Observations will be made of the storage. knowledge of the hazardous materials. labeling the container to the use of. containers (which may range from

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1 PHYSICAL ENVIRONMENT STANDARD / ELEMENT EXPLANATION SCORING PROCEDURE SCORE Hazardous Materials - Routine Monitoring. Monitoring of hazardous materials and wastes is conducted to reduce the exposure potential to harmful agents. Routine inspections of the occupied areas of the hospital shall occur to observe and record how hazardous substances are stored, handled, and organized. Environmental tests are performed for substances that produce harmful vapors to ensure that engineering controls are adequate to provide a safe environment. Policies and procedures have been developed to comply with these Federal regulations. DOCUMENT REVIEW Review documented routine monitoring of hazardous materials e.g. ethylene oxide, nitrous oxide, halogenate analogous formylamide, etc. Observations will be made of the storage containers (which may range from labeling the container to the use of explosion proof cabinets), the availability and use of personal protective equipment, and staff knowledge of the hazardous materials and wastes program. 3 = Evidence of semiannual inspections only in last 12 months or two or more materials lack documentation of inspection. 4 = Non compliance Written Fire Control Plans. The hospital must have written fire control plans that contain provisions for: prompt reporting of fires; extinguishing fires; protection for patients, personnel and guests; evacuation; and cooperation with fire fighting authorities (b)(7) Self-explanatory. DOCUMENT REVIEW Review the hospital s written fire control plans to verify they contain the required provisions of the Life Safety Code or State Law. Verify that hospital staff reported all fires as required to State officials. INTERVIEW Interview staff throughout the hospital to verify their knowledge of their responsibilities during a fire (this is usually done during the LSC survey, but health surveyors may also verify staff knowledge). 1 = Plans in place that meet criteria. 2 = Plans in place but one criteria was not addressed. 4 = No plans or more than one criteria was missing. February 2005 (HFAP) Healthcare Facilities Accreditation Requirements for Healthcare Facilities 11-40

2 PHYSICAL ENVIRONMENT STANDARD / ELEMENT EXPLANATION SCORING PROCEDURE SCORE Ventilation, Light, and Temperature Controls. There must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas (c)(4) There must be proper ventilation in at least the following areas: Areas using ethylene oxide, nitrous oxide, guteraldehydes, eylene, pentamidine, or other potentially hazardous substances; Locations where oxygen is transferred from one container to another; Isolation rooms and reverse isolation rooms (both must be in compliance with Federal and State laws, regulations, and guidelines such as OSHA, CDC, NIAH, etc.); Excessive humidity in the operating room is conductive to bacterial growth and compromises the integrity of wrapped sterile instruments and supplies. Acceptable standards such as from the Association of Operating Room Nurses (AORN) or the American Institute of Architects (AIA) should be incorporated into hospital policy. Organization staff should obtain and be aware of current guidelines from the American Institute of Architects (AIA) and the Center for Disease Control (CDC). Verify that all food and medication preparation areas are well lighted. Verify that the hospital is in compliance with ventilation requirements for patients with contagious airborne diseases, such as tuberculosis, patients receiving treatments with hazardous chemical, surgical areas, and other areas where hazardous materials are stored. Verify that food products are stored under appropriate conditions (e.g., time, temperature, packaging, location) based on nationally-accepted sources such as the United States department of Agriculture, the Food and drug Administration, or other nationally-recognized standard. 2 = Same areas of hospital need correction and a program is in place to address needed corrections. 3 = Some areas of hospital need correction but no program in place to address needed corrections. 4 = Significant noncompliance. Pharmaceutical preparation areas (hoods, cabinets, etc.); and Laboratory locations. There must be adequate lighting in all the patient care areas, and food and medication preparation areas. Temperature, humidity and airflow in the operating rooms must be maintained within acceptable standards to inhibit bacterial growth and prevent infection, Verify that pharmaceuticals are stored at temperatures recommended by the product manufacturer. Verify that each operating room has temperature and humidity control mechanisms. DOCUMENT REVIEW Review temperature and humidity tracking log(s) to ensure that appropriate temperature and humidity levels are maintained. February 2005 (HFAP) Healthcare Facilities Accreditation Requirements for Healthcare Facilities 11-53

3 PHYSICAL ENVIRONMENT STANDARD / ELEMENT EXPLANATION SCORING PROCEDURE SCORE Americans with Disabilities Act The hospital has taken actions to comply with Federal laws dealing with the Americans with Disabilities Act. Facilities shall demonstrate through the development and implementation of policies and procedures that they have addressed the issues and spirit of the act. Self-explanatory. DOCUMENT REVIEW Review organization policies and procedures, tracking systems, and their ability to demonstrate compliance. Verify that the hospital complies with the Americans with Disabilities Act. 2 = Partial compliance with policies and procedures and physical plant modification. 3 = Marginal compliance with policies and procedures and physical plant modification. 4 = Non compliance Occupational Safety and Health Act (OSHA). The hospital has taken actions to comply with the Occupational Safety and Health Act (OSHA). Facilities shall demonstrate through the development and implementation of policies and procedures that they have addressed the issues and spirit of this act. Self-explanatory. DOCUMENT REVIEW & Review organization policies and procedures, tracking systems, and their ability to demonstrate compliance. 2 = Partial compliance with policies and procedures. 3 = Marginal compliance with policies and procedures. 4 = Non compliance Safe Medical Device Act (SMDA). The hospital has taken actions to comply with the Safe Medical Device Act (SMDA). Facilities shall demonstrate through the development and implementation of policies and procedures that they have addressed the issues and spirit of this act. Self-explanatory. DOCUMENT REVIEW & Review organization policies and procedures, tracking systems, and their ability to demonstrate compliance. 2 = Partial compliance with policies and procedures. 3 = Marginal compliance with policies and procedures. 4 = Non compliance. February 2005 (HFAP) Healthcare Facilities Accreditation Requirements for Healthcare Facilities 11-55

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