropriate intervals) for all operating components of utility systems on the utility management inventory (which is, of course, populated through an arduous risk assessment process). It’s my understanding that continuous monitoring through the good graces of a building automation system is an acceptable means of compliance with this requirement, but if you don’t have a building automation system, you’d best be prepared to produce, in writing, the activities and intervals as noted above (a computerized work order system might work – but it has to be a pretty robust platform).

And so we’ve reached the end of yet another batch of fun facts and figures – next week, we’ll wrap it all up – until next year!

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Steve MacArthur About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Briefings on Hospital Safety. Contact Steve at stevemacsafetyspace@gmail.com.

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  1. Does an eye wash station need to be in a designated “clean sink” or can it be in any sink. Some of our Labs only have one sink, so that sink is considered to be a dirty sink, so don’t know if we can have the eye wash station there or not.

  2. Hi Chris- managing editor Will Kilburn here. Good question– and here’s your answer, which Steve MacArthur provided recently to a similar question posed on a different thread here:

    “It really depends on the setup of the environment. The overarching concern is making sure that the eyewash is appropriately accessible (within 10 seconds of unimpeded travel time – which means no intervening doors). ‘Dirty’ areas are generally the locations with the greatest potential for an exposure, and if that area has only one sink, then that’s in all likelihood where the eyewash would best be installed.

    “If the area has a clean sink _and_ a dirty sink, then the clean sink would be the better option. Eyewash stations are designed with protective covers (which should be intact and in place at all times) that help ensure the eyewash doesn’t become contaminated along with the workers.”

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