1. Physical Environment: Most Common Surveyor Findings
Presented by
Brad Keyes, CHSP
Jamie Crouch, BSBM, MHA

2. Topics… Today, we will cover the following topics:
Top findings regarding the Physical Environment by HFAP surveyors
Frequent Issues with the Document Review Session
Questions you may have…

3. Top Physical Environment Findings
The following are the top findings cited by HFAP surveyors regarding the Physical Environment…
They are listed in the order of frequency cited…

4. Top Physical Environment Findings
– Eyewash Stations and Emergency Showers
Eyewash stations observed do not meet ANSI Z requirements
Most common deficiency issue with the non-ANSI approved eyewash stations is they do not operate within 1 second

5. Top Physical Environment Findings
– Eyewash Stations and Emergency Showers
Other problems with eyewash stations include improper use of the eyewash stations… in this case access to the eyewash station is obstructed

6. Top Physical Environment Findings
– Eyewash Stations and Emergency Showers
Still other problems include lack of weekly flushing… for both the eyewash stations and the emergency showers
Some eyewash station were not located within 10 seconds of the caustic or corrosive chemicals (which is usually considered to be 55 feet)
Some eyewash stations did not deliver ‘tepid’ water (60°F to 100°F)

7. Top Physical Environment Findings
– Eyewash Stations and Emergency Showers
Portable squeeze bottles by themselves are not a violation; However, they are not permitted in lieu of ANSI Z approved eyewash stations

8. Top Physical Environment Findings
– Eyewash Stations and Emergency Showers
You may download your own copy of the ANSI Z standards from the ANSI Webstore at:

9. Top Physical Environment Findings
– Eyewash Stations and Emergency Showers
Where injurious corrosive materials exists, the hospital must conduct a risk assessment to determine if an eyewash station is required.
Eyewash stations are only required if caustic or corrosive materials can be splashed into the eyes (the risk assessment must assume PPE is not worn).

10. Top Physical Environment Findings
– Building Safety
Rooftop exhaust fans serving isolation rooms were not marked with a Bio-hazard symbol
A key was observed to be left in the controls to operate the compactor

11. Top Physical Environment Findings
– Building Safety
Rust, slime and dirt were observed inside HVAC air handler units
Dirty and rusty HVAC air diffusers were observed

12. Top Physical Environment Findings
– Building Safety
This standard is also a CMS standard and encompasses the overall hospital environment regarding general safety.

13. Top Physical Environment Findings
– Fire Drills - Quarterly
Fire drills are not performed within the proper time-frame
No hospital-wide fire drills conducted (Fire drills were conducted locally without activating the fire alarm system)
No fire drills conducted at offsite locations

14. Top Physical Environment Findings
– Fire Drills - Quarterly
Fire drills must be conducted quarterly on all shifts classified as healthcare occupancy and ambulatory occupancy.
Fire drills must be conducted annually on all shifts in business occupancies.

15. Top Physical Environment Findings
– Fire Drills - Quarterly
Fire drills must be conducted without prior warning (no overhead announcement “This is just a drill”).
Fire drills must simulate emergency conditions.
The fire alarm system MUST be activated each time a drill is conducted; however between the hours of 9pm and 6am a coded announcement may be used in lieu of activating the audible alarms

16. Top Physical Environment Findings
– Fire Drills - Quarterly
Fire drills should take into consideration of the non-customary shifts and weekend/holiday shifts.
Quarterly fire drills are conducted 3 months from the previous drill, plus or minus 10 days.

17. Top Physical Environment Findings
– Fire Drills - Quarterly
Annual fire drills are conducted 12 months from the previous drill, plus or minus 30 days.
Staff participate in each drill in accordance with the hospital’s policy.

18. Top Physical Environment Findings
– Medical Equipment & Systems - Maintenance
Rusty medical equipment located in Surgery
Medical equipment not inspected

19. Top Physical Environment Findings
– Medical Equipment & Systems - Maintenance
Past-due inspections performed on medical equipment
No annual evaluation of the CMS AEM program
NOTE: Hospitals that choose to use the CMS AEM program must comply with all of the requirements identified in

20. Top Physical Environment Findings
– Medical Equipment & Systems - Maintenance
While stickers applied to medical equipment identifying the next inspection due date are not a requirement of this standard, there must be some form of effective communication to the staff on the current preventative maintenance program of that equipment.

21. Top Physical Environment Findings
– Ventilation, Light, and Temperature Controls
No monitoring of ventilation of sensitive areas (i.e. Central Processing; Clean/Dirty Utilities Rooms)
15 air changes per hour (ACH) were not maintained in Surgery (Identified in a report)
Improper air pressure relationships of Clean/Dirty utility rooms and Central Processing room

22. Top Physical Environment Findings
– Ventilation, Light, and Temperature Controls
The hospital should follow standards on ventilation as appropriate, based on state and local regulations. In the absence of specific ventilation requirements, then recommendations from AORN, CDC and FGI Guidelines should be followed. Hospitals are not expected to retroactively comply with current ventilation requirements, unless other HFAP standards require it.

23. Top Physical Environment Findings
– Periodic Monitoring for Safety Issues
Safety inspections are not conducted twice per year in patient care areas
When safety inspections are conducted, not all areas are actually inspected
Some hospitals mistakenly think all business occupancies (i.e. physician’s offices) are only to be inspected once per year

24. Top Physical Environment Findings
– Periodic Monitoring for Safety Issues
The physical environment of each facility used for treating or housing patients must be inspected once every six months in patient care areas, and once every 12 months in non-patient care areas.

25. Top Physical Environment Findings
– Storage and Disposal of Trash
Soiled utility room doors were not locked
(NOTE: There is no direct requirement for soiled utility room doors to be locked, but if there is a perceived risk to safety with the door being unlocked, then a finding may result if the organization does not have a risk assessment on the issue)

26. Top Physical Environment Findings
– Storage and Disposal of Trash
Trash accumulating around the trash compactor
The hospital did not have any policies on the routine order of trash

27. Top Physical Environment Findings
– Storage and Disposal of Trash
The term trash refers to common garbage as well as bio-hazard waste. The storage and disposal of trash must be in accordance with Federal, State, and local laws and regulations.

28. Top Physical Environment Findings
– Required Plans & Performance Standards
There was no annual review of the PE management plans

29. Top Physical Environment Findings
– Required Plans & Performance Standards
Management plans must be reviewed and approved at least once every 12 months by the organization’s safety committee. The annual review must be documented.

30. Top Physical Environment Findings
– Security Sensitive Areas
The organization did not identify their Security sensitive locations
The hospital must identify areas that they consider to be security sensitive (i.e. Nurseries, L&D, ICU, Admin, HR, Medical Records, Lab, Pharmacy, etc.), and have control systems (i.e. approved door locks) in place to protect the areas and contents.

31. Top Physical Environment Findings
– Hazardous Materials – Routine Monitoring
The organization had not monitored Zylene and Formalin in the Lab since 2012
Hazardous materials in general had not been monitored

32. Top Physical Environment Findings
– Hazardous Materials – Routine Monitoring
A hazardous material is defined as any substance or materials that could adversely affect the safety of the public, handlers or carriers during use, transportation, storage, or disposal.

33. Transition…
Now let’s look at the frequent problems with the document review session for the Physical Environment…

34. Frequent Issues with Document Review
Lack of a risk assessment conducted for an eyewash station where caustic or corrosive materials are used.
No documentation of weekly flushing and annual inspections of eyewash stations and emergency showers.

35. Frequent Issues with Document Review
Quarterly fire drills not conducted within the 3 months plus or minus 10 day window.
The PE management plans do not address all of the required information in the HFAP standards. Performance Improvement (PI) goals are not stated in the management plans.

36. Frequent Issues with Document Review
Lack of temperature/humidity documentation of critical areas, and lack of ventilation documentation for air-pressure relationships and air changes per hour is sensitive areas.
Lack of follow-up documentation on issues observed during routine inspections.

37. Frequent Issues with Document Review
Lack of policies on the proper storage and disposal of trash.
Lack of documentation on routine monitoring of hazardous materials.

38. Achieving Accreditation…
Achieving Accreditation for Hospitals and Life Safety Code Education, September 23 — 24, 2016
This is an HFAP event that is being held in Washington, DC on September

39. Achieving Accreditation…
This is a must-attend seminar for hospital leaders seeking to demonstrate compliance with the CMS hospital conditions of participation (CoPs). Over the past three years, CMS has updated a multitude of federal regulatory expectations across all hospital service lines

40. Achieving Accreditation…
During this same time, CMS has increased scrutiny regarding compliance with the hospital conditions of participation (CoPs).
Regardless of its accreditation organization, facilities accredited by the AOA/HFAP, Joint Commission, CIHQ, and DNV Healthcare must all demonstrate significant compliance with these regulations.

41. Achieving Accreditation…
HIGHLIGHTS……
NFPA Life Safety Code New Requirements
On May 4, 2016, CMS approved the 2012 edition of the NFPA 101 Life Safety Code.
Attendance at this portion of this seminar will prove to be indispensable when preparing for the LSC/EM/Physical Environment portion of an HFAP survey.

42. Achieving Accreditation…
Content includes…
Identification of environmental deficiencies that may trigger a Condition-level deficiency, such as locked paths of egress, medical gas systems, and more.
Identification of testing and inspection requirements
Frequency for conducting these required tests and inspections

43. Achieving Accreditation…
Content includes….
How to ensure vendor reports document all required items
Identification of required elements of an Emergency Operations Plan, including disaster drills and the all-important Business Continuity Plan
Identifying potential Condition Level Findings, and Immediate Jeopardy issues.

44. Achieving Accreditation…
Registration details have already been sent to your hospital accreditation compliance coordinator.
For further questions regarding this seminar, please contact Pam Holloway at or at

45. Questions….

46. Want to ask Questions later?
Contact Brad Keyes at:
Or, please submit questions to:

47. Certificate of Attendance
___________________________
Awarded 1.0 contact hours
Physical Environment: Most Common Surveyor Findings
A 60 minute audio-conference
August 18, 2016
_________________
Brad Keyes, Presenter
HFAP Engineering Advisor