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Surgery center staff must conduct research about and work proactively to comply with all federal, state, and local requirements, as well as accreditation standards. If attention to the Life Safety codes is lax, ambulatory surgery centers (ASCs) might experience code problems related to the National Fire Protection Association (NFPA) codes or Occupational Safety and Health Administration (OSHA) regulations.
One of OSHA’s common questions when it finds a violation during a survey is, “Did you know about your violation?” The next question is, “Should you have known about your violation?” says Thomas Salamone, vice president of the Long Island Healthcare Life Safety Association in Ronkonkoma, NY. The association conducts audits to help organizations prepare for a department of health inspection. “They refer to this as a general duty clause,” Salamone says.
To avoid OSHA and other citations, Salamone says ASCs might pay attention to the following 10 areas:
1. Bloodborne pathogens. Common citations are for failure to maintain a written exposure plan, failure to complete an annual review of the written exposure plan, and failure to conduct a safer medical device assessment, Salamone explains.
ASCs should develop — or adapt from other sources — an exposure plan. They can start with a template and customize it for their own facility, Salamone offers.
“I had one facility that used an exposure plan from another facility, and the sad part was they didn’t go through the document and change it, so the name of the other surgery center was on their plan, and that became a real nightmare,” Salamone recalls. “I said, ‘If you use another facility’s plan, then retype it or do a word search.’”
OSHA also might cite ASCs for failure to train employees about handling sharps, blood products, or other infectious material. The training must be competency-based.
“What I usually recommend is to develop a questionnaire of 10 questions with the goal that employees demonstrate a 90% competency level,” Salamone says.
The questionnaire, if administered during one-on-one instruction, can include open-ended questions. If it’s in a classroom, it could be written and include multiple choice and true-false questions. Other problems might include failure to use needleless devices, improper placement of sharps containers, or maintenance of sharps containers.
“Make sure the sharps containers do not go above the fill line,” Salamone warns. “Let’s say you have a surgery center that takes care of children. You want to make sure that container is not within their reach. Some centers put it right by the exam table, and when you turn your back on the child, they might go through it.”
2. Hazard communication. Common citations are failure to maintain a written program that outlines the flammables, corrosives, and hazards encountered in the workplace. Other citations include:
• failure to maintain training;
• failure to maintain labeling;
• failure to maintain a safety data sheet.
“In the old days, these were referred to as material data sheets,” Salamone says. “Now, these are referred to as safety data sheets to make it more global. They know what safety data sheets are anywhere in the world.”
A written exposure program for bloodborne pathogens is an inventory of flammables, corrosives, and hazards. It includes the necessary personal protective equipment.
“You have to notice what the hazardous materials are and have precautions in place,” Salamone says.
Labeling problems can occur when someone transfers chemicals from one container to another without labeling the new container.
“There’s an exception if you transfer chemicals from one container to another and it doesn’t leave your possession,” Salamone notes. “But if you don’t label it and put it in a room, you don’t know who could walk in and use it.”
The label must include a NFPA diamond that shows whether the chemical is flammable and corrosive, he adds.
3. Respiratory protection. As with the others, failure to create a written program is a top citation. Others are failure to:
• provide a medical evaluation to determine the employees’ ability to use a respirator;
• provide respirators;
• ensure the use of tight-fitting face pieces or fit-testing;
• identify and evaluate respiratory hazards.
“You want to make sure the respirator fits the face,” Salamone says. “Make sure it’s tight-fitting.” All these actions should be performed and then put in writing. “If it’s not in writing, then it didn’t happen,” Salamone adds.
4. Electrical safety. ASC directors can start by checking extension cords and wires. Other common problems involve:
• open junction boxes: “Sometimes you find an electrical box above the ceiling, and the cover is missing,” Salamone says.
• unsecured electrical panels: All electrical panels must be secured, labeled, and unobstructed, Salamone stresses.
• improper ground fault circuit interrupters: “If you have an electrical receptacle within six feet of a water source, they must have GFCI,” Salamone notes.
• improper electrical receptacles: “Are they properly inspected, tested, and maintained?” Salamone asks. “This is really important because a lot of facilities don’t know the code requirement, so they’ll have a policy that says, ‘I inspect all receptacles once a year.’ But how do you prove that? And, two, is it required?”
Consider this an issue for all policies and procedures: If an ASC puts an action in its policy and the action is not in code or required by a regulatory or accreditation organization, then the ASC has increased the requirement, Salamone explains.
“For example, the code says you only need to test and maintain certain receptacles, but if you put in the word ‘all,’ then you’ve increased the code,” he adds.
“Many of the violations in surgery centers, with respect to the department of health and the feds, are very expensive,” Salamone says. “They mainly deal with electrical and fire safety.”
One new code concerns the proper electrical protection for wet procedure locations. This means that if ASCs are conducting procedures that cause a wet environment and there’s a risk of pooling water in the surgery center, then the centers must use either GFCIs or line isolation monitors.
“The code allows either, but the line isolation monitors are much more reliable,” Salamone offers. “GFCIs sometimes fail prematurely, and you don’t want that to happen on that table.”
Other items that can create safety problems are space heaters and microwaves.
“Nurses are great at providing nursing, but they don’t know how to make popcorn,” he says. “There are a lot of records of fires in microwaves that are being used for popcorn.”
The simplest solution is to ban popcorn from the center’s microwave. This prohibition should be put in writing, preferably on the door of the microwave.
5. Asbestos. ASCs must perform an exposure assessment and identification, depending on the age of the facility. The assessment will identify areas that contain asbestos or the potential for asbestos. Facilities built within the past two decades should not contain asbestos. In facilities built in the middle part of the 20th century, asbestos could exist. There’s a problem when asbestos becomes friable, meaning it has been disturbed, Salamone notes.
“OSHA says that if you don’t know if it’s asbestos or not, you have to assume it is, and you need to have written plans and policies in place for identifying and handling asbestos,” he adds.
6. Egress routes. The Life Safety Code calls for facilities to install adequate aisles with a clear width. Also, all exits must be maintained and not locked for exiting. Deadbolts are not allowed.
“Unfortunately, in this world, we lock a lot of exits, but we have to lock them [to keep strangers from entering] and not from coming out of the building,” Salamone says. “Make sure you have proper maintenance of the ingress and egress of your facility.”
Use the Life Safety Code for compliance, following its rules on keeping exit routes free and unobstructed, Salamone adds.
7. Recordkeeping. Two big deficiencies include failure to comply with OSHA 300A and 301 forms for recording injuries and illnesses and failing to enter information within seven calendar days and posting records when necessary, Salamone says.
“They have to post, by Feb. 1 of every year, their OSHA logs,” he says. “They have to be posted in an area where all employees can see them.”
Many facilities post these notices by the punch clocks. The logs list how many people were hurt and the number of lost work days.
8. Eye wash stations. In terms of OSHA citations, eye wash stations are hot, becoming the most cited item in recent months, Salamone says.
“They’re on their way up, being cited so much,” he says. “Basically speaking, you have an eye wash station wherever corrosives and caustic chemicals are used. They have to be proper, and eyes have to be plumbed with tepid water.”
OSHA requires facilities to make a bottle available for eye washing. It must hold at least six gallons.
“What I find is people put these squeeze bottles in the eye wash stations, and they don’t hold six gallons,” Salamone explains. “Are they located where they need to be? Are they properly located? Are they high off the floor?”
The stations should be situated so that staff can put their heads in there and flush their eyes with water. There should be 0.4 gallons of water per minute for 15 minutes, which is six gallons total, Salamone says.
“Sometimes when I’m doing an audit, I point out which items are corrosive,” he says. “The problem is people often don’t know what is corrosive and caustic. The easiest way to find out is to go to the safety data sheet and look at the chemicals.”
9. Portable fire extinguishers. To comply with NFPA codes, ASCs must maintain fire extinguishers and store them in proper locations.
“You’re supposed to do a monthly visual inspection and then an annual maintenance,” Salamone says. “The monthly inspection can be done in house — you just need someone who is knowledgeable about what to look for.”
Salamone has trained maintenance staff to perform monthly fire extinguisher inspections. “They need to heft the fire extinguisher, picking it up to see if it feels like it’s full,” he explains.
10. Automatic sprinkler systems. Proper placement and maintenance is required for NFPA and Life Safety Code compliance.
“The problem is that people are not educated in those codes,” Salamone says. “Maybe sprinklers are not located with respect to their area of coverage and location.”
Also, the ASC should perform a fire protection audit, studying the number of sprinkler heads per room and how those heads are spaced.
“If rooms are used as office space or an exam room, the sprinkler head spacing would be less than if they were placed in a storage room,” Salamone explains. “For light hazard sprinklers, you need 225 square feet; for ordinary hazard sprinklers, you need 130 square-foot spacing.”
Financial Disclosure: Editor Jonathan Springston, Editor Jill Drachenberg, Editorial Group Manager Terrey L. Hatcher, Author Melinda Young, and Nurse Planner Kay Ball, RN, PhD, CNOR, FAAN, report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study. Stephen W. Earnhart discloses that he is a stockholder and on the board for One Medical Passport.
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