Public Health Apps

Environment of Care Documentation Checklist

Whether inpatient or outpatient, any facility where patients are treated faces environmental risks, from security and fire safety to medical equipment and hazardous waste. An environment of care management plan creates a culture of safety for staff, patients and visitors. Maintaining a safe environment of care involves more than just quality health care, it includes construction and renovation, emergency management, utility and equipment maintenance, and more. Use this Environment of Care Documentation Checklist to minimize risk, ensure patient, staff, and visitor well-being, and preserve quality and safety of care.

Source: https://www.ashe.org/environment-care-documentation-checklist

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Environment of Care Documentation Checklist

Facility Name

Facility Address

Date

Written Plans

Written Environmental Safety Plan

Written Security Plan

Written Hazardous Material and Waste Plan

Written Fire Safety Plan

Written Medical Equipment Plan

Written Utility System Plan

Notes

Safety and Security Risks

Process to identify safety and security risks associated with EOC

Written procedures following a security event, including infant abduction

Notes

Prohibits Smoking

Written Policy prohibiting smoking in all buildings

Notes

Manages Hazardous Material and Waste Risk

Written, current inventory of hazardous materials and waste used, stored, and generated. Only for materials addressed by law and regulation.

Written procedures, including precautions and PPE, to follow in response to hazardous material and waste spills or exposures.

Document permits, licenses, manifests, and SDS required by law and regulation.

Notes

Manages Fire Risk

Written fire response plan describes the specific roles at and away from the fire's point of origin. Includes when and how to sound and report fire alarms, how to contain smoke and fire, how you use a fire extinguisher, how to assist and relocate patients and how to evacuate Area's of Refuge. Staff is periodically instructed on their duties under the plan. A copy of the plan is readily available with the operator or security.

Notes

Conducts Fire Drills

Conducts fire drills once per shift per quarter in buildings with health care occupancy. Conducts quarterly drills in buildings with ambulatory health care occupancy

Conducts fire drills every 12 months from the date of the last drill in all freestanding buildings with business occupancy and in which patients are seen or treated

Fire drills are critiqued to evaluate fire safety equipment, fire safety building features and staff response. The evaluation is documented.

Notes

Maintains Fire Safety Equipment and Fire Safety Building Features

Supervisory Signals (except tamper switches) - Quarterly

Water flow devices and valve tamper switches - Semi Annual

Duct, heat, smoke detectors, pull stations - Annually

Notification devices (audible & visual). Including speakers and door-releasing devices - Annually

Emergency services notification transmission equipment - Annually

Fire pump(s) tested under no-flow conditions ( Diesel - Weekly, Electric - Monthly)

Sprinkler water storage tank high & low level alarms - Semi Annual

Sprinkler water storage tank low water temp alarms (cold weather only) - Monthly

Sprinkler systems main drain tests on all risers - Annually

Fire department connections inspected - Quarterly

Fire pump(s) tested annually underflow - Annually

Water flow test for standpipe systems - 5 years

Kitchen auto extinguishing systems inspected - Semi Annually

Gaseous extinguishing systems inspected - Annually

Portable fire extinguishers inspected monthly - Monthly

Annual maintenance on all portable fire extinguishers - Annually

Hydrostatic tests on standpipes occupant hoses 5 years after installation and three years thereafter. - 36 Months

Operate fire smoke dampers one year after installation and then at least every six years to verify that they fully close.

Smoke detection shutdown devices for HVAC tested - Annually

All horizontal & vertical roller & slider fire doors tested - Annually

Test all door assemblies - Annually

Test firefighter emergency operations for all applicable elevators. - Monthly

Documentation of maintenance, testing and inspections (and any follow-up activity required) for fire alarm and water based fire-protection systems(see above list) 1) Name of activity 2) Date of activity 3) Inventory of devices, equipment, or other items 4) Required frequency of activity 5) Name and contact info, including affiliation, of person who performed the activity 6) NFPA standard(s) referenced for activity 7) Results of activity

Notes

Manages Medical Equipment Risks

Maintains a written inventory of all medical equipment

Identifies high-risk medical equipment on inventory for which there is a risk of serious injury or death to a patient or staff member should the equipment fail.

Identifies the activities and associated frequencies, in writing, for maintaining, inspecting, and testing all medical equipment on the inventory. These activities and associated frequencies are in accordance with manufacturers' recommendations or with strategies of an Alternative Equipment Maintenance (AEM) program.

Activities and frequencies for inspection, testing, and maintaining the following items must be in accordance with manufacturers recommendations: 1) Equipment subject to federal or state law or Medicare CoP's in which inspecting, testing, and maintaining must be in accordance with manufacturers' recommendations, or otherwise establishes more stringent maintenance requirements. 2) Medical laser devices 3) Imaging and radiologic equipment (whether used for diagnostic or therapeutic purposes) 4) New medical equipment with insufficient maintenance history to support the use of alternative maintenance strategies

A qualified individual uses written criteria to support the determination whether it is safe to permit medical equipment to be maintained in an alternative manner that includes the following: 1) How the equipment is used, including the seriousness and prevalence of harm during normal use. 2) Likely consequences of equipment failure or malfunction, including seriousness of and prevalence of harm. 3) Availability of alternative or back-up equipment in the event the equipment fails or malfunctions. 4) incident history of identical or similar equipment. 5) Maintenance requirements of the equipment

Identifies medical equipment on its inventory that is included in an AEM program

Have written procedures to follow when medical equipment fails, including using clinical interventions and backup equipment.

Notes

Inspects, tests, and maintains Medical Equipment

Inspect, test and maintains all high-risk equipment.

Inspect, test and maintains all non-high-risk equipment on the medical equipment inventory.

Conducts performance testing of and maintains sterilizers.

Performs equipment maintenance and chemical and biological testing of water used in hemodialysis.

Staff inspects, tests, and calibrates nuclear medicine equipment annually. - Annually

For CT services: A diagnostic medical physicist does the following: 1) Measure the radiation dose (CDTIvol) produced by each diagnostic CT imaging system for the following four CT protocols: adult brain, adult abdomen, pediatric brain, pediatric abdomen. If one or more of these is not used by the hospital, other commonly used CT protocols may be substituted. 2) Verifies that the radiation dose (CTDIvol) produced and measured for each protocol tested is within 20 percent of the CTDIvol displayed on the CT console. - Annually

For CT services: A diagnostic medical physicist conducts a performance evaluation of all CT imaging equipment. The evaluation includes the use of phantoms to assess the following imaging metrics: 1) Image uniformity 2) Slice thickness accuracy 3) Slice position accuracy (when prescribed from a scout image) 4) Alignment light accuracy 5) Table travel accuracy 6) Radiation beam width 7) High-contrast resolution 8) Low-contrast resolution 9) Geometric or distance accuracy 10) CT number accuracy and uniformity 11) Artifact evaluation - Annually

A diagnostic medical physicist or MRI scientist conducts a performance evaluation of all MRI imaging equipment. The evaluation includes the use of phantoms to assess the following imaging metrics: 1) Image uniformity for all RF coils used clinically 2) SNR for all coils used clinically 3) Slice thickness accuracy 4) Slice position accuracy 5) Alignment light accuracy 6) High-contrast resolution 7) Low-contrast resolution (or contrast-to-noise ratio) 8) Geometric or distance accuracy 9) Magnetic field homogeneity 10) Artifact evaluation - Annually

A diagnostic medical physicist or nuclear medicine scientist conducts a performance evaluation of all MRI imaging equipment. The evaluation are conducted for all of the image types produced clinically by each NM scanner (for example, planar and/or tomographic) and includes the use of phantoms to assess the following imaging metrics: 1) Image uniformity/system uniformity 2) High-contrast resolution/system spatial resolution 3) Sensitivity 4) Energy resolution 5) Count-rate performance 6) Artifact evaluation - Annually

A diagnostic medical physicist conducts a performance evaluation of all PET imaging equipment. The evaluation are conducted for all of the image types produced clinically by each PET scanner (for example, planar and/or tomographic) and includes the use of phantoms to assess the following imaging metrics: 1) Image uniformity/system uniformity 2) High-contrast resolution/system spatial resolution 3) Low-contrast resolution or detectability (not applicable for planar acquisitions) 4) Artifact evaluation - Annually

Notes

Manages risks associated with Utility Systems

Maintains a written inventory of all operating components of utility systems.

Identifies high-risk operating components of utility systems on the inventory for which there is a risk of serious harm or death to a patient or staff member should they fail.

Identify activities and associated frequencies, in writing, for inspecting, testing, and maintenance in accordance with manufacturers recommendations or AEM program.

The Hospital's activities and frequencies for inspecting, testing, and maintaining the following items must be in accordance with manufacturers' recommendations: 1) Equipment subject to federal or state law or Medicare COP in which inspecting, testing, and maintaining be in accordance with the manufacturers' recommendations, or otherwise establishes more stringent maintenance requirements. 2) New operating components with insufficient maintenance history to support the use of alternative maintenance strategies. 3) Records provided by the hospital's contractors 4) Information made public by nationally recognized sources 5) Records of the hospital's experience over time

A qualified individual(s) uses written criteria to support the determination of whether it is safe to permit operating components of utility systems to be maintained in an alternate manner that includes the following: 1) How the equipment is used, including the seriousness and prevalence of harm during normal use. 2) Likely consequences of equipment failure or malfunction, included seriousness of and prevalence of harm. 3) Availability of alternative or back-up equipment in the event the equipment fails or malfunctions. 4)Incident history of identical or similar equipment. 5) Maintenance requirements of the equipment.

The Hospital identifies operating components of utility systems on it's inventory that are included in an AEM Program.

The Hospital has written procedures for responding to utility system disruptions.

The Hospital maps the distribution of its utility systems

Operating rooms are considered wet procedure locations, unless otherwise determined by a risk assessment authorized by the facility governing body. Operating rooms defended as wet locations are protected by either isolated power or ground-fault circuit interrupters. A written record of the risk assessment will be available for inspection.

Notes

Has a reliable Emergency Electrical Power Source

The hospital implements a policy to provide emergency backup for essential medication dispensing equipment identified by the hospital

The hospital implements a policy to provide emergency backup for essential refrigeration for medications identified by the hospital

Notes

Inspects, test, and maintains Utility Systems

The hospital tests utility system components on the inventory before initial use and after major repairs or upgrades. The completion date and the results of the test are documented.

The hospital inspects, tests, and maintains the following: High-risk utility system components on the inventory. The completion date and the results of the activities are documented.

The hospital inspects, tests, and maintains the following: High-risk utility system components on the inventory. The completion date and the results of the activities are documented. The hospital inspects, tests, and maintains the following: Infection control utility system components on the inventory. The completion date and the results of the activities are documented.

The hospital inspects, tests, and maintains the following: Non-high-risk utility system components on the inventory. The completion date and the results of the activities are documented.

Line isolation monitors (LIM), if installed, are tested by actuating the LIM test switch per NFPA 99-2012: 6.3.2.6.3.6, which activates both visual and audible alarms. For LIM circuits with automated self-testing, a manual test is performed at least annually. LIM circuits are tested per NFPA 99-2012: 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results.

Notes

Inspects, tests, and maintains Emergency Power Systems

The hospital performs a functional test of emergency lighting systems and exit signs required for egress and task lighting for a minimum duration of 30 seconds, along with a visual inspection of other exit signs. The test results and completion dates are documented.

The hospital performs a functional test of battery-powered lights on the inventory required for egress and exit signs for a duration of 1 1/2 hours. For new construction, renovation, or modernization, battery-powered lighting in locations where deep sedation and general anesthesia are administered is tested annually for 30 minutes. The test results and completion dates are documented. - Annually

The hospital performs a functional test of Level 1 stored emergency power supply systems (SEPSS) on a monthly basis and performs a test of Level 2 SEPSS on a quarterly basis. Test duration is for five minutes or as specified for its class (whichever is less). The hospital performs an annual test at full load for 60% of the full duration of its class. The test results and completion dates are documented

The hospital inspects the emergency power supply system (EPSS), including all associated components and batteries. The results and completion dates of weekly inspections are documented.

The hospital tests each emergency generator beginning with a cold start under load for at least 30 continuous minutes. The cool down period is not part of the 30 continuous minutes. The test results and completion dates are documented.

If the hospital does not meet either the 30% of nameplate rating or the recommended exhaust gas temperature during any test in EC.02.05.07, EP 5, then it must test the emergency generator once every 12 months using supplemental (dynamic or static) loads of 50% of nameplate rating for 30 minutes, followed by 75% of nameplate rating for 60 minutes, for a total of 1½ continuous hours.

The hospital tests all automatic and manual transfer switches on the inventory. The test results and completion dates are documented.

The hospital tests the fuel quality to ASTM standards. The test results and completion dates are documented.

The hospital tests each emergency generator for a minimum of 4 continuous hours. The test results and completion dates are documented.

The 36-month diesel-powered emergency generator test uses a dynamic or static load that is at least 30% of the nameplate rating of the generator or meets the manufacturer’s recommended prime movers' exhaust gas temperature.

Notes

Tests and inspects medical gas and vacuum systems

The hospital inspects, tests, and maintains critical components of piped medical gas and vacuum systems, waste anesthetic gas disposal (WAGD), and support gas systems on the inventory. This inventory of critical components includes at least all source subsystems, control valves, alarms, manufactured assemblies containing patient gases, and inlets and outlets. Activities, dates, and results are documented.

The hospital tests piped medical gas and vacuum systems for purity, correct gas, and proper pressure when these systems are installed, modified, or repaired. The test results and completion dates are documented.

Notes

Collects Information to Monitor Conditions of the Hospital

The hospital evaluates each environment of care management plan, including a review of the plan’s objectives, scope, performance, and effectiveness.

Notes

Designs and Manages a physical environment that complies with The Life Safety Code

The hospital performs a building assessment to determine compliance with the “Life Safety” (LS) chapter.

The hospital maintains current and accurate drawings denoting features of fire safety and related square footage. Fire safety features include the following: - Areas of the building that are fully sprinklered (if the building is partially sprinklered) - Locations of all hazardous storage areas - Locations of all fire-rated barriers - Locations of all smoke-rated barriers - Sleeping and non-sleeping suite boundaries, including the size of the identified suites - Locations of designated smoke compartments - Locations of chutes and shafts - Any approved equivalencies or waivers

The hospital maintains documentation of any inspections and approvals made by state or local fire control agencies.

Notes

Protects occupants during periods when the life safety code is not met or during periods of construction

The hospital has a written interim life safety measure (ILSM) policy that covers situations when Life Safety Code deficiencies cannot be immediately corrected or during periods of construction. The policy includes criteria for evaluating when and to what extent the hospital implements LS.01.02.01, EPs 2–15 to compensate for increased life safety risk. The criteria include the assessment process to determine when interim life safety measures are implemented.

When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital evacuates the building or notifies the fire department (or other emergency response group) and initiates a fire watch when a fire alarm system is out of service more than 4 out of 24 hours or a sprinkler system is out of service more than 10 hours in a 24-hour period in an occupied building. Notification and fire watch times are documented.

When the hospital identifies Life Safety Code deficiencies that cannot be immediately corrected or during periods of construction, the hospital does the following: Inspects and tests temporary systems monthly. The completion date of the tests is documented. The need for these inspections and tests is based on criteria in the hospital's interim life safety measure (ILSM) policy.

Notes

Assessment Score