Just a quick little list of recent survey findings – not necessarily having anything to do with the Top 20 most frequently cited standards. That said, I do think that this provides ample indication that the survey process is intent on identifying any EC/LS/EM deficiency that could be lurking in the furthest (farthest?) regions of your facility. So, how about:
Have you included (those of you who have them) lightning protection systems in your Utility Management inventory – or completed a risk assessment that indicates inclusion in the inventory is not appropriate?
Do you still maintain (at least) one hard copy of your organization’s Material Safety Data Sheets? If not, what’s your backup and how do you know it’s effective?
What about those rooftop exhausts for isolation rooms—have they been labeled? The biohazard symbol on your rooftop exhausts (or any isolation exhausts) makes quite a statement – and never goes out of style.
What about those flexible and rigid endoscopes? Have you included them in your medical equipment inventory or completed a risk assessment that indicates inclusion in the inventory is not appropriate?
How about those electrical receptacles in locations within 6 feet of sinks and other water sources—are they on GFCI protection? Could be the outlet, could be at the panel, but you need to know, ‘cause if you don’t…
Those of you who are performing manual disinfection of patient care devices / instruments, most frequently using an OPA product: Have you evaluated the process as a function of what is actually required by the manufacturer? This is a very complicated process (with lots of steps to go awry) and perfection is not merely the goal, it must be attained at every step, every time. Perfect, perfect, perfect…
What about those open floor plan areas (frequently ED’s, ICU’s, PACU’s, OR’s) where staff have all manner of equipment and stuff parked outside the rooms (hopefully not obstructing access to the zone shutoff valves) – have you officially designated those areas as suites, and updated the life safety drawings to reflect that designation? If you haven’t, that’s a survey slam dunk for an RFI – better get on it!
I know we’ve spoken of this in the past (or at least I think we have), you have to pay very close attention to the ins and outs of LS.02.01.30 EP #2, which has to deal with combustible storage areas greater than 50 square feet in area. (Storage room = door that self or auto-closes and latches.) And if there’s a “former” patient room (including procedure rooms in the OR, etc.) that’s been converted to storage (particularly if the conversion occurred after March, 2003), then you are looking at the requirements for “new” healthcare, which means sprinklers, one-hour walls, with a 45 minute fire-rated door. I know folks are trying to minimize corridor clutter, but you get right into a whole ‘nother pickle if you don’t watch for these kinds of transformations.
Anything ring any bells for anyone? Might be worth a little mental checklist to make sure you’ve got these areas covered.