(a) Building and grounds.

1. (1) The building and equipment shall be maintained in a state of good repair at all times.
2. (2) Facilities and their premises shall be kept clean, neat, and free of litter and rubbish.
3. (3) Rooms for gas-fired equipment shall not be used for storage except for noncombustible materials.

4. (4) Portable equipment shall be:

   1. (A) Supervised by the department having control of such equipment; and
   2. (B) Stored in areas that are not accessible to patients, visitors, or untrained personnel.

5. (5)

   1. (A) Exit access corridors shall be maintained clear and unobstructed of stationary and nonpatient-related portable equipment.
   2. (B) Stationary or portable nonpatient-care furnishings or equipment shall not be stored in an exit access corridor.
   3. (C) Any portable equipment such as a gurney, wheelchair, linen care, etc., that is not actively used within a thirty-minute time period is considered "stored".
   4. (D) The facility's fire plan and training program shall address the relocation of these items during a fire.
   5. (E)

(b) (b) Suite of rooms greater than ten thousand square feet (10,000 sq. ft.).

1. (ii) “Area” is defined as occupiable net floor space.

   1. (F) Encroachments on the width of the means of egress in an exit access corridor by stationary objects or furnishings shall not be allowed.

   2. (G) The width of the means of egress in an exit access corridor shall be defined by physical means such as:

      1. (i) Corridor walls;
      2. (ii) Columns; or
      3. (iii) Other approved methods.

   3. (H) The means of egress may provide both visual and physical barrier design characteristics conducive to establishing a common egress that provides for either:

      1. (i) A change in floor texture; or
      2. (ii) Self-illumination in the dark.
   4. (I) Alternative consideration. Means of Egress Requirements for Health Care Occupancies of NFPA 101 or equivalency per 20 CAR § 43-142.

2. (6)

   1. (A) Each hospital shall develop a written preventive maintenance plan.
   2. (B) This plan shall be available to the Department of Health for review at any time.

   3. (C) Such plans shall provide for maintenance as recommended by:

      1. (i) Manufacturer;
      2. (ii) Applicable codes; or
      3. (iii) Designer.
3. (7) The handwashing facilities in visitors' restrooms and the handwashing facilities used by staff personnel shall be equipped with a soap dispenser and a towel dispenser.

4. (8)

   1. (A) A supply of hot water for patient use shall be available at all times.
   2. (B) A weekly hot water temperature log shall be maintained.

5. (9)

   1. (A) Heating, ventilating, and air conditioning systems shall be operated and maintained in a manner to provide a comfortable and safe environment for patients, personnel, and visitors.
   2. (B) An air filter changeout log shall be maintained.

(b) Maintenance and engineering.

1. (1) The physical plant and equipment maintenance programs shall be under the direction of a person:

   1. (A) Qualified by training and/or experience; and
   2. (B) Licensed where required.

2. (2) Equipment management program.

   1. (A) There shall be a preventive maintenance program designed to ensure the electrically powered patient care equipment used to monitor, diagnose, or provide therapy performs properly and safely.

   2. (B) This program shall be administered by:

      1. (i) Individuals qualified through training and/or experience; or
      2. (ii) Procuring a contractual maintenance agreement.

   3. (C) The following are minimum program elements:

      1. (i) A current list of electrically powered patient care equipment shall be maintained regardless of location or ownership;
      2. (ii)

(b) (b) The elements of these procedures shall be based on the manufacturer's directions;

1. (iii) Each device shall be tested at intervals of not more than six (6) months unless there is documented evidence that less frequent testing is justified;

   1. (iv) Historical records documenting acceptable performance as established by the procedures shall be maintained;

      1. (v) A program to identify and repair equipment failures shall be maintained;
      2. (vi) User or owner departments shall be notified of the status of their equipment when it will be out of service more than twenty-four (24) hours;
      3. (vii) There are operator and maintenance instructions for each device or group of similar devices on the electrically powered patient care equipment list; and
      4. (viii)

(b) (b) This training shall be documented.

1. (3) Utilities management program (UMP).

   1. (A) There shall be a preventive maintenance program designed to ensure that the physical plant equipment and building systems perform properly and safely.

   2. (B) This program shall be administered by:

      1. (i) Individuals qualified through training and/or experience; or
      2. (ii) Procuring a contractual agreement.

   3. (C) This program shall consist of at least the following minimum elements:

      1. (i) A list of physical plant equipment and/or building system or systems shall be maintained regardless of location or ownership;
      2. (ii)

(b) (b) The elements of these procedures shall be based on the:

1. (1) (1) Manufacturer's directions; and/or

2. (2) (2) Experience of the repair technician or operator;

   1. (iii) Equipment and/or building system or systems shall be tested, serviced, or inspected at intervals of not more than twelve (12) months unless there is documented evidence that less frequent service is justified;

      1. (iv) Historical records documenting acceptable performance as established by the procedures shall be maintained;
      2. (v) A program to identify and repair equipment failures shall be maintained;
      3. (vi) User or owner departments shall be notified of the status of their equipment or system when it will be out of service for more than twenty-four (24) hours;
      4. (vii) There shall be operator and/or maintenance instructions for each piece of equipment or building system on the list; and
      5. (viii)

(b) (b) This training shall be documented.

1. (4) Life safety management program (LSM).

   1. (A) There shall be a preventive maintenance program designed to ensure that all circuits of fire alarm and detection systems shall be inspected, tested, and maintained in accordance with NFPA 72.
   2. (B) Analog detection devices that provide automatic self-testing are exempt from the quarterly testing requirement.

   3. (C) This program shall be administered by:

      1. (i) Individuals qualified through training and/or experience; or
      2. (ii) Procuring a contractual maintenance agreement.

   4. (D) This program shall consist of the following minimum elements:

      1. (i) A list of all fire protection equipment or component groups shall be maintained;
      2. (ii)

(b) (b) The elements of these procedures shall be based on the:

1. (1) (1) Manufacturer's recommendations; and/or

2. (2) (2) Experience of the repair technician or operator;

   1. (iii) Fans or dampers in air handling and smoke management systems shall be reliable and functional at all times;

      1. (iv)

(b) (b) Records documenting acceptable performance as established by the procedures shall be maintained;

1. (v) A program to identify and repair equipment and/or component group failures shall be maintained;

   1. (vi) Systems for transmitting fire alarms to the local fire department shall be reliable and functional at all times;

      1. (vii) There shall be operator and maintenance instructions for each piece of equipment and/or component group on the list;
      2. (viii) Individuals shall be trained to operate and maintain all equipment and/or component group on the list; and
      3. (ix) Portable fire extinguishers shall be clearly identified.

2. (5) Emergency procedures program (EPP).

   1. (A) There shall be written emergency procedures or a disaster management plan for utility system disruptions or failures that address the specific and concise procedures to follow in the event of a utility system malfunction or failure of the:

      1. (i) Water supply;
      2. (ii) Hot water system;
      3. (iii) Medical gas system;
      4. (iv) Sewer system;
      5. (v) Bulk waste disposal system;
      6. (vi) Natural gas system;
      7. (vii) Commercial power system;
      8. (viii) Communication system;
      9. (ix) Boiler; or
      10. (x) Steam delivery system.
   2. (B) These procedures shall be kept separate from all other policy and procedure manuals to facilitate their rapid implementation.

   3. (C) These procedures shall contain but are not limited to the following information:

      1. (i) A method of obtaining alternative sources of essential utilities;
      2. (ii) A method of shutoff and location of valves for malfunctioning systems;
      3. (iii) A method of notification of hospital staff in affected areas; and
      4. (iv) A method of obtaining repair services.
3. (6) Policies and procedures shall include job descriptions and orientation practices for employees.

4. (7)

   1. (A) Policies and procedures shall have evidence of ongoing review and/or revision.

   2. (B) The first page of each manual shall have the:

      1. (i) Annual review date; and
      2. (ii) Signature of the department supervisor and/or person or persons conducting the review.

5. (8)

   1. (A) Relevant educational programs shall be conducted at regularly scheduled intervals with no fewer than six (6) per year.

   2. (B) There shall be evidence of:

      1. (i) Program dates;
      2. (ii) Attendance; and
      3. (iii) Subject matter.

6. (9) The department director shall:

   1. (A) Ensure that all employees annually attend mandatory educational programs on:

      1. (i) Fire safety;
      2. (ii) Back safety;
      3. (iii) Infection prevention and control;
      4. (iv) Universal precautions;
      5. (v) Emergency procedures; and
      6. (vi) Disaster preparedness; or
   2. (B) Make provisions to conduct these departmentally.

7. (10) There shall be sufficient supervisory and support personnel to provide maintenance services in relation to the:

   1. (A) Size and complexity of the facility; and
   2. (B) Services that are provided.

8. (11) An ongoing QA/PI program with a liaison with the Infection Prevention and Control and Safety Committees.

   1. (c) Environmental services.

9. (1) The environmental services shall be under the direction of a person:

   1. (A) Qualified by training and/or experience; and
   2. (B) Licensed where required.

10. (2) There shall be written policies and procedures that include:

    1. (A) Cleaning of the physical plant;
    2. (B) The use, care, and cleaning of equipment;

    3. (C) Specific cleaning methods used for:

       1. (i) Operating rooms;
       2. (ii) Delivery rooms;
       3. (iii) Nurseries/infant care units;
       4. (iv) Emergency rooms;
       5. (v) Isolation areas; and
       6. (vi) Other units as appropriate;
    4. (D) Job descriptions;
    5. (E) Orientation practices;
    6. (F) Safety practices;
    7. (G) Infection prevention and control measures;
    8. (H) Methods used for evaluation of cleaning effectiveness;
    9. (I) Personal hygiene;
    10. (J) The selection of housekeeping and cleaning supplies; and
    11. (K) The proper use of housekeeping and cleaning supplies.

11. (3)

    1. (A) The policy and procedure manual shall have evidence of ongoing review and/or revision.

    2. (B) The first page of each manual shall have the:

       1. (i) Annual review date; and
       2. (ii) Signature of the department and/or person or persons conducting the review.

12. (4)

    1. (A) Relevant in-service educational programs shall be conducted at regularly scheduled intervals with no fewer than six (6) per year.

    2. (B) There shall be written documentation with:

       1. (i) Employee signatures;
       2. (ii) Program title/subject;
       3. (iii) Presenter;
       4. (iv) Date; and
       5. (v) Outline or narrative of presented program.
13. (5) Expendable supplies (i.e., soap, paper products, etc.) shall be stored in a manner that shall prevent their contamination prior to use.

14. (6) Solutions, cleaning compounds, disinfectants, vermin control chemicals, and all other potentially hazardous substances that are used in connection with environmental services shall be:

    1. (A) Kept in containers that accurately reflect at least the following:

       1. (i) Content name;
       2. (ii) Concentration of solution; and
       3. (iii) Expiration date and lot number;

    2. (B)

       1. (i) Stored in a secured area.
       2. (ii) Under no circumstances shall these substances be stored in or near food storage or food preparation areas; and

    3. (C)

       1. (i) Selected by the director of environmental services or other appointed qualified person.
       2. (ii) The Infection Prevention and Control Committee shall initially approve the list of chemicals used in the facility and, thereafter, any additions or deletions to the list.
15. (7) A designee from this department shall be a member of the Infection Prevention and Control Committee.
16. (8) The use of common towels and common drinking utensils shall be prohibited.
17. (9) Dry or untreated dusting, sweeping, or mopping, except vacuum-type cleaning, shall be prohibited within the facility.

18. (10) There shall be an ongoing QA/PI program with a mechanism for reporting results.

    1. (d) Linen services.

19. (1) Laundry services shall be under the direction of a person:

    1. (A) Qualified by training and/or experience; and
    2. (B) Licensed where required.

20. (2) There shall be sufficient support personnel to provide linen services in relation to the:

    1. (A) Size and complexity of the facility; and
    2. (B) Services that are provided.

21. (3) There shall be written policies and procedures that include:

    1. (A) Collection of soiled, wet, and contaminated linen;

    2. (B) Transporting of soiled, wet, and contaminated linen to:

       1. (i) The laundry service; or
       2. (ii) A designated area for commercial pick-up;
    3. (C) Storage of soiled, wet, and contaminated linen until laundering or being picked up by the commercial laundry;
    4. (D) Storage of clean linen; and

    5. (E) Specific laundry requirements (type detergent, sours, bleach, time, and temperatures used) for washing:

       1. (i) New linen;
       2. (ii) Diapers; and
       3. (iii) Soiled, wet, and contaminated linen;
    6. (F) Personal hygiene;
    7. (G) Evaluation of washing/cleaning effectiveness;
    8. (H) Job descriptions;
    9. (I) Orientation practices for new employees;
    10. (J) Safety practices; and
    11. (K) Infection prevention and control measures.

22. (4)

    1. (A) Policies and procedures for linen services shall have evidence of ongoing review and/or revision.

    2. (B) The first page of the manual shall have the:

       1. (i) Annual review date; and
       2. (ii) Signature of the department supervisor and/or person or persons conducting the review.

23. (5)

    1. (A) Relevant in-service educational programs shall be conducted at regularly scheduled intervals with no fewer than six (6) per year.

    2. (B) There shall be written documentation with:

       1. (i) Employee signature;
       2. (ii) Program title/subject;
       3. (iii) Presenter;
       4. (iv) Date; and
       5. (v) Outline or narrative of presented program.

24. (6) Facility linen service.

    1. (A) Sorting of soiled laundry shall be done in a designated area.
    2. (B) Tables or bins shall be provided for sorting of soiled laundry.

    3. (C) Lint traps shall be:

       1. (i) Provided on dryers; and
       2. (ii) Cleaned regularly.

    4. (D) Prerinsing shall be done in the laundry service, not in:

       1. (i) Showers;
       2. (ii) Bathtubs; or
       3. (iii) Lavatories.

    5. (E) Removal of solid soil shall be done in:

       1. (i) Soiled utility rooms; or
       2. (ii) Rooms that are designated for this purpose.
    6. (F) Patient clothing may be washed in the patient area if a separate equipped laundry room is available.
    7. (G) A rinsing sink shall be provided in the soiled linen area of the laundry.
    8. (H) Hot water supplied to laundry areas shall be in accordance with Table 9 of Appendix A.
    9. (I) Linen contained in hot water-soluble plastic bags identified as being contaminated shall be placed directly into the washing machine without being removed from the bag for sorting.
    10. (J) A lavatory equipped with wrist action controls, a soap dispenser, and a towel dispenser shall be provided in the laundry for use by the personnel.
    11. (K) Personnel with infectious disease or open wounds shall not be permitted in the laundry.

    12. (L) Personnel assigned to laundry duties shall wash their hands:

        1. (i) After handling wet or soiled laundry;
        2. (ii) Before leaving the laundry;
        3. (iii) After using the toilet; and
        4. (iv) As often as is necessary to maintain good hygiene.
    13. (M) Note. Laundry equipment and installation requirements are set forth in 20 CAR § 43-163, physical facilities — linen services.

25. (7)

    1. (A) Soiled linen from isolation areas, surgical cases, etc., shall be placed into impervious bags and, if leakage occurs, bagged into a second bag with proper identification.
    2. (B) Suitable precautions shall be taken in transport, handling, and processing.
26. (8) Soiled, wet, and contaminated linens shall be transported in a closed container.

27. (9)

    1. (A) Soiled, wet, and contaminated linens shall be stored in closed containers or impervious bags in designated areas off the floor.
    2. (B) Areas for storage of soiled, wet, and contaminated linens shall have forced ventilation to the outside of the building.
28. (10) All new clothing, linen, and diapers shall be laundered before being used.
29. (11) There shall be a designated area for the storage of clean linens.
30. (12) The linen service within the facility shall have a capacity sufficient to process a continuous supply of clean laundry ready for use.

31. (13)

    1. (A) Temperature used in the dryer will depend on the type of fabric.
    2. (B) An employee shall be present at all times when the dryer is in operation.
32. (14) There shall be an ongoing QA/PI program with a mechanism for reporting results.
33. (15) Linen service shall include a written contingency plan indicating an alternative provision that may be followed in the event the laundry is unable to meet the production demand of the facility.
34. (16) Separate containers for the disposal of infectious waste and sharps shall be located in the soiled linen sorting area.

35. (17) Laundry workers handling infectious linens shall wear protective equipment, including but not limited to:

    1. (A) Waterproof, puncture-resistant gloves;
    2. (B) Protective over-clothing; and
    3. (C) Where necessary, face shields or goggles.

36. (18) Facilities that do not have linen services:

    1. (A) The facility shall:

       1. (i) Determine that all launderable items are processed in a commercial laundry in accordance with standards set forth in this section;
       2. (ii) Conduct annual onsite inspections of the commercial laundry; and
       3. (iii) Require written verification of compliance by the laundry.
    2. (B) Soiled, wet, and contaminated laundry shall be stored in a the commercial laundry;

    3. (C) A designated clean area shall be:

       1. (i) Provided for receiving clean laundry; and
       2. (ii) Separate from the soiled linen area; and
    4. (D) Clean linen shall be packaged and protected from contamination during transportation and storage.
37. (19) Refer to 20 CAR § 43-117, infection prevention and control, for additional requirements.

(e) Safety services.

1. (1)

   1. (A) There shall be an effective program to enhance safety within the facility and grounds.
   2. (B) The program shall be monitored by a safety committee appointed by the administrator.

   3. (C) Committee members may be selected from areas such as:

      1. (i) Administration;
      2. (ii) Nursing;
      3. (iii) Maintenance;
      4. (iv) Housekeeping;
      5. (v) Laboratory;
      6. (vi) Respiratory care;
      7. (vii) Rehabilitation services;
      8. (viii) The medical staff; and
      9. (ix) Others, as appropriate.

2. (2)

   1. (A) The safety committee shall meet a minimum four (4) times per year to fulfill safety objectives.
   2. (B) Minutes of each meeting shall be recorded and kept in the facility.

3. (3) The administrator shall designate a specific individual to:

   1. (A) Carry out policies established by the safety committee; and
   2. (B) Gather data for the Safety Committee to study safety-related incidents.

4. (4)

   1. (A) Safety policies and procedures shall have evidence of ongoing review and/or revision.

   2. (B) The first page of each manual shall have the:

      1. (i) Annual review date; and
      2. (ii) Signature of the department supervisor and/or person or persons conducting the review.

   3. (C) Safety policies and procedures shall include:

      1. (i) Facility-wide hazard surveillance program;
      2. (ii) Response to medical device recalls and hazard notices;
      3. (iii) Safety education;
      4. (iv) Reporting of all accidents, injuries, and safety hazards;
      5. (v) External and internal disaster plans;
      6. (vi) Fire safety; and
      7. (vii) Safety devices and operational practices.

5. (5) The orientation program for the facility shall include the:

   1. (A) Importance of general safety and fire safety; and
   2. (B) Responsibility of each individual to the program.

6. (6) The Safety Committee shall have the following functions:

   1. (A) Monitoring the results of the safety program and analyzing the effectiveness of the program annually;
   2. (B) Monitoring fire drills and disaster drills at required intervals;
   3. (C) Conclusions, recommendations, and actions of the safety committee shall be reported to the board at a minimum annually; and

   4. (D) Ensuring each department or service shall have a safety policy and procedure manual within their own area that:

      1. (i) Is a part of the overall facility safety manual; and
      2. (ii) Establishes safety policies and procedures specific to each area.

7. (7)

   1. (A) Fire extinguishers shall be:

      1. (i) Provided in adequate numbers of the correct type; and
      2. (ii) Properly located and installed.
   2. (B) Personnel shall be trained in the proper use of fire extinguishers and equipment.
   3. (C) Personnel shall follow procedures in fire containment and evacuating patients in case of fire or explosion.
   4. (D) There shall be an annual check of all fire extinguishers by qualified persons in accordance with the applicable sections of the National Fire Protection Association's Standard 10 (NFPA 10).

   5. (E) The date the check was made and the initials of the inspector shall be recorded on:

      1. (i) The fire extinguisher; or
      2. (ii) A tag attached to the extinguisher.

8. (8)

   1. (A) Any fire or disaster event at the facility shall be reported immediately to the Department of Health by telephone 501-661-2201 during regular working hours or 501-661-2136 after normal working hours, holidays, and weekends.
   2. (B) If any fire or fires or disaster is not reported to the Department of Health, the facility is subject to a fine, refer to 20 CAR § 43-103(j), licensure and codes.

9. (9) There shall be policies and procedures governing the routine methods of handling and storing flammable and explosive agents, particularly in:

   1. (A) Operating rooms;
   2. (B) Delivery rooms;
   3. (C) Laundries; and
   4. (D) Areas where oxygen therapy is administered.

10. (10)

    1. (A) There shall be keys available to ensure prompt access to all locked areas.
    2. (B) All doors shall be devised so they can be opened from the inside of the locked area.
    3. (C) Special door locking devices are acceptable in limited areas.
    4. (D) Usage is subject to all codes and regulations.
11. (11) All required exit doors shall remain unlocked per NFPA requirements.

12. (12) A list of material safety data sheets (MSDS) for solutions, cleaning compounds, disinfectants, vermin control chemicals, and other potentially hazardous substances used in connection with the facility shall be readily available:

    1. (A) To the Safety Committee, emergency room, and environmental services; and
    2. (B) As directed by facility policy and procedures.