1. CIHQ - All Rights Reserved 2017
Top Hits in the Physical Environment September Billy Kinch, MHA, HACP
CIHQ - All Rights Reserved 2017

2. Presentation Objectives
By the conclusion of this program, the participant will be able to:
Identify the top findings from the physical environment
Strategies for maintaining compliance
CIHQ – All Rights Reserved 2017

3. How To Impress a Life Safety Surveyor
When asked a question about the Life Safety Code. Your first response is always “IT DEPENDS!”
Be able to point out what a sprinkler escutcheon is
CIHQ - All Rights Reserved 2017

4. CIHQ - All Rights Reserved 2017
Top Findings
Security Risk Assessment
Psychiatric Units
DOT Training
Eye Wash Stations
Junction Boxes
Testing Documentation
Emergency Lighting
Emergency Power
Generator Inspection
Electrical Panels
IT Closets
Equipment Inventory
Cylinder Storage
Power Strips
Temperature/Humidity
Ventilation
Medical Gas Shut-off Valves
Fire/Smoke Barrier
Sprinkler
Hazardous Areas
Doors
Means of Egress
CIHQ - All Rights Reserved 2017

5. Security Risk Assessment
Infant Security
National Center for Missing and Exploited Children
Cyber Security
CIHQ - All Rights Reserved 2017

6. CIHQ - All Rights Reserved 2017
Psychiatric Units
Assessment
Design Guide for the Built Environment of Behavioral Health Facilities
Ligature Points
CIHQ - All Rights Reserved 2017

7. CIHQ - All Rights Reserved 2017
DOT Training
Department of Transportation Training Requirements
Hazmat Employee
Loads, unloads, or handles hazmat
Prepares hazmat for transportation
Signs waste manifests
Training required within 90 days of hire and 3 years thereafter
Training Records
the hazmat employee’s name;
the completion date of the most recent training;
training materials used (copy, description, or location);
the name and address of the hazmat trainer; and
certification that the hazmat employee has been trained and tested
CIHQ - All Rights Reserved 2017

8. CIHQ - All Rights Reserved 2017
Eye Wash Stations
ANSI Z
Plumbed vs. Non-plumbed
Weekly Inspections
Annual Inspections
CIHQ - All Rights Reserved 2017

9. CIHQ - All Rights Reserved 2017
Junction Boxes
Must be closed
Creates a fire hazard
CIHQ - All Rights Reserved 2017

10. Testing Documentation
Sets the tone of the survey
Inventory of devices
Pass/Fail documentation
Corrective action and retest for failed devices
Other requirements based on device tested
Updated versions of NFPA codes
Checklist on CIHQ Website
CIHQ - All Rights Reserved 2017

11. CIHQ - All Rights Reserved 2017
Emergency Lighting
EXIT Signs NFPA
Battery Powered Lights NFPA
CIHQ - All Rights Reserved 2017

12. CIHQ - All Rights Reserved 2017
Emergency Power
Manual Stop Button
NFPA
CIHQ - All Rights Reserved 2017

13. Generator Inspections
Annual Fuel Quality Test
Based on ASTM Standards
Weekly inspections
CIHQ - All Rights Reserved 2017

14. CIHQ - All Rights Reserved 2017
Electrical Panels
Must have a 36-inch clearance
Directory must be complete – including spares
CIHQ - All Rights Reserved 2017

15. CIHQ - All Rights Reserved 2017
IT Closets
Unsealed penetrations
Plywood on walls – NFPA /
CIHQ - All Rights Reserved 2017

16. CIHQ - All Rights Reserved 2017
Equipment Inventory
Written Inventory of Equipment
Unique ID Number
Equipment Manufacturer
Equipment Model Number
Equipment Serial Number
Description of Equipment
Location of Equipment (when kept in a fixed location)
Department considered to own equipment
Service Provider
Acceptance Date
CIHQ - All Rights Reserved 2017

17. CIHQ - All Rights Reserved 2017
Cylinder Storage
Less than 300 cubic feet
,000 cubic feet
3,000 – 30,000 cubic feet
E-Cylinder = 23 cubic feet
H-Cylinder = 244 cubic feet
Full vs. Empty/In-Use
CIHQ - All Rights Reserved 2017

18. CIHQ - All Rights Reserved 2017
Power Strips
Patient Care Vicinity
UL1363A or – Patient Care Equipment
UL1363 – Non-patient Care Equipment
Permanently Affixed
75% of Rating
Included on Inventory
Routine Maintenance
CIHQ - All Rights Reserved 2017

19. Temperature/Humidity
Proper ranges
No corrective action
ASHRAE
CIHQ - All Rights Reserved 2017

20. CIHQ - All Rights Reserved 2017
Ventilation
Improper pressures
ASHRAE
CIHQ - All Rights Reserved 2017

21. Medical Gas Shut-off Valves
Properly Labeled
Blocked Access
CIHQ - All Rights Reserved 2017

22. CIHQ - All Rights Reserved 2017
Fire/Smoke Barrier
Unsealed penetrations NFPA
Not properly marked on the Life Safety drawings
Doors NFPA
CIHQ - All Rights Reserved 2017

23. CIHQ - All Rights Reserved 2017
Sprinkler
Missing escutcheon NFPA
Items being supported on sprinkle pipe NFPA
Spare sprinkler heads/wrench NFPA
Testing documentation
CIHQ - All Rights Reserved 2017

24. CIHQ - All Rights Reserved 2017
Hazardous Areas
Not properly identified on drawings
Doors not latching NFPA /
Not properly rated room
CIHQ - All Rights Reserved 2017

25. CIHQ - All Rights Reserved 2017
Doors
Fire doors having missing or painted over rating labels NFPA
Not properly latching NFPA
Door wedges NFPA
CIHQ - All Rights Reserved 2017

26. CIHQ - All Rights Reserved 2017
Means of Egress
Hallway clutter NFPA /
Special Locking Arrangements NFPA /
Confusing Exits NFPA
Wheeled Equipment
CIHQ - All Rights Reserved 2017

27. © CIHQ – All Rights Reserved 2017
That’s Enough
Thanks for listening.
Any Questions?
  
© CIHQ – All Rights Reserved 2017