Robert Beckmann, CHFM, CHSP-Life Safety Code Specialist

 

Surveyor Program(s): Hospital

Surveyor Tenure: x 2008

Lives: Texas

TJC Bio:

Other Background:

• Currently CHFM certified (as of 10/31/12) in the state of Texas (1/30/2002 to 1/31/2014) – [CHFM Certifications by State]
• Member of ASHE – American Society for Healthcare Engineering   [2011 ASHE Recognition Program]

Comments & Recommendations

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** Sample Survey Citations (Premier Level)**

[private Membership premier]

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Sample Citations:

2013

2012

• EC.02.06.01/EP 20/ Observed in Individual Tracer – DNP standing wat
  • The library in the 7 A unit treatment mall was being used as a group room. A desk in the corner of the room was in obvious disarray. A scattered pile of papers supported a plastic mesh box with specimen containers and loose tissues. A three hole punch machine was on the floor under the desk. This space was not inviting or in keeping with a clean, safe, and functional patient environment.
  • Group room 124 in the unit 7 treatment mall was observed. A styrofoam cup was on the floor, as was a poster that had fallen off of the wall. A pile of brown, organic material which appeared to be smoking tobacco, was on top of a chest-high cabinet used to store group supplies. The condition of the space was not in keeping with a clean, functional environment.
  • During the review of the patient sleeping rooms and common areas on unit 7B , it was noted that the iron window protector located in patient bedrooms had layers of dust and debri on them and there were items which had accumulated due to patients pushing cigarette butts and other items there. There was evidence of a need to conduct more extensive environment of care rounds, and to keep these patient occupied areas clean.
    
• EM.02.02.15/EP 2/ Observed in Emergency Management Session – The hospital had not identified, in writing, those individuals responsible for assigning disaster responsibilities to volunteer practitioners who are not licensed independent practitioners.
  
• EM.02.02.15/EP 4/ Observed in Emergency Management Session – The hospital had not described, in writing, how it will oversee the performance of volunteer practitioners who are not licensed independent practitioners who have been assigned disaster responsibilities.
  
• EM.03.01.01/EP 3/ Observed in Emergency Management Session – The hospital EOP stated the inventory would be reviewed at least annually and the results documented in the Safety/Environment of Care Committee Minutes. There was no documentation of a review in the past 12 months of minutes.

2010 (Med Surg Hospital)

• EC.02.02.01/EP 7/ Observed in Environment of Care Session – There was no written documentation that the individuals that had signed the generator’s certification, on the hazardous material shipping document for medical waste, had received US Department of Transportation training for the safe packaging and transportation of hazardous materials.
• EC.02.03.05/EP 1/ Observed in Document Review – There was no written documentation that the “fire pump running” and “fire pump power loss” supervisory signals had been tested quarterly in 2010.
  
• EC.02.05.07/EP 6/ Observed in Document Review – There was no written documentation that the transfer switch, that serves the fire pump for the Lutheran building, had been tested monthly. It had not been part of the monthly generator load test. It did not appear on the list of automatic transfer switches on the monthly generator test form.
  
• LS.02.01.10/EP 9/ Observed in Building Tour – There were penetrations, in the floor of mechanical rooms P4 and P5 that were not properly sealed.
  
• LS.02.01.30/EP 11/ Observed in Building Tour – The corridor door, to patient room 9, had paper stuffed into the strike plate causing the door not to close properly and positive latch.
  
• LS.02.01.30/EP 18 / Observed in Building Tour – There was a cable tray penetrating the smoke partition wall, by room P11 that was not properly sealed.
  

2009

• EC.02.06.01/EP 1/ Shower mixer valve cab unlocked, plastic switchplates w/non-tamper screws, wires exposed
• EC.02.06.01/EP 20/ DNP standing water and trash/cig butts in outside area t
• LS.02.01.10/EP 5/ Fire door not latching @School>Pt Area •EP09: Penetrations in firewall schl>Pt area
• LS.02.01.30/EP 18 Multiple smoke partition wall penetrations
• LS.02.01.10/EP 9/ There were penetrations, in the floor of mechanical rooms and cable trays penetrating the fire rated walls
• LS.02.01.30/EP 11/ The corridor door, to patient room ###, had paper stuffed into the strike plate causing the door not to close properly and positive latch.
• LS.02.01.30/EP 18/ There was a cable tray penetrating the smoke partition wall

 

 

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