Wednesday, August 31, 2011

Tuesday, August 30, 2011

PM Documentation

For PM documentation within our Documentation for Administrative Surveyor, how much do you suggest we show a surveyor in these books for daily, weekly, monthly, etc?

Thursday, August 25, 2011

Fire Drill Response


When a code Red is called in a hospital, is there a general expectation or standard that states the floor above, below and lateral shall respond by closing doors, etc?  Do other locations have the same response?

Thursday, August 18, 2011

ILSM Assessments

Does TJC require documented ILSM assessments for all life safety code deficiencies, or is documenting ILSM assessments only required for the more significant life safety code deficiencies (>45 day items) ok?

Wednesday, August 17, 2011

Fire Extinguisher Inspection

For monthly fire extinguisher inspections, is TJC expecting the documentation (tag) to include: MM\DD\YY + initials, or is MM\YY + initials ok?

Monday, August 15, 2011

Drinking Water for Disasters

Is there a standard in Emergency Management for how much drinking water a healthcare facility (Hospital, Rehab., Nursing Home) needs on hand during a disaster event?  If so, what is the potable water requirements for the different areas in a healthcare facility?

Friday, August 12, 2011

Emergency Water Supply

CDC introduces Emergency Water Supply Planning Guide for Hospitals and Health Care Facilities 


In order to maintain daily operations and patient care services, health care facilities need to develop an Emergency Water Supply Plan (EWSP) to prepare for, respond to, and recover from a total or partial interruption of the facilities’ normal water supply. Water supply interruption can be caused by several types of events such as natural disaster, a failure of the community water system, construction damage or even an act of terrorism. Because water supplies can and do fail, it is imperative to understand and address how patient safety, quality of care, and the operations of your facility will be impacted.
A health care facility must be able to respond to and recover from a water supply interruption. A robust EWSP can provide a road map for response and recovery by providing the guidance to assess water usage, response capabilities, and water alternatives.
Read it here

Thursday, August 11, 2011

Decommissioning Dampers



We are considering decommissioning multiple dampers that are not required. Is there a requirement that the organization notify in writing to The Joint Commission that a number of specified dampers are being decommissioned?

Wednesday, August 10, 2011

Sprinklers in Elevator Equipment Rooms

We removed all sprinkler heads in the elevator equipment rooms in lieu of installing shunt trips.  Does this mean our facility is no longer fully sprinklered?

Monday, August 8, 2011

Thursday, August 4, 2011

Sensor Lighting in Stairwells

In order to reduce energy costs, we are looking at installing lighting fixtures that have motion/proximity sensors for when there is no activity (they will drop to a night light mode until someone enters the stairwell again).  Are these allowed by code?

Monday, August 1, 2011

Shelving and Sprinkler Heads

I know JCAHO requires that shelving not be closer than 18 inches to sprinkler heads. What about shelving on the walls on the perimeter of the room? Some of ours go almost to the ceiling. Are wall units exempt from the 18-inches rule?