The purpose of this section is to manage environmental hazards and risks, prevent accidents and injuries, and maintain safe conditions for patients, visitors, and staff.

1. (1) Hospitals must have an environment of care management plan that addresses safety, security, hazardous materials and waste, emergency preparedness, fire safety, medical equipment, utility systems and physical environment.
2. (2) The hospital must designate a person responsible to develop, implement, monitor, and follow-up on all aspects of the management plan.

3. (3) Safety. The hospital must establish and implement a plan to:

   1. (a) Maintain a physical environment free of hazards;
   2. (b) Reduce the risk of injury to patients, staff, and visitors;
   3. (c) Investigate and report safety related incidents;
   4. (d) Correct or take steps to avoid reoccurrence of the incidents in the future;
   5. (e) Develop and implement policies and procedures on safety related issues such as but not limited to physical hazards and injury prevention; and
   6. (f) Educate and periodically review with staff, policies and procedures relating to safety and job-related hazards.

4. (4) Security. The hospital must:

   1. (a) Establish and implement a plan to maintain a secure environment for patients, visitors, and staff, to include preventing abduction of patients;
   2. (b) Educate staff on security procedures; and
   3. (c) Train security staff to a level of skill and competency for their assigned responsibility.

5. (5) Hazardous materials and waste. The hospital must:

   1. (a) Establish and implement a program to safely control hazardous materials and waste according to federal, state, and local regulations;
   2. (b) Provide space and equipment for safe handling and storage of hazardous materials and waste;
   3. (c) Investigate all hazardous material or waste spills, exposures, and other incidents, and report as required to appropriate authority; and
   4. (d) Educate staff on policies and procedures relating to safe handling and control of hazardous materials and waste.

6. (6) Emergency preparedness. The hospital must:

   1. (a) Establish and implement a disaster plan designed to address both internal and external disasters. The plan must be:

      1. (i) Specific to the hospital;
      2. (ii) Relevant to the geographic area;
      3. (iii) Readily put into action, twenty-four hours a day, seven days a week; and
      4. (iv) Reviewed and revised periodically;

   2. (b) Ensure the disaster plan identifies:

      1. (i) Who is responsible for each aspect of the plan; and
      2. (ii) Essential and key personnel responding to a disaster;

   3. (c) Include in the plan:

      1. (i) A staff education and training component;
      2. (ii) A process for testing each aspect of the plan; and
      3. (iii) A component for debriefing and evaluation after each disaster, incident or drill.

7. (7) Fire safety. The hospital must:

   1. (a) Establish and implement a plan to maintain a fire-safe environment that meets fire protection requirements established by the Washington state patrol, fire protection bureau;
   2. (b) Investigate fire protection deficiencies, failures, and user errors; and
   3. (c) Orient, educate, and conduct drills with staff on policies and procedures relating to fire prevention and emergencies.

8. (8) Medical equipment. The hospital must establish and implement a plan to:

   1. (a) Complete a technical and engineering review to verify medical equipment will function safely within building support systems;
   2. (b) Inventory all patient equipment and related technologies that require preventive maintenance;
   3. (c) Perform and document preventive maintenance;
   4. (d) Develop and implement a quality control program;
   5. (e) Assure consistent service of equipment, independent of service vendors or methodology;
   6. (f) Investigate, report, and evaluate procedures in response to equipment failures; and
   7. (g) Educate staff on the proper and safe use of medical equipment.

9. (9) Utility systems. The hospital must establish and implement policies, procedures and a plan to:

   1. (a) Maintain a safe and comfortable environment;
   2. (b) Assess and minimize risks of utility system failures;
   3. (c) Ensure operational reliability of utility systems;
   4. (d) Investigate and evaluate utility systems problems, failures, or user errors and report incidents and corrective actions;
   5. (e) Perform and document preventive maintenance; and
   6. (f) Educate staff on utility management policies and procedures.

10. (10) Physical environment. The hospital must provide:

    1. (a) Storage;

    2. (b) Plumbing with:

       1. (i) A water supply providing hot and cold water under pressure which conforms to chapter 246-290 WAC;
       2. (ii) Hot water supplied for bathing and handwashing not exceeding 120°F;
       3. (iii) Cross connection controls meeting requirements of the state plumbing code;

    3. (c) Ventilation to:

       1. (i) Prevent objectionable odors and/or excessive condensation; and
       2. (ii) With air pressure relationships as designed and approved by the department when constructed and maintained within industry standard tolerances;
    4. (d) Clean interior surfaces and finishes; and
    5. (e) Functional patient call system.

[Statutory Authority: Chapter 70.41 RCW and RCW 43.70.040. WSR 09-07-050, § 246-320-296, filed 3/11/09, effective 4/11/09.]