982 hospital environmental inspection team 12-7-06

7/29/2019 982 Hospital Environmental Inspection Team 12-7-06

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Coalinga State HospitalPATIENT RESTRICTED

OPERATING MANUALSEC-TION - HUMAN RESOURCESADMINISTRATIVE DIRECTIVE NO. 982(Replaces AD 982 dated 111 9106)Effective Date: December7, 2006

SUBJECT: HOSPITAL ENVIRON MENTA L INSPECTION TEAMI. PURPOSE

The Hospital Environmental lnspection Team (HEIT) serves as a proactive corr~ponentfor enhancing the Safety Surveillance Program at Coalinga State Hospital (CSH).This is accomplished through regularly scheduled facility inspections.The HElT assesses the environment for potential risk factors that may pose harm orliability to Individuals, employees, visitors, and the hospital. Inspections include, butare not limited to, patient residential and treatment areas, the visiting center, dininghalls and the equipment designated to each of these locations. It is the responsibilityof all employees at CSH to ensure the hospital maintains a safe and effective workingenvironment.

II. AUTHORITYCalifornia Code of Regulations (CCR), Section 6400; Title 8, Section 3203 (Injury andIllness Prevention Program (IIPP); Title 22, Division5, Chapters 2&4; Department ofJustice Recovery Model.

Ill. POLICYCSH shall maintain a proactive Environmental Safety Surveillance Program.Environmental inspections shall be conducted in pre-designated patient care areasweekly. Additionally, environmental inspection rounds, outside of patient care areas,shall be conducted bi-annually.

IV. METHODA. Hospital Environmental lnspection Team

The HElT shall conduct hazard surveillance activities of all hospital areas,provide on-going consultation, and assist staff as requested or required. Teammembers who are unavailable on the day of the inspection shall arraqge for analternate to take their place.

A.D. No. 982


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PATIENT RESTRICTEDThe HElT shall include:a. Clinical Services Representativeb. Fire Chiefc. Health and Safety Officerd. Hospital Police Services Representativee. Housekeeping Representativef. Plant Operations Representative9. Public Health Nurseh. Standards Compliance Representativei. Guests

2. The HElT shall visit specified areas determined by the Health and SafetyDepartment's Master Environmental lnspection Schedule, theenvironmental survey, injury reports, Quality Assurance Committeeissues, andlor other data made available to the team. The HElT shalluse the Environment of Care lnspection Checklist (Attachment) todocument all inspections. Contact the Health and Safety Officer to viewthe Master Environmental lnspection Schedule or lnspection Checklist.. At the conclusion of the inspection, the HElT shall provide the areamanagerlsupervisor with a verbal debriefing of findings so immediateissues andlor concerns may be addressed. A written report of thefindings will be provided to area managerslsupervisors for correctiveaction. The Health and Safety Committee will also be provided with acopy of the report for review.

4 . The Program DirectorlDepartment Manager shall be responsible forensuring that all identified risks in their area are corrected in a timelymanner. A Plan of Correction (POC) will be initiated by the ProgramDirectorlDepartment Manager for all deficiencies noted. If a work orderis required, the Prograrr~DirectorlDepartment Manager will verify thestatus and notify the Health and Safety Officer upon completion. TheHealth and Safety Unit will conduct on-site audits to verify completion.B. Environmental Safety Surveillance Program

1. The surveillance shall include a HElT and safety representatives fromeach programldepartment:

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PATIENT RESTRICTED

All employees are responsible to correct or report unsafeconditions to the appropriate supervisory personnel. Supervisorsshall report unsafe condi~tions, hich cannot be correctedimmediately, to the appropriate departmentlprogram. If theunsafe condition is not corrected in a reasonable amount of time,the Health and Safety Unit should be notified.b. Safety Representatives

Safety Representatives or assigned personnel shall conductmonthly inspections of the work area in their departmentlprogram.The representatives shall report immediately to supervisory and/ormanagement any unsafe condition(s) or practices seen duringinspection or at any other time.V. DATA COLLECTION PROGRAM

After each inspection, the Health and Safety Unit will review collected data anddistribute copies of findings with noted deficiencies to team members for follow-up onPOCs with area manager/supervisor. When POCs are completed, team members willnotify the Health and Safety Unit. The Risk Manager will serve as a consultant to theHElT and will assist the Health and Safety Unit compile and analyze collected data togenerate reports pertaining to the environmental status of the hospital.VI. REPORTING

The Standards Compliance Department and the Health and Safety Unit shall produceand distribute a bi-annual report on the inspection findings to the Manager's Meetingand the Governing Body. Additionally, the Health and Safety Committee Chair will beresponsible for tracking all Plans of Correction and their associated time frames toensure that each are completed in a timely manner. All Plans of Correction shall besubmitted to the Health and Safety Unit upon completion.

VII. INSPECTIONSThe schedule shall be published annually by the Health and Safety Department. Acopy of the schedule will be distributed to all departnient heads no later thanDecember 31'' each year.

W. T. VOSSExecutive DirectorAttachment - Environment of Care Inspection Checklist

A.D. No. 982


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Department of Mental HealthEnvironmen t of Care Inspection C hecklist

Facility: Coalinga State Hospital

I. INSPECTION PROCESS:A. This document w ill be used to inspect all areas of the Hospital at least twice a year

1 . At least one program 1department will be completed monthly2. The H ealth & Safety Inspection Team will adhere to the procedures outlined inHospital Adm inistrative Directive # 9823 . The com pleted report will be routed as follows:a. Supervisor of the area inspectedb. Health & Safety Officerc. Hospital Administrator -All Hospital De partmentsd. Clinical Administrator - All Hospital Programse. Standard Compliance by the1f the following monthf. Safety Committee4. The Supervisor of the area inspected, shall be responsible for working with the a ppropriatedepartment(s), discipline(s), comm ittee(s) to correct any deficiencies identified5. Deficiency correction is to be documented on this report and returned to theHealth & Safety office when all deficiencies have been corrected, but no later than 30 daysfollowing the inspection

CSH- Revised October, 2006


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PROGRAM 1DEPARTMENT: UNIT DATE:

1 I. lRE PREVENTIONI lRE SAFETY:

Yes = Compliance - No = Non Compliance NA = Non Applicable (If no, comp lete the other 3 columns)Standard 1 , .1 5 . . ,+ L'.; a 2 -

- 7 . : , , * . $,, .%.- .a) Fire 1 smoke doors are:

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closedfree of obstructionb) Automatic door closures are presentand operativec) Egress areas are clear of obstruction

f) Fire extinguishers are:unobstructed 1 C]!El CII

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d) Emergency exits are:

ConcernslCommendations:

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CSH - Revised October, 2006

marked and visibleilluminatede) Smoke detectors & sprinkler heads arefree of dust

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1 confirm that daily monitoring of personal1 living space is being conductedby staff 1 01 01 01 l o l o lCSH- Revised October, 2006 3


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CSH- Revised October,2006


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when opened and kept no longert h a n d a y s - verified by ensuringPharmacy Staff Med. Room Inspection is



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4.SMOKING:a) IndividualsI taff are not smoking indirect pathway of entrances, exits, ramps,stairwells, windows, or within 25 feet ofplaygrounds or air intakesb) Buildings, patios, and stairwells are freeof ciaarette buttsc) No smoking signs are posted inappropriate areasd) Ashtrays are a minimum of 20 feetaway from entrances, exits and windowse) There is a smoking cessation programfor individuals who want to stop smoking,f) Smoking policy is currentConcernslCommendations:



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1 and inventoriede) Staff know the location of the MSDS

I ConcernslCommendations:)inderf) Staff are aware of what hazardoussubstances they work withg) There is a MSDS sheet for eachhazardous substanceh) Staff are aware of procedures for amercury spilli) Staff are aware of procedural steps totake in the event of a chemical spillj) Emergency criteria (product name,phone #, 1 s t aid, & PPE) are highlighted oneach MSDSk) Staff is aware of what PPE to useregarding each product, and where theyare locatedCSH- Revised October, 2006

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Yes = Compliance - No = Non Compliance NA = Non Applicable (If no, complete the other 3 columns)

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e) Staff know what number to dial in case.of an emergencyf) Radio communication is checked dailyand operableConcernslCommendations:

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I Yes = Com~l iance No = Non Com~l iance A = Non A ~ ~ l i c a b l el f no. com ~le tehe other 3 columns)~ -~. . ,. ., .. . . . . . : ' . Dateo fCorrection. . . . . .. .. . . . ' 1 .. . . . . ., ,


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CSH- Revised October, 2006 12


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13 . DIETETIC SERVICES: SATELLlTlESPersonnela) Staff have a neat appearanceb) UniformI lothing is clean

11qq Elqd) Infections and illnesses reported tosupervisorUtensils 8 Food Handlinga) Proper food handling, use of equipmentand wearing gloves is practicedb) Staff grasp utensils by handles,(spoons, tongs, spatula, forks, etc.)c) Staff pick up and handle glasses by thebase, cups by the handles, etc.Refrigerator Outsidea) Outside is cleanb) Top free of dustc) Door gaskets free of dirt & mold: ingood repaird) Outside motor1 air vent free of dust: ingood working conditionRefrigerator Insid ea) Inside walls & floors clean, shelvescleanb) Motor clean and in good workingconditionc) Calibrated thermometer is present, and

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General Environm ent

Ela) Fans are clean and free of lint andgreaseb) Floors are clean and litter freec) Floor drains are clean, litter free, andare draining properlyd) Trash cans are clean and coveredwhen not in useStationary Hot Carta) Cart are clean and free of crumbs andburned spills

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Main Storerooma) Store area is clean at all times, free


frbm litter and spillsb) Trash cans are emptied dailyc) Floors are swept, mopped andmaintained according to policyd) Desks are kept tidye) Foods are kept 12 inches away fromwalls and 12 inches above the floor onpallets where applicable9 FIFO rotation is practicedg) Absence of storage of pesticides, othertoxic substances and drugs and cleaningsolutionsh) All transport equipment (e.g. carts) arecleani) LockoutI agout procedures are in placefor maintenance of all energizedequipmentRefrigerator@)a) 'Thermometers are reliable: refrigeratorand temps are maintained at 40 deg. F orbelowb) Door gaskets are dirt 1mold free and ingood repairc) Motor clean and in good workingconditiond) Foods are stored in suitable containerse) Foods dated on delivery, expirationdate noted and properly rotated using theFIFO methodf) Refrigerators are not overloadedg) Where applicable, raw foods are storedbelow ready-to-serve foodsh) Specific refrigerator temperatures:1. Meat and Poultry: 32 to 38 F; 75 to85%2. Fish: 30 to 34 F; 75 to 85%

, 3. Eggs: 36 to 38 F; 75 to 85%4. Most Fruits and Vegetables: 40 to45F

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Cal Code- 6 inchesfrom the floor, but nostandard from the wall

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Freezer@)a) Thermometers are calibrated:

Yes = Compliance - No = Non Compliance NA = Non Applicable (If no, complete the other 3 columns)Standard: . . .

' temperature is maintained at 0 deg. F orbelowb) Door gaskets free of dirt and mold; ingood repair

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c) Motor clean and in good workingconditiond) Foods are stored in suitable containers1 e) Foods dated on delivery, expiration


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date noted and properly rotated using theFIFO methodf) If frozen-food products are removedfrom original cartons, they are repackagedin air-tight containers when applicableg) Release mechanism inside freezer door

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is operational to prevent staff from beinglocked in freezer 0 0 0

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I Yes = Compliance - No = Non Compliance NA = Non Applicable (If no, complete the other 3 columns)


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. , , .. , .. . - . . . .. - . . . ' .. . . . , . . .. . . . , . . . ^. , , . , .. : . . , , ..., ..,. . a . .' :I . * , . .. :, . . < , . . ' . . . I . . , .d) Spice room is locked at all timee) The last person who leaves thestoreroom at the end of the day isresponsible to lock the room9 ContrabandI ontrolled items aremonitored and logged per policyg) Security walk-thrus are ongoing anddocumented

Time In : Time Out:

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Inspection Team Members Present:Hospital Police:Fire Chief:Housekeeping:Plant Operations:Public Health:Health & safety:

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ClinicallNursing:Dietetic Services:Guest:Guest:

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982 hospital environmental inspection team 12-7-06

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