10/28/2015. Enjoy Your TJC Survey. Bill H. McCully CHFM SASHE. Senior Consultant MSL Healthcare Partners. MSL Healthcare Partners, 2015 PREPARATION

Transcription

1 Enjoy Your TJC Survey Bill H. McCully CHFM SASHE Senior Consultant MSL Healthcare Partners PREPARATION 1

2 Top Eight Most Cited Standards (George Mills) EC News May 2015 Top Citations EC % EC % IC % LS % EC % LS % LS % EC % 4 2

3 Top Eight Cited Standards 1. EC EP s 1 and 13 Unsecure gas cylinders Mixed O2 Cylinders, no signs Electrical Panels, blocked, unmarked, unlocked. Extension cord, tripping hazard. Lack of humidity monitoring, EP 13. Pressure relationships, EP 13. EC EP 15 56% Utility System Risks Number 2 on the list EP 15 Pressure Relationships Air Balance and Air Exchange Testing Automatic Condition Level EP 1 SEPSS in Generator Room, lack of pump supervisory signal, extension cord installation. 6 3

4 LS Means of Egress Number Three on the list: EP 13 Egress obstructions EP Egress illumination EP 29 Stair signage 5+ floors EP 30 No Exit signs Suites, dead end corridors, travel distance, etc. 32 EP s in this standard. 7 Pop Quiz 1. If an organization uses automatic release devices and to hold stairway doors open, and the sprinkler or fire alarm system activates the release of one door then. a. all doors serving the stairway must close b. only the affected door must close c. the affected door and the doors immediately above and below it must close. 8 4

5 The Correct answer is: A All doors serving the stairway must close. Organizations can choose to hold stairway doors open with automatic release devices such as magnetic sensors as long as these devices connect to the fire alarm system. When any device activates the system all doors in the stair enclosure must close. LS, EP 9 9 # 4 EC EP s 1 25 Fire Safety Testing EP 1 Supervisory Circuits EP 2 Tamper and Flow switches EP 3 Duct, heat, & smoke detectors, Electromechanical releasing devices, manual pull stations. EP 4 Visual and audible devices EP 5 Off site reporting 10 5

6 EC Cont. EP 6 Fire Pump Weekly Churn EP 7 Water Tanks Water Level EP 8 Water Tanks Temperature EP 9 Main Drains EP 10 Fire Department Connections EP 11 Fire Pump full flow tests EP 12 5 year standpipe flow test 11 EC Cont: EP 13 Kitchen Hood Systems EP 14 Other fire extinguishing gas systems. EP 15 Monthly portable fire extinguishers EP 16 Annual Maintenance for Portable fire Ext. EP 17 Fire Hoses EP 18 Fire and smoke dampers EP 19 AHU Shutdown 12 6

7 EC Cont: EP 20 Sliding and rolling fire doors. EP 25 Name and date of activity, frequency, name and contact of the contractor and person, NFPA standard, and results of the activity. 13 POP Quiz An organization must create EC management plans that govern safety, security, hazardous materials, fire, and. a. information systems, and human resources b. medical equipment, and utilities c. supply chain, and communications 14 7

8 The Answer is B B, medical equipment, and utilities. To ensure a well-functioning environment, organizations must have high-level written management plans that guide operations in the following areas: safety, security, Haz. Matls., fire, Med. Equip., and utilities. These plans should provide an operational roadmap that anyone can read to get a sense of how the organization manages the EOC. EC EP LS Building Fire Protection Features Number Five on the list EP 5 Doors EP 9 Penetrations EP 4 Openings in 2 hour walls, Painted door labels. 16 8

9 LS Building Features Number Six 25 EP s deals with hazardous areas, corridor partitions, doors, openings, smoke compartments, etc. 17 POP Quiz An organization can use a tabletop emergency management drill in which of the following circumstances? a. In any emergency management exercise b. Only during an exercise involving an influx of simulated patients. c. Only during the community portion of an escalating event exercise 18 9

10 The Answer IS C Only during the community portion of an escalating event exercise. Although they are useful, tabletop drills are not meant to fully teat all aspects of an organizations Emergency Operations Plan. 19 LS Extinguishing Systems Number Seven EP 4 Sprinkler piping support EP 5 Sprinkler heads, corrosion, dirty, and foreign materials. EP 6 18 inch rule EP 14 Meets all other LSC, Blocked Fire Ext., Missing Escutcheons in ROOMS

11 EC Hazardous Materials Number Eight EP 5 Eye wash issues EP 7 Lead apron logs, MRI signage and screening. EP 9 Labeling Exhaust Fans EP 10 OR Waste Gas, Nitrous, etc. 21 QUESTIONS BILL H MCCULLY CHFM SASHE SENIOR CONSULTANT MSL HEALTHCARE PARTNERS, INC BMCCULLY@MSLPARTNERS.COM