University of Rochester
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Environmental Health & Safety

JCAHO Response Procedures

I.                   PURPOSE

This procedure provides guidance to EH&S office staff to coordinate notifications of appropriate internal staff who will need to respond to an unannounced JCAHO inspection.  To provide direction to EH&S staff to respond to and prepare for the unannounced inspection.

To gather all pertinent information for the audit that would need to be presented to JCAHO surveyors as supporting documentation to their management plans.

II.                PERSONNEL AFFECTED

Director, Support staff, Manager of Pest Control & Senior Sanitarian, Radiation Safety Officer, SMH Fire Safety Coordinator, Occupational Safety Specialist, IH Technician responsible for ECC Surveys.

III.             DEFINITIONS

IV.              RESPONSIBILITIES

    1. The Director of Environmental Health and Safety will be notified via the hospital JCAHO paging notification system
    2. The Director of EH&S will notify the CFO/Senior Vice President for Administration and Finance
    3. The Director of EH&S will call the Main EH&S Office and notify the front office staff either by direct communication or by voice mail
    4. The front office staff receiving the message will make the following notification:
      1. Manager of Pest Control & Senior Sanitarian
      2. Radiation Safety Officer
      3. Hospital Fire Safety Coordinator
      4. Occupational Safety Specialist
      5. IH Technician responsible for ECC Surveys
    5. After opening meeting, Director will notify front office staff to make the following notification of the EOC document review meeting.
      1. Manager of Pest Control & Senior Sanitarian
      2. Radiation Safety Officer
      3. Occupational Safety Specialist
      4. Med. Center Security Manager (275-3333 and request to be paged)
      5. Clinical Engineering (275-1616 + ID = 6526, 220-2699, 275-5501)

V.                 PROCEDURES

    1. The Director of EH&S will gather one years worth of disaster drill summary reports and after action reports and report to the opening conference. The opening conference will take place in the ACF Board Room.
    2. The Director of EH&S, Radiation Safety Officer, Manager of Pest Control and Senior Sanitarian, Occupational Safety Specialist will accommodate the JCAHO Life Safety Surveyor during the hospital tour.
    3. The Hospital Fire Safety Coordinator will gather the 12 month history of the following documents and bring them to the Hospital’s Director’s Office Conference Room:
      1. Fire detection system testing
      2. Fire door inspections
      3. Weekly fire pump tests
      4. Fixed extinguishing system inspections
      5. Sprinkler main drain test
      6. Helipad foam system inspections
      7. Quarterly circuit tests
      8. Quarterly sprinkler tests
      9. Monthly valve inspections
      10. Semi-annual valve tamper tests
      11. On-site fire drill reports (2-books)
      12. Off-site fire drills/disaster drill reports
      13. Interim Life Safety Assessments
      14. Life Safety Plan (Fire Marshal’s office)
      15. Emergency Preparedness Book (Fire Marshal’s office)
    4. The Hospital Fire Safety Coordinator will then tour the hospital and ensure the following
      1. No doors propped or wedged open
      2. No door latches taped over
      3. All doors and hardware in good repair, all positively latch (unassisted if equipped with a closer)
      4. Stairwells free of obstructions and debris
      5. Corridors free of storage, debris, combustible items or items blocking egress
      6. Electrical and telephone closets free of debris
      7. Ceiling tiles and grids in place and in good repair
      8. Fire extinguisher inspections are current and signs are visible
      9. Fire extinguishers, fire alarm stations, fire hose cabinets, medical gas valves not blocked by storage, properly labeled and inspected
      10. Verify no smoke detectors are covered
      11. Inspect construction sites to ensure fire load is low
      12. Verify extinguishers at construction sites are inspected and hot work activity is compliant with procedures
      13. All exit lights functioning and all exit signs unobstructed
      14. Ensure ILSM measures are posted at all locations
      15. All fire breaches properly fire sealed and patched
      16. Oxygen and other gas bottles upright and properly secured in a stand or chained to prevent tipping NOTE:  Oxygen Storage – if there are more than 12 tanks present you are to contact the nurse manager IMMEDIATELY
      17. Report status to Fire Marshal
      18. Repeat sweeps once per day for the duration of JCAHO’s visit.
    5. The Manager of Pest Control and Senior Sanitarian (Chair, MWMC) will:
      1. Retrieve and make available for the EOC Document Review session the Materials/ Waste Management Committee MWMC) binder.  This binder will contain at a minimum the last 12-month period of meeting minutes, quarterly reports and supporting documentation. The binder also contains the Hazardous Materials/Waste plan and the previous year’s evaluation and supplemental goal accomplishments. The Senior Sanitarian (Chair, MWMC) will be available and present during the EOC Document Review Session and notify other Committee members they should be available for specific questions in their area of expertise.
      2. Participate in the Building Tour for the Dietary and Waste Processing areas.
      3. Be available and prepared to answer questions regarding pest control services and IPM methods routinely used in SMH. Also be available to fill select duties as described above for the Director of EH&S in his absence.
    6.  The Radiation Safety Officer will gather the 12 month history of the following documents and bring them to the Hospital’s Director’s Office Conference Room:
      1. Quarterly reports submitted to ECC
      2. Radiation Safety Management Plan
      3. Quality Assurance Matrix
      4. Records of misadministrations
    7. The Occupational Safety Specialist will have a 12 month history of the following ECC documents available for inspection:
      1. Safety Management Plan
      2. Review of prior year’s Safety Management Plan
      3. Quarterly Safety Management Plan Reports
      4. Quarterly Additional Accomplishments Reports
      5. Laser Safety Report
      6. Employee Incident Reports
      7. Departmental Safety Policy Review Committee Report
      8. Visitor & Patient/Public Areas Report
      9. Blood Exposure Report
      10. Identification of location of all other areas which fall under the Safety Management Plan (i.e. Product Recalls, Smoking Policy)
    8. The Industrial Hygiene Technician in charge of ECC Inspections will compile the last three years worth of ECC Inspection binders to be taken for the document review and aid the Occupational Safety Specialist with any needed up to date sample surveys, quizzes, or other needed documentation for the Safety Management Plan.
    9. All EH&S staff will be available to answer questions or resolve open issues.

VI.              REFERENCES

    1. Emergency Preparedness Plan
      1. Disaster Drills
    2. Life Safety Plan
    3. Safety Management Plan
      1. Laser Safety Plan
      2. Radiation Safety Plan
    4. Hazardous Materials Plan

VII.           APPENDICES/FORMS

    1. Comprehensive Accreditation Manual for Hospitals

VIII.        REVISION HISTORY

Date

Revision No.

Description
     

QUESTIONS? Contact Environmental Health & Safety at (585) 275-3241 or e-mail EH&S Questions.

This page last updated 1/5/2007. Disclaimer.