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Survey monitor: HVA and other disaster preparations receive scrutiny

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August 1, 2009

The Joint Commission’s 2009 life safety and emergency management chapters have proven to be focus areas for surveyors, at least based on a visit to Oregon State Hospital’s (OSH) Portland and Salem behavioral health campuses February 23–27.

The hospital retained its accreditation, with four direct impact findings spread across the 635-bed facility and 51 others under elements of performance (EP) with lesser criticality levels. Under The Joint Commission’s new scoring system, a facility the size of OSH could have up to 13 direct impact findings before citations affected accreditation.

Many of the indirect impact findings were related to EC and life safety standards. That isn’t a surprise, says Ted Ficken, quality improvement director at OSH, as the facility is fairly long in the tooth, with one of its buildings dating back to 1883.

Follow-up survey expected

At the time Briefings on Hospital Safety interviewed Ficken in June, the hospital was still within its 45-day period to rectify the indirect impact findings through the evidence of standards compliance process. Once that process is complete, the surveyors will come back to the facility.

“We were told we’d maintain full accreditation, but they intend to make another visit just to look at life safety and environment of care issues,” Ficken says. “My response to them was, ‘If we have full accreditation, then we don’t want to pay for a return visit,’ but they said it would be free.”

The combination of three sentinel events in the past year (after five years without any), new construction under way, and the age of the existing facilities probably influenced The Joint Commission’s decision to revisit OSH, says Ficken.

Emergency response plan reviewed

Ficken says he sent word out through the facility’s communications center that The Joint Commission (formerly JCAHO) was on its way after getting 30 minutes’ advance notice on the facility’s extranet site. Surveyors reviewed OSH’s emergency plan and found its hazard vulnerability analysis (HVA) “not completed to their satisfaction,” Ficken says.

This observation is in line with a warning given by George Mills, FASHE, CHFM, CEM, senior engineer at The Joint Commission, during a May Joint Commission Resources audio conference. HVA problems have been challenges for surveyed hospitals in 2009, Mills said.

At OSH, surveyors also required the facility to perform more testing on emergency generators that power a well on one of the properties. The well provides backup water if municipal supplies go down.

There was no tabletop exercise to test the facility’s 96-hour plan, which surveyors often conduct at acute care hospitals. However, with a new facility under construction—due to open at the end of 2011—surveyors wanted to know how the old facilities would deal with a surge of behavioral patients in a disaster.

The answer? “We wouldn’t take in new patients” until the completion of the new facility, Ficken says. Surveyors noted in the final report that they wanted that point written down in the emergency operations plan.

Issues noted by life safety specialist

The life safety specialist found several items that other hospitals preparing for upcoming Joint Commission visits might want to double-check:

  • Stairwell signs (LS.02.01.20, EP 29). Surveyors required more detailed wording for multistory buildings indicating what floor someone in the stairwell is on and the direction and story of exit discharge. OSH added more signs.
  • Vendor paperwork (various potential standards, such as EC.02.03.05). A contractor had conducted fire safety checks on behalf of the hospital but hadn’t filled out reports completely because dates or signatures were missing. OSH went back to the contractor and got the reports completed properly.
  • Electrical requirements (various potential standards, such as LS.02.01.70). Surveyors found inadequately labeled circuit breaker boxes, so OSH amended its signs at the breaker boxes.
  • Monthly portable fire extinguisher checks (EC.02.03.05, EP 15). Out of more than 500 fire extinguishers, three had not been checked in the month prior to the survey.
  • Water temperature (EC.02.01.01, EP 1). Eyewash stations with hot and cold taps weren’t regulated properly, which leaves open the potential to deliver water that could burn someone’s eyes. This is an interesting example of an item a life safety specialist noted that has little to do with fire protection requirements, a pattern that occasionally shows up during surveys.

Regarding the eyewash stations, Ficken says the facility disconnected the hot water tap, so it only runs cold.

Hospitals should be wary of this move, however, as eyewash provisions from the American National Standards Institute generally promote the use of tepid water. OSH also offers portable eyewash bottles that are always at room temperature.

Waiting out the old

Most of the issues uncovered in the survey won’t be concerns in the new, more modern facility OSH recently began building, Ficken says. Until it’s open, the facility can address all of its survey problems through fixes or small upgrades.

However, in some cases (e.g., exposed pipes under sinks acting as suicide risks), workers will need to address the danger through more frequent surveillance rounds.

“We’ve eliminated as much of [the risks] as we could—and could afford,” Ficken says. “For now, to keep patients and staff safe, we’ve got continuous rounds.”

Finally, Ficken offered this pair of pointers for EC folks:

  • Keep your periodic performance review detailed and up to date—by doing so, there won’t be many surprises come survey time.
  • Go over the 2009 standards, focusing on the life safety EPs. “[Surveyors] really paid attention to that,” Ficken says.



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