Statement of Conditions Policy
Scope:This policy applies to the ______MedicalCenter and all associated satellite facilities and clinics.
Purpose:A current and accurate Statement of Conditions is maintained by the ______
______MedicalCenter to meet current Joint Commission requirements and document
compliance with Life Safety Code requirements and identified deficiencies.
Implementation: This policy has been reviewed and approved by the medical center safety committee andincludes each of the elements listed below:
1. SOC Responsibility – ______is responsible to complete the Basic Building Information (BBI) and Life Safety Assessment (LSA) portions of the SOC, ensure that the compartmentation drawings are accurate, determine whether life safety deficiencies exist that require resolution and enter the required information electronically into the Joint Commission Connect site. This (individual, group or outside vendor) is qualified by training and education to complete these documents and is familiar with the ______MedicalCenterand currentLife Safety Code requirements.
2. BBI and LSA Review – The Basic Building Information (BBI) documents are revised whenever changes are required and re-entered electronically into the Joint Commission Connect site. The Life Safety Assessment forms are reviewed and revised as necessary, but at least annually.
3. PFI Guidelines – If a life safety deficiency is discovered that requires less than 45 days to resolve, it is entered into the work order system and tracked for final resolution. If a deficiency requires more than 45 days to resolve, it is entered into the electronic PFI Connect database. Whenever a PFI is entered, an evaluation is performed and documented to determine whether interim life safety measures are required to be implemented.
4. Building Maintenance Program (BMP) – A Building Maintenance Program (BMP) has been implemented and includes scheduled inspections to evaluate whether specific life safety features operate as designed. The program effectiveness is measured, documented and reported to the medical center safety committee. For additional information, refer to the Building Maintenance Program policy, # ______.
5. Organization of the SOC Documents – A binder has been created to organize and maintain all of the required Statement of Conditiondocuments. This binder includes the following sections: a) this Statement of Conditionspolicy; b) the downloaded BBI forms from the e-SOC; c) accurate compartmentation drawings for each floor of the facilities listed on the BBI forms; d) the most recent LSA document for each e-BBI facility; e) the current, downloaded, e-PFI forms and the PFI documents from the previous survey that were signed by the surveyor, and; f) communication documents with theJoint Commission or local Authority Having Jurisdiction (AHJ), such as approved equivalencies, FSES documents or special correspondence related to the SOC.
Approved by: ______Date: ______