Part 1 appeared in the September/October 2009 issue of Compliance News.
Part 2 appeared in the November/December 2009 issue of Compliance News.
Schedules (policies and procedures, forms, lists, etc.) would have to be established for the following types of items (listing is not all-inclusive):
• Fire drills, safety rounds, safety monitoring and security monitoring of EC
• Ongoing testing, inspections and maintenance
• Inspections of all ‘previous’ Building Maintenance Plan (BMP) components – (smoke and corridor walls; fire, smoke and corridor doors; exit signs and egress lights, trash and linen chutes, grease producing devices, and means of egress free of blockage such as ice and snow)
• Inspections of fire walls
• Inspections of fire and smoke dampers, including the special one-year inspection
• Fire alarm systems, devices and equipment; fire protection systems, devices and equipment; fire extinguishers
• Eyewash stations
• Emergency power, medical gas and vacuum, and other systems
Labeling would be expected for hazardous materials and waste, utility system controls to facilitate partial or complete emergency shutdowns, medical gas and vacuum system valves, both permanent and temporary signage, and maps if they are used. Standard labels may not meet all of the AHJ requirements.
Project record documentation that meets the AHJ requirements for mapping of utility systems would be acceptable if it is available during survey. The utility systems include normal and emergency power, steam, chilled water, domestic water, sanitary piping, fire protection, medical gas and vacuum, fire alarm and emergency communications, telecom, and any other systems included in the Utility Systems Management Plan scope.
Utility maintenance documentation is required to be accessible during survey. This includes documentation generated both internally and by outside services. The organization needs to have processes (and contract provisions) to obtain, store and access all such documentation during both equipment failures and unannounced surveys. The decision process for the types of maintenance (preventive, predictive, reliability-centered, corrective, or metered) to be performed on all new equipment should also be documented and available during survey.
Similar requirements apply to maintenance documentation for other types of equipment, including equipment serviced by both internal biomedical engineering departments and external service organizations.
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