If you manage or are responsible for maintenance at a medical office building (MOB), skilled nursing center, or other healthcare-related facility that is subject to state surveyors or seeks accreditation from The Joint Commission (TJC), than you are aware of the value of preparation in advance of a property inspection.
That preparation is best addressed by designing and implementing a program of regular facility inspections that monitor and check compliance with the requirements generally covered under the Environment of Care and Emergency Management sections of the TJC accreditation standard, related state survey standards or your organizations own internal operational risk management program and standards.
It is incumbent upon every property management and facilities team to have a program in place that requires continual monitoring of the facility and related compliance requirements. That inspection must process must document deficiencies and schedule corrective action immediately so that there is a strong level of confidence that they are always “inspection-ready.” The importance is magnified by the significant implications (fines, delayed accreditation, increased operating risk, decreased tenant comfort, safety and lease renewal issues) of not passing an inspection.
We previously shared best practices guidance for a general inspections program, but now want to focus on the very specific needs of the rapidly growing healthcare facilities market. Again, whether a company is still conducting inspections with paper and pencil on a clipboard (by in-house staff or a service provider), or using an automated and mobile data collections tool like the Inspections Manager from Building Engines, it’s mission-critical to have a formal process, documentation and inspections program in your facility that will include the following key items for TJC inspections:
1. Written management plans for each of the Environment of Care and Emergency Management areas:
- Hazardous Materials
- Emergency Management
- Fire Prevention, Medical Equipment and Utilities Management
Management plans must be consistent in format and in place for any associated facility of a main hospital such as ambulatory sites or business clinics that may be surveyed. They must have been approved by the safety committee and leadership during the last twelve months.
2. Written annual effectiveness evaluation documents for each of the Environment of Care and Emergency Management areas sections.
- Be sure that the documents address the Scope, Objectives, Performance and Effectiveness as well as Objectives for the Following Year for each “EC” area.
3. Safety committee minutes for the previous 12 months.
- Arrange the minutes in chronological order and ensure that they include a description of the agenda item, action required, responsibility and action taken as well as any required follow-up.
- Attendance at the meetings should be documented, average at least 70% for the standing members and must include representatives from administration, clinical services and support services.
Building Engines Fire & Life Safety Module can help you ensure compliance with this requirement as well as store related documentation for easy retrieval.
4. Statement of Condition documents
- For each building that is a healthcare facility or has ambulatory occupancy that is used to treat or counsel patients, the Basic Building Information (e-BBI) and questionnaire forms must be completed electronically to indicate the facility occupancy classification.
- For ambulatory and healthcare facilities, a Life Safety Assessment (LSA – not electronic) and Plan for Improvement (PFI – electronic) forms must also be completed.
- Be sure to also create and make available a Statement of Conditions (SOC) binder that includes an SOC policy, downloaded e-BBI and e-PFI forms, compartment drawings for each building, a completed LSA document and the PFI forms from the previous Joint Commission survey.
- Each of the PFI items from the previous survey must have the actual completion dates filled in. The SOC binder should be updated as necessary and readily available for an unannounced survey.
5. Areas likely to be inspected during the facility tour include the following:
- Boiler room
- Emergency generator location(s)
- Loading/ receiving dock
- Central storage/ warehouse
- Laundry (if applicable)
- Food service areas and dry storage area
- Compressed gas storage rooms
- Locker rooms
- Clean and soiled linen rooms, including the chute receiving rooms
- Infectious waste storage areas
- Hazardous chemical storage areas
- Other hazardous storage areas
- Mechanical equipment rooms and interstitial spaces
- Smoke and fire door
- Exit signage
- Penetrations in smoke and fire walls and compartments
- Utility chases
- Electrical and communication closets
- Fire pump(s)
- Fire annunciator panel
- Emergency generators
- Medical gas manifold rooms
- Medical air and vacuum system components
- Building roof
- Elevator penthouse
- Construction areas
- Other selected mechanical systems, such as air handlers
- Other selected electrical systems, such as switchgear and load centers
- Other areas of interest to the Life Safety Specialist