TJC Environment of Care Survey Tool for Ambulatory Care 2009

Area: Surveyor 1: I. Date: Surveyor 2: Manager: Score:

The organization plans activities to minimize risk in the EOC.

EC 01.01.01 Answers

1. Management Plans found in the Red Book are current and complete 2. Fire Safety 3. Emergency Management Subplan including internal security code. 4. Disruption of Service 5. Tornado 6. Emergency Response Guides are posted.

Must use standard template or include ALL the requirements Must include location or weather radio where applicable

II. The organization manages safety and security risk.

1. The clinic has a security plan to respond to security emergencies and threats. 2. Staff can articulate the key points of the plan. 3. Access to the clinical area or other sensitive areas is controlled. 4. If the clinic has panic alarms they are tested at regular intervals. 5. Staff can articulate when to activate a panic alarm and when to call 911. 6. There has been a security drill (Code Pink or Gray) in the last 12 months. 7. All employees are wearing their photo ID badges above the waist. 8. All doors but the front doors are locked from the outside to prevent unauthorized access. 9. Prescription pads are either kept with providers or locked up.

EC.02.01.01 Answers

Must have a means to communicate a security emergency that would not alert patients/visitors Includes when to use Security Code, what to do once one is activated Where possible based on physical structure of clinic Recommend monthly Panic alarms are for when you cannot safely call 911

III.The organization prohibits smoking. EC.02.01.03

1

1. Tobacco free signs are posted in front of the facility

IV.

The organization manages risks related to hazardous materials and wastes. Answers
Includes MSDS for all medications not in pill form.

1. The clinic has a current chemical inventory and matching Material Safety Data Sheets. 2. All chemicals containers have the appropriate labels. 3. Staff using hazardous chemicals knows who to call for disposal. 4. Clinics using high level disinfectants and formalin have Neutralex available for spills 5. High Level Disinfection (HLD) is done in a well ventilated area using a closed or covered system. 6. Clinics doing high level disinfection have properly installed emergency eyewashes. 7. Clinics with emergency eyewashes check them weekly. 8. Clinics have appropriate PPE available for patient care, procedures and handling of chemicals 9. Gloves powder free low protein latex or nitrile 10. Gowns 11. Full Face protection 12. N95 respirators or PAPRs 13. Staff can articulate the 4 steps to cleaning up blood 14. Clinic has an approval spray disinfectant for blood spills (not wipes). 15. Staff knows what to do if they sustain a blood or body fluid exposure. 16. When available, only safety devices are used for injections, phlebotomy and cutting. 17. Needleboxes are secured and not overfilled. 18. Bag/valve/masks are available in appropriate sizes for clinic population.

694-2794 Ask for Environmental Programs

Eyewashes must be accessible, i.e. cannot be installed under cabinets.

Nitrile required for clinics that use HLD Masks/goggles, mask/shield combinations, full face shields glove, absorb, clean and disinfect

Call Blood and Body Fluid Hotline 684-8115, fill out SRS

No table top or floor boxes unless secured

19. All staff responsible for shipping specimens outside of Duke have had the required shipping training in the past 2 years. 20. Pick up sheets and certificates of destruction are available for regulated medical wastes. 21. There is no eating or drinking in areas where blood, body fluids or chemicals are handled. 22. Oxygen and other compressed gasses are stored appropriately. 23. One oxygen tank is designated for emergency use only. 24. Staff knows how to manage known or suspected TB patients to prevent exposure. 25. Duke Clinic Building only staff can articulate what to order from Equipment Supply when they have a known or suspected TB patient. 26. Staff can articulate the policy for use of N95 respirators in their clinic. For Clinics With Lasers.. 1. All staff working with lasers has had laser safety training in the past 12 months. 2. Staff knows what PPE to wear when working with lasers. 3. Appropriate Laser PPE is available. 4. There is correct Laser signage available for posting, when the laser is in use, on or over the doors to the laser rooms For Clinics With Diagnostic X-Ray 1. There is a written Radiation Safety SOP that is signed annually by all the techs and responsible physician in clinic 2. Current registration is available 3. PM documentation within the past 12 months 4. Caution Radiation sign is posted 5. Pregnancy warning is posted 6. Technique chart is posted 7. All staff are wearing dosimeter badges on

their collars 8. Dosimeter badge reports are available and current 9. Control badges are stored OUTSIDE of radiation area 10. Radiation PPE is checked and documented annually 11. Radiation PPE is stored correctly

Not in control roomin clinic

V. The organization manages fire risks EC.02.03.01 VI. The organization conducts fire drills EC.02.03.03 VII. The organization maintains fire safety equipment and fire safety building features EC.02.03.05 Answers
1. 2. 3. 4. Staff can articulate RACE RACE signs are posted Staff can articulate PASS Fire extinguishers are clearly visible and not blocked 5. Staff, including LIPs can articulate their specific role in a fire 6. Staff knows how they are notified of or how to communicate the presence of a fire in their clinic 7. Staff knows where the pull stations are located 8. Combustibles are stored away from ignition sources 9. Alcohol hand hygiene products are not mounted over electrical outlets or equipment 10. Alcohol hand hygiene products are not mounted over carpet in nonsprinkled buildings. 11. All items are stored 24 inches from the ceiling (non sprinkled building) or 18 inches from sprinkler heads in sprinkled buildings 12. Exit hallway egress is not blocked or compromised 13. Doors are not blocked nor locked from the inside unless a push bar or similar device is present or they release with the fire alarm

e.g. paper products are not stored up next to water heaters.

14. In Business Occupancy fire drills are conducted every 12 months 15. Ambulatory surgery centers have quarterly fire drills 16. Fire Drill reports are sent to Fire Safety 17. Fire Plan includes the roles of staff and licensed independent practitioners 18. If there is construction in the building then Fire Safety has been notified and Interim Life Safety measures have been implemented as appropriate 19. All testing and maintenance records of the fire system and its components are on site for review during the survey 20. Staff can articulate how to dispose of battery operated cautery devices.

50% of these must be unannounced. Keep originals, fax copy to 684-8427

This refers to documentation of fire suppression systems, alarms, etc.

Using forceps or other device and wearing eye protection break off metal tips and place in needlebox. Dispose of handles in regular trash.

VIII. The organization manages medical equipment risks

1. All Duke equipment has a current PM tag 2. PM records are available and current on all leased equipment 3. Staff knows what to do in the event of equipment failure 4. Staff can articulate the weight limits (i.e. maximum weight) for: a. Radiology Equipment b. Exam tables / chairs and wheelchairs c. Waiting room furniture

EC.02.04.01 Answers

IX. X. XI.

The organization manages risks associated with utility systems EC.02.05.01 The organization inspects tests and maintains utility systems EC.02.05.05 The organization inspects tests and maintains medical gas and vacuum systems EC.02.05.09 Answers

1. Electrical panels have 36 inches of clearance in

all planes (clear access 36 deep x 36 wide x 78 high for working space) 2. Electrical boxes have no open slots and are labeled

3. Clinics that see children either have tamper proof outlets or plugs in all public access outlets. 4. Cords and power strips are off the floor. 5. Staff can show you the location of their emergency gas shut off valves 6. Valves are labeled correctly 7. Documentation is available that shows that the organization inspects, tests, and maintains critical components of piped medical gas systems 8. Documentation is available that shows that the organization tests piped medical gas and vacuum systems for purity, correct gas and proper pressure whenever these systems are installed, modified or repaired-date is documented

XII. The organization has a reliable emergency electrical power source EC.02.05.03 XIII. The organization inspects, tests and maintains emergency power systems (where applicable) EC.02.05.07 Answers
1. Emergency Lights are checked monthly for 30 seconds and annually for 90 minutes documentation is current 2. If no EM lights the flashlights and batteries are available 3. Clinic has documentation that 12 times a year at intervals not less than 20 days and not more than 40 days the emergency generator is tested for 30 continuous minutes 4. Documentation shows that emergency generator tests are conducted with a dynamic load that is least 3o% of the nameplate rating of the generator or meets the manufacturers recommended prime movers exhaust gas temperature. If not then it must test each EG

once every 12 months using supplemental (dynamic or static load) of 25% of nameplate rating for 30 minutes followed by 75% of nameplate rating for 60 minutes for a total of 2 hours of continuous testing 5. Documentation shows that 12 times a year at intervals not less than 20 days and not more than 40 days the organization tests all automatic transfer switches 6. Documentation shows that at least once every 36 months test each emergency generator for a minimum of 4 continuous hours. This test shows a dynamic or static load that is at least 30% of the nameplate rating of the generator or meets manufacturers prime movers exhaust gas temperature 7. If emergency power fails the organization documents a retest after making the necessary repairs or corrections

XIV. The organization establishes and maintains a safe, functional environment Answers
1. The clinic is clean and suitable for care, treatment or services provided. 2. The organization provides emergency access to all locked and occupied spaces (bathroom keys) General appearance and overall cleanliness

EC.02.06.01

XV.

The organization manages its space during demolition, renovation or new construction EC.02.06.05 Answers

1. Prior to any construction / renovation the clinic meets with EOC, Infection Control and Fire Safety personnel to review the plans and develop a risk assessment for maintaining a safe environment for patient care 2. If construction is currently in progress then action has been taken, based on the

previous risk assessment (e.g. barriers are up, ILSM are in place, etc.)

XVI. Staff and LIP are familiar with their roles and responsibilities relative to the Environment of Care. Answers
1. Staff and LIPs know how to report a patient, visitor or employee injury , near misses or any concerns with Environment of Care even prior to an incident occurring.

XVII. The organization collects information to monitor conditions in the environment EC.04.01.01 XVIII. The organization analyzes identified environment of care issues EC.04.01.03 XIX. The organization improves its environment of care EC.04.01.05
1. Ask staff to identify any safety hazards they have identified in the EOC. Have they filled out an SRS? 2. There are no slip/trip/or fall hazards

Cords running across rooms, pulled up carpet, broken tiles, wet floors, etc.

XX.

Janitorial PI Project Answers

1. Only approved products are being used 2. There is a chemical inventory and MSDS that match products found in the clinic 3. All containers are labeled appropriately 4. All chemicals are ready to use or dispensed through an automated mixer/dispenser 5. PPE is available 6. No food or drink is found in the janitorial closet 7. Cleaning SOP is available on site 8. Company able to provide information about compliance and employee training upon request

XXI. Emergency Preparedness Answers

1. The clinic has a hazard vulnerability analysis available for review 2. Staff can articulate what HICS means 3. Staff can identify applicable HICS codes 4. Off site clinics have a NOAA weather alert radio that is plugged in and working 5. The clinic has an annual tornado drill

XXII Container Management

1. Staff can articulate what to do when they receive a new container 2. Staff can articulate what to do if they receive a breached/damaged container, including who to notify. 3. Staff can show surveyor where they hold area is located. 4. Staff can articulate how to discard empty containers. Check that seal is intact, label matches order, etc. Place in designated hold area, notify supervisor who calls procurement

Remove/deface any PHI, deface label and do not replace cap prior to discarding

XXII.

Other