Accreditation’s top tunes: The next batch

Moving on through the rest of the list (we’ll finish this up next week), again no surprises if you’ve been paying attention to the survey process over the last decade or so (this really started to gain traction round about ’09). I do wish I had a better sense of what the numbers were in terms of how often these conditions and/or practices were cited. I do know that they match up pretty closely to what I know to be the typical vulnerabilities in the field. My commentary follows each standard/performance element (as if you really needed me to tell you that).

NFPA Auto Extinguishment (L.2.1.35.14)

• Obstructed or blocked fire extinguishers and sprinkler heads
• Ceiling membrane gaps and unsealed penetrations
• Improper installation or maintenance of fire suppression equipment

This one is a little curious, but I think it’s good news; as there is a specific performance element that covers sprinkler heads, the fact that this represents a combination of sprinkler heads and fire extinguishers makes me think that maybe, just maybe, we’re doing a better job at the whole 18” storage concern. I will say that I see it much less frequently in the field (I always carry a tape measure when I’m touring—it’s fun to point out when the red line around a storage area or some such is actually at the wrong spot; or it’s not clear if we’re using the top or the bottom of the line).

As to gaps in the ceiling membrane, there are certain inevitabilities if there’s a suspended ceiling in, for example, an IT closet or the MRI equipment room. Also, as a related aside, for your construction projects in which the suspended ceiling has been removed and there are still sprinkler systems in the space, make sure you account for the potential impairment if the sprinkler heads are too far away from the deck above. You can certainly compensate for the impairment, but if you don’t call it out in your assessment, it can make for some uncomfortable conversations during survey.

Furnish-Equip Safe-Maintained (E.2.6.1.26)

• Damaged or degraded patient care equipment and furniture
• Environmental and facility maintenance issues
• Improper repairs or temporary fixes

As we noted last week relative to surfaces, there isn’t anything in a healthcare facility that can’t get busted (cue Ray Charles). And, as noted last week, there is no cloak of invisibility that comes into play when a piece of furniture or equipment is damaged. If something is broken, damaged, etc., there is no amount of tape that can effectively—and safely—correct the deficiency. If only we chased tape with the same vigor that was employed in the eradicating of cardboard … Again, I will “rest” this one on the notion that buildings are never more perfect than the moment before you let people in—after that … not so much perfection.

Haz Chemical Handling-Storage (E.2.2.1.5)

• Eyewash station accessibility and functionality issues
• Non-compliance with inspection and maintenance protocols
• Inadequate hazard controls and personal protective equipment (PPE)

Ah, this one. This is the one that always concerns me the most, mostly because it tends to end up being overcomplicated, but it really is very straightforward. 29 CFR 1910.151 Medical services and first aid (c): “Where the eyes or body of any person may be exposed to injurious corrosive materials, suitable facilities for quick drenching or flushing of the eyes and body shall be provided within the work area for immediate emergency use.”

As part of the OSHA Hazard Communication Standard, each employer has an obligation to know about the hazards in the workplace and to communicate the management of those hazards to staff. When it comes to the handling, etc. of chemicals, it really starts with the Safety Data Sheet (SDS). Think of the SDS as an extension of the manufacturer’s Instructions For Use; the information contained in the SDS is every bit as important, critical, etc. to the proper use of the chemical product. If the chemical product represents a risk of occupational exposure to an injurious chemical, then you have to have an eyewash station. If there is no risk of an occupational exposure to an injurious chemical, then an eyewash station is not required—but you have to know that that is the case. A risk assessment is the simplest approach, though you can get lost in a sea of risk assessments. Pick your moments (and pay extra special attention to the ambulatory care locations in your organization; that’s going to be the next area of intense scrutiny of the physical environment).

Also, a quick word about inspection and maintenance protocols (actually, two words). While I understand that compliance is more easily attained by assigning the weekly testing to a specific individual or department, I know in my heart of hearts that not having the folks who “own” the eyewash equipment do the weekly testing decreases the likelihood that they will have a clear understanding of how the device works, why it’s important not to park stuff in front of it, why it’s important to make sure the water pressure is good, etc. I am a great believer in the “hands on” approach to emergency equipment, particularly if there is a fair potential for it being needed. Face it, folks don’t use PPE as often as they should (I’ve seen too many pairs of pristine safety glasses hanging in closets, etc.). Knowing how to get to the eyewash equipment, basically with your eyes closed, could be the only defense against a catastrophic injury.

Closing thought: the American National Standards Institute (ANSI) standard for emergency eyewash and shower equipment recommends annual maintenance of said emergency equipment, basically ensuring that the installation specifications are met. You might want to schedule that PM in your work order system if haven’t already done so.

Dedicated Sprinkler Piping (L.2.1.35.4)

• Sprinkler piping used to support other items
• Immediate onsite correction and compliance documentation

If your facility has spaces that are older than last week, it is more than likely that there is something attached to, hanging over, etc. a sprinkler pipe or the sprinkler piping supports. This one’s kind of like a Life Safety Commandment: thou shalt not have anything touching a sprinkler pipe! I don’t know if it’s gravity or the constant upgrading of information systems and associated cabling, but, like dusty sprinkler heads, there’s always at least one. And if you can find one, you can usually find more. There’s no easy way to police this, and you can tell the contracted cabling folks until you’re blue in the face, it’s still going to happen. In fact, it’s happening right now … somewhere.

Fire Barrier Penetration Seal (L.2.1.10.14)

• Unsealed or improperly sealed penetrations
• Use of non-compliant materials

In some ways, this is the most ancient of physical environment findings (I suppose eyewashes might be in this hallowed group, along with corridor clutter). If Life Safety compliance had a classic rock station, unsealed or improperly sealed penetrations would be played at the top of every hour (and most of the rest of the hour). I think the important piece of this is to have a very clear understanding of what does and does not constitute a compliant assembly and for that, you need to consult the Instructions For Use for the firestopping product being used. There is a right way to use the stuff and then there are the other ways—for example, no mixing of materials, make sure you can access the specifications for the product if you have “unusual” colors of firestopping products. In fact, if you have multiple colors above your ceilings, take pictures of the products and do a little session with the surveyor before they start the above-ceiling survey. Let them know what they’ll be seeing; it also serves as evidence that you’ve looked, too!

That’s it for this week, but please come back next time for our (almost) exciting conclusion.

About the Author: Steve MacArthur is a safety consultant with The Chartis Group. 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 an advisory board member for Accreditation and Quality Compliance Center. Contact Steve at stevemacsafetyspace@gmail.com.