2014 and 1st Qtr 2015

*Top LSC & EOC Joint Commission Findings

Ron Neet, CPE, CEM Life Safety, EOC, & EM ManagerProvidence Health and Services

Learning Objectives - At the conclusion of this presentation, the participant will be able to:1. Identify the components of a Joint Commission

Life Safety & EOC Survey.2. Identify the top compliance issues in Life Safety and the Environment of Care.3. Be able to describe the “Environment of Care” “triggers” to a CMS “Immediate Jeopardy” finding and the consequences associated with the finding.4. Be able to describe and implement “tips” for a successful survey.

Trivia

How many light bulbs should youconsider for lighting at the exit?

Only one is required At least two More than two

Trivia - Answer

7.8.1.4 Required illumination shall bearranged so that the failure of any singlelighting unit does not result in anillumination level of less than 0.2 ft candles(2 lux) in any designated areas.

– Surveyors are looking for two bulbs in the outside exit area.– Have you evaluated at night?

Trivia

In Chapter 7 Means of Egress – 2000LSC is it:

– A. Not an Exit– B. No Exit– C. I don’t care

Trivia - Answer7.10.8 Special Signs.

7.10.8.1* No Exit. Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows:

NOEXIT

Such sign shall have the word NO in letters 2 in. (5 cm) high with a stroke width of ⅜ in. (1 cm) and the word EXIT in letters 1 in. (2.5 cm) high, with the word EXIT below the word NO. “No Exit” not to scale.

Trivia

What is the “maximum” height you can mount a portable fire extinguisher?

– 4ft– 3 ½ ft– 3 ft– 5 ft

Trivia - Answer1-6.10 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more 5 ft (1.53 m) above the floor.

Fire extinguishers having a gross weight greater than 40 lb (18.14 kg) (except wheeled types) shall be so installed that the top of the fire extinguisher is not more than 3 1/2 ft (1.07 m) above the floor

Trivia

What is the “minimum” distance that a portable fire extinguisher is mounted off the floor?– 4ft– 3 ft– 4 inches– 12 inches

Trivia - Answer:

In no case shall the clearance between the bottom of the fire extinguisher and the floor be less than 4 in. (10.2 cm).

Trivia

What information is required to be shown on a set of Life Safety Drawings?Standard LS.01.01.01, EP 2, requires an organization to have a current SOC. Part of having a current SOC is creating and maintaining an up-to-date and complete Basic Building Information (BBI). The BBI requires organizations to indicate the location of current LS drawings. So, if your organization could not supply current LS drawings, then it was not in compliance with the requirement for a current BBI and consequently an up-to-date SOC

Trivia – AnswerAccording to The Joint Commission’s “Life Safety” chapter, Life Safety Code drawings must clearly display the following information:

1) A legend that clearly identifies features of fire/Life safety 2) Areas of the building that are fully sprinklered (if the building is partially sprinklered) 3) Locations of all hazardous storage areas 4) Locations of all fire-rated barriers 5) Locations of all smoke barriers 6) Suite boundaries, including the sizes of the identified suites — both sleeping (maximum 5,000 square feet) and nonsleeping (maximum 10,000 square feet) suites 7) Locations and size (sqft) of designated smoke compartments 8) Locations of chutes and shafts 9) Any approved equivalencies or waivers

TriviaProvide some parameters regardingthe 18” inch storage rule:

– 1.– 2.– 3.– 4.

The RuleSprinklers and storage areas (including perimeter wall shelving)There must be 18” clear from the bottom of the sprinkler deflector to any storage or shelving. This is measured as a horizontal plane in the room (not conical measurement from the sprinkler head). This is a vertical measurement. Horizontally sprinklers can be as close as 4” (closer in some instances with special installations). (See NFPA 13-2010, 8.6.3.3 “Minimum Distances from Walls. Sprinklers shall belocated a minimum of 4 in. (102 mm) from a wall.”) and A.8.6.6 regarding shelving

Trivia

What is the “height” that a manual fire alarm pull station should be mounted off the floor?– 2 ½ ft – 5 ½ ft– 4ft - 5 ft– 3 ½ ft - 4 ½ ft– 12 inches

Trivia – AnswerPer NFPA 72 2-8.1 Each manual fire alarm box shall be securely mounted. The operable part of each manual fire alarm box shall not be less than 3 ½ feet and not more than 4 ½ feet above the floor.

Trivia

What is the recommended height tomount a sharps container?

– 52-56 inches– 50-54 inches– 40-46 inches– It depends

Hint: NIOSH DHHS Publication Number 97-111 Selecting,Evaluating, and Using Sharps Disposal Containers – 1998

Trivia - Answer

The Joint Commission Life Safety and

Environment of Care Survey Process

• The Joint Commission survey process continues to evolve along with its standards. Providence Health & Services has created a “CORE SURVEY TEAM” to conduct mock Joint Commission surveys at all of its 36 hospitals in the 5 western states.

• The size and composition of the Joint Commission survey team varies according to the size of the organization and types of services being surveyed. However, the team includes some combination of nurse, physician, and/or administrative surveyor . A life safety code & Environment of Care specialist is also on the survey team for all hospitals.

• Today, all surveys are unannounced, and organizations are encouraged to maintain a state of continuous readiness. The unannounced survey process emphasizes the need for training and involvement of all staff in managing the patient care environment.

The Life Safety Code Specialist The life safety code (LSC) specialist focuses on compliance with the Life Safety Code, the Joint Commission’s Statement of Conditions(eSOC) and Plans for Improvement (ePFI), the Environment of Care standards, and in most surveys Emergency Management.

The Life Safety specialist is usually a Facilities Manager/Director and/or Safety Officer with >20+ years experience.

Depending on the size of the facility, the survey process will take anywhere from 1 to 3 days.

The Life Safety/EOC survey usually consists of the following elements:

1. Document Review – 2 hrs. to half day

2. Building Tour - will tour the building and may want to tour construction sites – from half day to 1 ½ days depending on size of facility

3. Environment of Care Session

4. Emergency Management session

Note: Some surveys do a combined EOC and EM session

The Providence Core Survey Team

1. Core Surveys are designed to mirror actual Joint Commission Surveys, and survey to all of the JC and CMS standards

2. Digs much deeper into standards compliance than typical JC

3. Member of Core Survey Team attends all actual JC surveys to assist facility. (Usually one of the clinical team members)

4. Looks for survey trends and any “HOT BUTTONS” that the JC surveyors are identifying.

5. Communicates these survey trends and “HOT BUTTONS” to all Providence Hospitals so they can ensure compliance.

6. Utilize several approaches to communicate information to all affected staff across the “Providence System”, i.e., mass email distribution lists, weekly newsletters, monthly conference calls, regulatory updates when needed, and annual regulatory update 2-day conferences

Life Safety, Environment of Care, & Emergency Management Sessions

Day 1 - Morning - Life Safety Code Document Review:Attendees: Facilities/Physical Plant Manager, Life Safety Specialist, Construction Project Manager, Physical Plant Engineers/Specialists, Facilities Admin Asst.

1 eSOC with ePFI's2 Facility Life Safety Drawings

3 CMS Categorical Waivers in place (Ensure if any door locking arrangements exist that release with FA, waiver has been adopted)

3 Fire Alarm System testing, inspections and repair of deficiencies for last 2 years

4 Inventory of all fire alarm activation, notification, and door release devices (Include AHU shutdown devices and chime strobes)

5 Sprinkler System testing, inspection and repair of deficiencies for last 2 years6 Generator testing, inspection and repair of deficiencies for last 2 years

7 Qualifications and Certifications for all staff performing maintenance and servicing of Fire/Life Safety Systems, Life Support equipment, and bldg components

8 Elevator fire service monthly testing 9 Medical Gas system testing, inspection and repairs for last 2 years

10 Air exchange rates, air pressure relationships, temperature and humidity checks for all anesthetizing, procedural locations, central processing, and sterile storage areas

11 Construction projects currently underway and locations, daily construction inspection checklists12 Pre-Construction Risk Assessments, ILSM's and ICRA's implemented or in place at time of survey.13 Construction Risk Assessment, ILSM and ICRA policies.

Day 2 or 3 - Environment of Care document review:Attendees: Environment of Care Plan Managers and optional EOC/Safety committee members

1 Safety and Security Risk Assessments2 All EOC management plans3 All EOC management plan quarterly reports for last 2 years4 All EOC annual evaluation of plans (except CAH's)5 EOC meeting minutes for last 2 years

6 Utilities Equipment inventory list - (Will select random piece of critical equipment to trace for compliance with CMS S&C 14-07)

7 Medical Equipment inventory list - (Will select random piece of critical equipment to trace for compliance with CMS S&C 14-07)

8 If AEM is used, are Facility and Bio-Med equipment and systems inventoried by "following mfgs" or "following AEM"?

9 Hazardous Materials inventory list - 6 months hazardous waste manifests10 Hazardous Waste inventory list - 6 months Medical waste manifests11 DOT training certifications for HAZMAT handlers and shippers12 Hazardous Surveillance Rounds (EOC rounds) for last 2 years (including satellites)13 Performance Improvement data for all EOC Plans14 Fire Drills and Critiques for last 2 years (including satellites)15 Fire Response Plan (Fire Plan)16 Infant and Pediatric Abduction Plans and drills for last 2 years17 Nuclear Medicine Hot Lab Security Plan and Isotope Courier Delivery Procedure

Day 1 – Afternoon (and day 2 at larger facilities) – Building LS & EOC Tour

Day 2 - Emergency Management document reviewAttendees: EM Plan Manager and optional EM committee members

1 Identification of Plan manager and designated Senior leader responsible for Emergency Mgmt2 Emergency Operations Plan3 Hazard Vulnerability Analyses 4 Emergency Supply Inventory list5 Annual evaluations of EOP, HVA and Emergency Supply Inventory6 Annual reviews of MOU's for alternate care sites and transportation agreements7 Disaster drill critiques for last 2 years8 Utility Contingency Plans

9Documentation that the hospital has communicated, in writing, with each of its licensed independent practitioners regarding his or her role(s) in emergency response and to whom he or she reports to during an emergency.

Day 2 or 3 – End of survey report• Written and verbal report out of survey findings to C-Suite and

leadership team. Report all deficiencies identified and any recommendations to assist facility and staff with future compliance.

Top Joint Commission Findings in Life Safety and the Environment of Care for 2014 & 1st Qtr 2015

Standard EP Description %

6 (15)In areas designed to control airborne contaminants, ventilation system provides appropriate pressure relationships, air-exchange rates, and filtration efficiencies

33

8 Hospital labels utility system controls to facilitate partial or complete emergency shutdowns. 21

1 Hospital designs and installs utility systems that meet patient care and operational needs. 10

13Exits, exit accesses, exit discharges are clear of obstructions or impediments to public way, such as clutter, construction material, and snow and ice.

22

1 Doors in a means of egress are not equipped with a latch or lock that requires the use of a tool or key from the egress side. 17

1 Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment, and services provided. 39

13 The hospital maintains ventilation, temperature, and humidity levels suitable for the care, treatment, and services provided. 17

Non-Compliance Rate for the Most Challenging EC/LS Standards by EPs 2014 and 1st Qtr 2015

EC.02.05.01 (53%)

LS.02.01.20 (50%)

EC.02.06.01 (56%)

53% EC.02.05.01: Risks with Utility Systems

EP 15 - TJC is scoring problems with pressure differentials and air exchange rates in critical areas. Staff need to know what their special pressure relationship is, either positive or negative and what they can do while working in that environment to maintain the appropriate pressure relationship, such as keeping doors closed.

A meter, ball-in-the-wall, or performing a tissue test are all appropriate means to determine air pressure relationships.

TJC and CMS are looking for verification that periodic testing and balancing are occurring in critical care areas and staff are aware of what the readings mean, as well as what risks are present when pressure relationships are incorrect.

EP 8 – This is the EP that addresses Utility system emergency shutdown labeling. TJC is looking for placards mounted on or by the emergency shutoffs of all major utilities and bulk med gas systems. These locations should be the first major isolation points under the facilities control, examples include:

Natural gas shutoff valve just past the main regulatorMain normal-power electrical breaker(s)Main domestic water and fire sprinkler water valvesBulk O2 “source” valveMed gas manifold “source” valvesVacuum and med air plant “source” valvesMain steam shutoff valve(s)Main chilled water shutoff valve (s)Diesel or propane tank main shutoff valve (s)

Placards should list: “name of utility” Emergency Shutoff, area(s) served, and cautionary language “shut in event of emergency only”.

50% LS.02.01.20: Maintaining means of Egress

EP 13 Exit access and discharge clear of obstructions, to public way. This is the corridor clutter or junk in the hallways.

CMS has allowed a categorical waiver for corridor clutter and if adopted, will allow crash carts, infection control Isolation carts, rolling (portable) patient lift equipment, and patient transport equipment (stretchers and wheel chairs) to be stored in corridors providing there is an unobstructed 5’ clear width, and the entity has addressed in their fire plan, removal of such equipment during an emergency or fire event.

EP 1 Doors in means of egress unlocked in direction of egress.

CMS has also allowed a categorical waiver for door locking arrangements when their are “clinical needs” as long as certain procedures are followed, i.e. Behavioral health units, mother/baby units, some inpatient rehab units. Entity must adopt the waiver and have a written summary of the “clinical need”.

56% EC.02.06.01 Maintains safe functional environment

EP 1 Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment, and services provided.This is kind of a catch-all. This EP is also used for serious pressure relationship deficiencies and if cited, will be cited as a condition-level-finding requiring a re-survey in 45 days. In some instances where immediate corrections have occurred, TJC has rolled these back to EC.02.05.01 EP 15 as a standard-level finding.

EP 1 is also where TJC will soon be surveying for correct special relocatable power taps in the healthcare setting.

EP 13 Maintains ventilation, temp, humidity levels suitable for care. Operating room environments, Cath Labs, C-section OR’s, sterile processing, decontam, sterile supply storage areas all have special requirements relative to temperature and humidity. Temp and humidity in these areas must be either continuously monitored and alarmed, or logged daily on a special log sheet. Out-of-parameter temp and/or humidity excursions must be addressed by entities policy/procedure.

25 Documentation of maintenance, testing, and inspection activities for fire alarm and water-based fire protection systems. 17

3Every 12 months, the hospital tests duct detectors, electromechanical releasing devices, heat detectors, manual fire alarm boxes, and smoke detectors.

14

19 Every 12 months, the hospital tests automatic smoke-detection shutdown devices for air-handling equipment. 14

4 Every 12 months, the hospital tests visual and audible fire alarms, including speakers. 11

2 At least quarterly, the hospital tests water-flow devices. Every 6 months, the hospital tests valve tamper switches. 10

5 Every quarter, the hospital tests fire alarm equipment for notifying off-site fire responders. 10

9The space around pipes, conduits, bus ducts, cables, wires, air ducts, or pneumatic tubes that penetrate fire-rated walls and floors are protected with an approved fire-rated material.

24

5

Doors required to be fire rated have functioning hardware, including positive latching devices and self-closing or automatic-closing devices. Gaps between meeting edges of door pairs are no more than 1/8 inch wide, and undercuts are no larger than 3/4 inch.

20

4 Openings in 2-hour fire-rated walls are fire rated for 1 1/2 hours. 17

EC.02.03.05 (48%)

LS.02.01.10 (46%)

48% EC.02.03.05 Maintains fire safety equipment and bldg. features. TJC looks at most/all of the 21 EPs in this standard during document review. There are 6 EPs that have risen to the top.

EP 25 Documentation of maintenance, testing, and inspection activities for fire alarm and water-based fire protection systems includes the following:- Name of the activity,- Date of the activity,- Required frequency of the activity, - Name and contact information, including affiliation, of the person who performed the activity, - NFPA standard(s) referenced for the activity,- Results of the activityEP 3 Most of the FA devices are tested under this EP. Over half the hospitals across the nation are failing this. TJC is looking for complete inventories of all devices, by device and location, with pass/fail results for each device. A common flaw is not meeting the new timing requirements for the PM’s, or not including an inventor list of door release devices. Another flaw is not closing the loop when making device repairs and retest.

EP 19 Every 12 months, the hospital tests the automatic smoke-detection shutdown devices for air handling equipment. Common flaws are either not completing this separate AHU shutdown test in addition to the EP3 duct detector tests, or not including a complete inventory of all air handlers showing pass/fail of each when auto shutdown is tested.

EP 4 This covers the testing of all audible/visual FA devices, including speakers. The most common flaw found with this EP is doing the tests by saying something like “all strobes” or “all audible & visual devices” were tested and passed. But TJC is looking for a complete and detailed inventory of strobes, chimes, horns, speakers, etc., by location or other identifier, with pass/fail results for each device. EP 2 Quarterly testing of water flow devices and 6-mo testing of valve tamper switches. Hospitals cited under this EP either are not providing complete inventories of devices with pass/fail, or are not meeting the timing requirements for testing. Another flaw is not closing the documentation loop on repairs and retest.

EP 5 Quarterly testing of FA equipment for notifying off-site responders. The most common flaw here is not documenting the completion of this test or not showing response times on report.

• Every 36 months/every 3 years = 36 months from the date of the last event, plus or minus 45 days

• Annually/every 12 months/once a year/every year = 1 year from the date of the last event, plus or minus 30 days

• Every 6 months = 6 months from the date of the last event, plus or minus 20 days

• Quarterly/every quarter = 4 times a year, once in each quarter every three months, plus or minus 10 days

• Monthly/30-day intervals/every month = 12 times a year, once per month

Joint Commission’s Maintenance Timing Requirements

46% LS02.01.10 Building Features Minimize Effects of Fire and Smoke. This standard is usually scored at EP 5 for fire doors, or EP 9 for penetrations. EP 5 The fire door issue is often that the door does not auto-close and latch appropriately. This is usually caused from doors being banged into by carts, stretchers, and or rolling equipment. Another flaw found here is the gap between meeting door edges >1/8th inch or undercuts >3/4 inch.EP 9 The penetration issue is usually due to lack of an above ceiling permit program or contractors not sealing around conduits and pipes during new installations. A vigorous barrier inspection PM program along with inspection of new installation work by the facilities staff can usually catch most of these deficiencies.

EP 4 Openings in 2-hour fire-rated walls are fire rated for 1 ½ hours. Usually this EP is cited for missing labels on 90 minute fire doors including trash and linen chute doors, or failure of auto-closing and latching devices.

2 All hazardous areas are protected by walls and doors. 21

11

Corridor doors are fitted with positive latching hardware, are arranged to restrict the movement of smoke, and are hinged so that they swing. The gap between meeting edges of door pairs is no wider than 1/8 inch, and undercuts are no larger than 1 inch.

19

18Smoke barriers extend from the floor slab to the floor or roof slab above, through any concealed spaces, and extend continuously from exterior wall to exterior wall. All penetrations are properly sealed.

14

4 Piping for automatic sprinkler systems is not used to support any other item. 17

5 Sprinkler heads are not damaged and are free from corrosion, foreign materials, and paint. 12

6 There are 18 inches or more of open space maintained below the sprinkler deflector to the top of storage. 11

5 Hospital minimizes risks associated with selecting, handling, storing, transporting, using, and disposing of hazardous chemicals. 18

7 Hospital minimizes risks associated with selecting and using hazardous energy sources. 11

LS.02.01.30 (43%)

LS.02.01.35 (43%)

EC.02.02.01 (36%)

43% LS02.01.30 Protects Against Hazards of Fire & Smoke. These EP’s are primarily scored due to smoke door issues or problems with hazardous areas.EP 2 If a space meets the definition of a “Hazardous Areas”, it must be protected per NFPA 101-2000 18/19.3.2.1. This includes auto-closing doors and positive latching. Again, door closure and/or latch failures, or door damage usually leads to this finding.

EP 11 Corridor doors. Common findings under this EP include door damage, gaps >1/8th inch in meeting edges of double door assemblies, malfunctioning positive latching hardware, or undercuts >1 inch. EP 18 Smoke barriers. This EP is usually cited for penetration issues found in your smoke barrier walls. TJC has a history of choosing one or more smoke barrier walls and inspecting them from exterior wall to exterior wall.

43% LS.02.01.35 Maintains Systems for Extinguishing Fires

EP 4 Usually cited during building tour when discovered that things are tied off or draping over sprinkler pipe above the ceiling. Contractors and staff placing cables or wiring often tie these off to the sprinklers.

EP 5 Damaged, dirty, corroded, or painted sprinkler heads are cited under this EP. Also dust bunnies on sprinkler heads deposited from the air handler system are also cited.

EP 6 The infamous 18” clearance from the bottom of the sprinkler head deflector.

36% EC.02.02.01 Manage Risks Related to Hazardous Material & Waste

EP 5 This deals with hazardous waste and hazardous product management. Quite often the finding is related to hazardous chemicals and not having an eye wash station in the immediate area where the corrosive or toxic chemical is being used. Another common finding is the eye wash weekly logs. They are either missing or have gaps in the testing entries.

EP 7 You will see hazardous radiation issues scored against this EP, either staff not returning their dosimeter badges or failure to inspect lead shields each year.

CMS “Immediate Jeopardy” triggers Immediate Jeopardy - “A situation in which the provider’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.”

Only ONE INDIVIDUAL needs to be at risk. Identification of Immediate Jeopardy for one individual will prevent risk to other individuals in similar situations.

Serious harm, injury, impairment, or death does NOT have to occur before considering Immediate Jeopardy. The high potential for these outcomes to occur in the very near future also constitutes Immediate Jeopardy.

After determining that the “harm” meets the definition of Immediate Jeopardy, consider the following points regarding entity compliance:

• The entity either created a situation or allowed a situation to continue which resulted in serious harm or a potential for serious harm, injury, impairment or death to individuals.

• The entity had an opportunity to implement corrective or preventive measures

ISSUE TRIGGERSFailure to protect from widespread nosocomial infections; e.g., failure to practice standard precautions, failure to maintain sterile techniques during invasive procedures and/or failure to identify and treat nosocomial infections

1. Pervasive improper handling of body fluids or substances from an individual with an infectious disease;

2. High number of infections or contagious diseases without appropriate reporting, intervention and care;

3. Pattern of ineffective infection control precautions; or

4. High number of nosocomial infections caused by cross contamination from staff and/or equipment/supplies.

Infection Control

Physical Environment ISSUE TRIGGERS

Failure to provide safety from fire, smoke and environment hazards and/or failure to educate staff in handling emergency situations.

1. Nonfunctioning or lack of emergency equipment and/or power source;

2. Smoking in high risk areas; 3. Incidents such as electrical shock, fires;4. Ungrounded/unsafe electrical equipment;5. Widespread lack of knowledge of emergency

procedures by staff; 6. Widespread infestation by insects/rodents;7. Lack of functioning ventilation, heating or

cooling system placing individuals at risk; 8. Use of non-approved space heaters, such as

kerosene, electrical, in resident or patient areas;

9. Improper handling/disposal of hazardous materials, chemicals and waste;

10.Locking exit doors in a manner that does not comply with NFPA 101;

11.Obstructed hallways and exits preventing egress;

12.Lack of maintenance of fire or life safety systems; or

13.Unsafe dietary practices resulting in high potential for food borne illnesses.

“TIPS” for a Successful Life Safety and EOC survey

• Be present at the opening conference (Facilities Mgr/Director and Safety Officer)

• At the opening conference, disclose verbally and/or in writing, which CMS categorical waivers the facility has formally adopted. Adoption means approved by the facility’s EOC committee and the waivers have been written into comments section of eBBI on JC website.

• Have at least 2 years of operational and maintenance records available, organized, inventory’s of all devices, and easy to read. Recommend organizing them by JC standard and EP.

• Be familiar with the LS and EOC standards and elements of performance.

• Have a written policy and program in place that includes periodic air balance and pressurization checks of critical spaces, i.e., OR’s, C-Section rooms, Cath Labs, Sterile Processing, Decontam, Endoscopy procedure rooms, Scope cleaning rooms, Negative Pressure Isolation rooms, etc. How do you ensure you are in compliance 100% of the time?

Tips…..Continued• Are you monitoring temperature and humidity in all required

locations? i.e., OR’s, C-Section rooms, Sterile Core areas, Cath Labs, Sterile processing, all sterile supply storage locations, etc. Are the spaces monitored via a building automation system or are you using manual devices and logs? How do you ensure the continual accuracy of all field mounted temp and humidity devices?

• Have a written humidity and temperature policy that describes your program and also describes actions for clinical and non-clinical staff to take when excursions from the established operating ranges occur.

• Have an effective “above-the-ceiling permit” program in place as part of your barrier management program. Strongly enforce it with staff and contractors.

• Ensure your EOC program includes management of all off-site and satellite buildings under the hospital’s license. This includes annual evacuation fire drills, FA and sprinkler testing/maintenance (same as hospital), EM drills, environmental tours, etc.

• Have representation from your I.S. department on your EOC committee to represent and “ability to speak to” those vital network and communication “utility” systems.

• Have representation for all construction processes on your EOC committee.

• During EOC and EM sessions, brag about your accomplishments. Have staff attend that can represent and talk about all EOC functional areas.

Note: The more you share and talk during the sessions, the less questions the JC surveyor will ask.