1. The Second Survey Point of Vulnerability How Should I Prepare for the Facility Tour? Healthcare Engineering Consultants

2. The Second Survey Point of Vulnerability Checklist for all Hospitals in 2008 Smoke and fire doors (at least 2) Smoke and fire compartments (at least 2) Exit stairwells (at least 2) Linen/ trash chutes and receiving rooms Hazardous areas Fire pump Fire annunciator panel Soiled linen rooms Healthcare Engineering Consultants

3. The Second Survey Point of Vulnerability Checklist for all Hospitals in 2008 Medical waste storage Loading dock Kitchen area PFI verification ILSM verification Mechanical equipment rooms Note: For hospitals with > 750,000 square feet of occupied space as indicated on the BBI form, an additional Life Safety Specialist survey day will be scheduled Healthcare Engineering Consultants

4. The Second Survey Point of Vulnerability Checklist for all Hospitals in 2008 Previous list, plus: Emergency generators Medical gas systems Other selected areas Note: Because the Life Safety Specialist will be conducting the facility tour, the nurse, physician or administrative surveyor will have a two or three-hour block to devote to emergency management! Healthcare Engineering Consultants

5. The LSC Building Tour Healthcare Engineering Consultants Life Safety Specialist (LSS) survey responsibilities include: EC.5.20: SOC and Life Safety Code EC.5.40: Fire system tests, building features EC.5.50: Interim life safety measures EC.7.40: Emergency power systems EC.7.50: Medical gas and vacuum systems If the Life Safety Specialist finds other, unrelated issues during the facility tour, they will report those to the JCAHO team leader.

6. The Second Survey Point of Vulnerability What “Operational” Deficiencies are Likely to be Found During the Facility Tour? Healthcare Engineering Consultants

7. Example Operational Deficiencies Healthcare Engineering Consultants What’s wrong with this seal?

8. Healthcare Engineering Consultants Part 3A – Existing Health Care Occupancies

9. Healthcare Engineering Consultants Example Operational Deficiencies Does this look familiar?

10. Healthcare Engineering Consultants Example Operational Deficiencies What is the chair for?

11. Healthcare Engineering Consultants Corridor Interpretations Life Safety Code: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fir or other emergency (7.1.10.1) CMS and JCAHO: An 8-foot clear corridor width must be maintained... CMS permits items to be in the corridor for temporary use of one half-hour or less... Both agencies agreed that computers on wheels (COW’s) may not be plugged in to recharge while in a corridor (Mills, Zimmerman) JCAHO: Carts on wheels permitted in the corridor when in use; COW’s permitted when charting being performed; otherwise store in clean utility rooms or patient rooms (EC News, 2/07) Example Operational Deficiencies

12. Healthcare Engineering Consultants Operating Features A clear space >18 inches below sprinkler heads to the top of storage must be maintained Exception: Perimeter wall shelving, unless below sprinkler; also NFPA 13 exception Portable space heating devices must be prohibited in patient treatment and sleeping rooms, although an exception is provide in non-patient, non-sleeping areas (19.7.8) Combustible decorations are prohibited, unless flame retardant (19.7.5.4) Example Operational Deficiencies

13. Healthcare Engineering Consultants Operating Features Exceptions to “Corridor Clutter” permitted by JCAHO Furnishings, decorations or other objects may not obstruct access, egress or block the visibility of exits (7.1.10.2.1) Exit doors must be free of mirrors, draperies or hangings that may conceal, obscure or confuse the direction of exit (7.5.2.2) Example Operational Deficiencies

14. The Second Survey Point of Vulnerability Questions? Healthcare Engineering Consultants