Tag: Survey Readiness

There are thousands of health care facilities in the United States. I imagine there are mock surveys and actual surveys everyday somewhere. And during each one, many regulations and requirements are checked for compliance. An increasing focus is being paid to regulated medical waste or RMW.

Most health care facility professionals understand the need to be familiar with the regulatory complexities of managing waste. In Environmental Services we deal with a lot of waste, including RMW.

There are many regulations and standards, including the Joint Commission’s Leadership (LD), Environment of Care (EC) and Emergency Management (EM) standards, as well as the federal Department of Transportation, Environmental Protection Agency and many state and local rules and regulations.

Quite a few of the standards related to regulated medical waste can be found in these standards:

  • LD.04.01.01
  • EC.01.01.01 (EP 5)
  • EC.02.02.01 (EP 11, 12)
  • EC.04.01.01 (EP.01, 8, 15)
  • EM.02.02.05 (EP 4)

An organization can be fined thousands of dollars per day per violation by local, state and federal authorities if it is found noncompliant with waste regulations. Many of these fines vary by state. It is very important to be familiar and understand your own state’s current and emerging regulations to avoid these costly fines and remain a compliant leader within the health care industry and their community

What? You are housekeeping, not plant operations! Why should you care about life safety you ask?

For 2011, all hospitals, including critical access hospitals, will have a life safety surveyor for at least two days of a Joint Commission survey. Those hospitals with more than 1.5 million square feet will have a third day. Yet an additional day will be added for every three buildings classified as health care occupancy. This is considerably more than we are used to and it is not enough to be focused on cleaning. We in environmental services are the only department in a hospital to service every patient room daily, and all other areas at least periodically. We are the eyes for every facility service department.

So what are the areas we should be looking at during our daily cleaning and rounding.

  1. Penetrations: Holes in walls, ceiling tiles, and around fire sprinklers. These tend to happen and often get overlooked. Make a point of looking around and putting work orders in.
  2. Doors: The majority of fire, smoke and corridor doors will be checked. Make sure they positively latch. My staff close each patient door on a regular basis and makes sure they latch. We tell the patients that we are checking the door for proper operation for their safety. It is appreciated. This is a good time to check the hardware and look for missing screws. Yes, missing screws in the hinge have been found on many survey’s.
  3. Look up: Sure holes in ceiling tiles are important to correct, and so are stained or broken tiles. Get those reported and changed. Also ceiling grilles and diffusers are being checked for dust accumulation. Same goes for fire sprinklers. Dust and dust bunnies are just not appreciated anymore.
  4. Corridor Clutter: Recent inspectors are coming down hard on hospital clutter. The only items allowed to keep in corridors are code and isolation carts and equipment in use, E.G. not stationary for more than 30 minutes. Other than those you need to maintain either the 4’ or 8’ clear corridor width.

There certainly can be more things our staff can find that need to be corrected. If you are not already on board start with one area and build on it.

We had our “long awaited” Joint Commission Survey the beginning of this week. It seemed like forever, waiting for them to arrive… not really. While it might have seemed like a long time, it really was just another week for a hospital that prides itself on being the best possible caregiver to meet the physical, and spiritual needs of the community.

Environmental Services is the department that cleans, disinfects, and fights infection in every hospital. ES for short, is a department that touches every aspect of a healthcare facility, every patient, every staff member and every visitor. My team is no different, but we try to be different in one aspect; we don’t “get ready” for survey’s like The Joint Commission, or CMS, we practice survey readiness everyday.