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7.II. Infection Prevention and Control and Safety: Safety Standards
7.II.M. Fire prevention and safety are addressed in the written safety program.
7.II.M.1. Fire prevention and hazard policies are followed
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7.II. Infection Prevention and Control and Safety: Safety Standards
7.II.A. A written safety program approved by the governing body addresses the environment of care, the safety of patients, staff, and others, and meets or exceeds local, state, or federal safety requirements.
7.II.A.2. Processes for managing hazards, threats, near misses, safety concerns
7.II.A.3. Program includes processes to avoid medication errors
7.II.A.4. Program includes processes to prevent and report falls and physical injuries
7.II.A.6. Program includes practices to prevent skin and tissue injury from chemicals, cleaning solutions, hazardous exposure
7.II.B. The safety program requires performance of a proactive, documented risk assessment before commencing demolition, construction, or renovation while the facility is occupied.
7.II.B.1. Risk assessment identifies risks to occupant health or safety
7.II.B.2. Identifies actions to eliminate or mitigate risks
7.II.B.3. Monitoring and updating the risk assessment
7.II.F. All products including medications, reagents, solutions, and supplies that have a manufacturer's printed expiration date are monitored and disposed of in compliance with facility policy and manufacturers' guidelines.
7.II.F.1. Policy for monitoring and disposal of products
7.II.F.2. Policy describes monitoring products for currency
7.II.F.3. Policy complies with guidelines and regulations for disposal or return of expired items
7.II.G. A system exists for proper identification, management, handling, transport, and disposal of hazardous materials and wastes, whether solid, liquid, or gas.
7.II.G.1. Proper labeling of hazardous materials and waste
7.II.G.2. Management and disposal of hazardous materials per regulations
7.II.G.3. Responsible personnel demonstrate knowledge of laws and regulations
7.II.H. The temperature of items that are frozen, refrigerated, and/or heated is continuously monitored to ensure that the product manufacturer’s recommended temperature range is maintained.
7.II.H.1. Mechanism for temperature measurement (frozen, refrigerated, heated items)
7.II.H.2. Temperature monitoring documentation
7.II.H.4. Staff trained in temperature monitoring
7.II.I. A written policy requires documentation of the pre-cleaning, transport, and handling of medical devices intended for external vendor reprocessing, inspection, or repair.
7.II.I. Resources
7.II.J. Reprocessing of manufacturer-labeled single-use devices complies with FDA regulation and is limited to devices approved for reprocessing in accordance with FDA 510(k) clearance.
7.II.J.1. Approval for reprocessing single-use items
7.II.L. Prior to use, appropriate education is provided to intended operators of newly acquired devices or products to be used in the care of patients.
7.II.L.1. Designated person responsible for ensuring education before device or product use
7.II.M. Fire prevention and safety are addressed in the written safety program.
7.II.M.1. Fire prevention and hazard policies are followed
7.II.M.2. Fire safety surveillance includes fire safety, fire prevention, and fire drills
7.II.N. Health care workers are protected from biologic hazards, consistent with prevailing laws and regulations and nationally recognized guidelines.
7.II.N.1. Occupational health and safety regulations implemented by governing body
7.II.N.2. Exposure control plan reviewed, updated annually includes evaluation of safer devices
7.II.N.3. Immunization program offered to all staff
7.II.N.4. Tuberculosis detection and protection for all staff
7.II.O. Procedures addressing bloodborne pathogens are in place.
7.II.O.1. Hepatitis B vaccination program
7.II.O.2. Postexposure evaluation and treatment
7.II.O.3. Training in and communication of hazards
7.II.O.4. Record keeping and management
7.II.P. A program is maintained to assess and reduce risks associated with occupational chemical exposures.
7.II.P.1. Hazard assessment of chemicals in the workplace
7.II.P.3. Worker training programs included and documented in personnel files
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Element of Compliance
Fire prevention and hazard policies are followed
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