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Update of DOH Citations

Update of DOH Citations. Semi-Annual Review of Recent DOH Citations and Other Safety Issues Important to RHQN Members Randy Benson Executive Director Rural Healthcare Quality Network. Update of DOH Citations. Nurse Staffing Committee Fire Doors Fire Extinguishers

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Update of DOH Citations

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  1. Update of DOH Citations Semi-Annual Review of Recent DOH Citations and Other Safety Issues Important to RHQN Members Randy Benson Executive Director Rural Healthcare Quality Network

  2. Update of DOH Citations • Nurse Staffing Committee • Fire Doors • Fire Extinguishers • Fire Suppression System Maintenance • Electrical Wiring and Equipment • Hazardous Areas • Soiled Linen, Trash and Shredding Paper Receptacles • Disaster Plan

  3. Update of DOH Citations • Nurse Staffing Committee • WAC 246-320-111 - (1) Hospitals must: (a) comply with chapter 70.41 RCW and this chapter. • Problem • Not posting nurse staffing schedule and nurse staffing plan in public area as required by RCW 70.41.420. • Staffing Plan Must Be Posted For Public Viewing • Nursing Staff Schedule For Each Shift (Current) Must Be Posted • Not forming a nurse staffing committee as required by RCW 70.41.420 • Provide a Copy of the Nurse Staffing Committee Charter • Provide Minutes of Nurse Staffing Committee Meetings For the Last Three Years

  4. Update of DOH Citations • Fire Doors • Regulation Governed by CMS and NFPA Standards (19.3.6.3) and NFPA 101, 2000 Ed. • 1 ¾ inch thick solid-bonded core wood • Fire Rating of a Minimum of 20 Minutes • Doors in Sprinklered Areas Are Only Required to Resist the Passage of Smoke • No Flammable Materials Hanging on Doors • No Wedges • Doors Close Properly

  5. Update of DOH Citations • Fire Extinguishers • Regulation by CMS (9.7.4.1)and NFPA (10.18.3.5.6, 29.3.5.6) • Properly Maintained (Monthly Inspection, Annual Recharge) (Refill After Use)

  6. Update of DOH Citations • Sprinkler System Maintenance • NFPA Regulations (18.7.6, 19.7.6.4.6.12, FPA 13, NFPA 25, 9.7.5) • Overdue Inspections • Missing Escutcheon Plates • Paint On Sprinkler Head • Obstructed Sprinkler Head • 18” and 24” Rule (Obstacles to Spray Pattern)

  7. Update of DOH Citations • Electrical Wiring and Equipment • Regulation: NFPA 70, National Electrical Code 9, 1, 2 • No Items Blocking Access to Electrical Panels • Improper Use of Extension Cords • Properly Labeled Circuit Breakers and Breaker Boxes • Pediatric Protected Outlets • Portable Space Heaters • Unlocked Electrical Panels and Unlabeled Junction Boxes

  8. Update of DOH Citations • Hazardous Areas • Storage of Hazardous Materials Regulations: NFPA 9.4.1 and 9.3.5.4 • One Hour Fire Rated Construction • Dry Wall or Concrete Block/Poured Concrete • OR, Approved Automatic Fire Extinguishing System • Separated From Other Work Areas By Smoke Resisting Partitions and Doors • Doors Must Be Self-Closing • Proper Fire Resistant Rating on Doors (3/4 Hour)

  9. Update of DOH Citations • Linen, Trash and Shreddable Paper Receptacles • 32 Gallon Maximum • Storage Location (Treated As Hazardous Material) • Limits On Number Of Containers In Work Area

  10. Update of DOH Citations • Disaster Plan • Covered As Part Of EOC Management Plan (WAC 246-320-296) • Annual Emergency/Disaster Risk Assessment • Review and Revision of Disaster Plan • Exercise of Disaster Plan • Evaluation of Disaster Drills • Staff Education Concerning Disaster Plan

  11. Update of DOH Citations • QUESTIONS? Randy Benson 206 577-1821 randyb@wsha.org

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