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Title: Statement of Conditions Policy
Effective Date: / Reviewed : / Revised: /

Function: Environment of Care

POLICY:

It is the policy of Facility Nameto maintain existing environments of care to comply with the Life Safety Code, (NFPA 101, 2000 edition), including New/Existing Healthcare and New/Existing Ambulatory occupancies as applicable.

PROCEDURE:

Assignment:

Facility Namehas assigned responsibility for assessing compliance with the Life Safety Code to <Name>. Assessing compliance will consist of the following procedures:

  • Completing, and keeping current a hospital-wide Electronic Statement of Conditions (e-SOC™) compliance document.
  • Managing any Electronic Plans For Improvement (e-PFI™) created through the e-SOC™ process for completion within the timeframes set forth by the hospital, and accepted by The Joint Commission®
  • Overseeing regular preventive maintenance activities to identify any areas not compliant.
  • Monitoring the facility for effectiveness of the life safety program, and if applicable, revises the program to maintain compliance
  • Periodically reporting status of the life safety program to the Environment of Care Committee and Hospital Administration for review.

Inspection:

  • Life Safety Checks are a preventative maintenance (PM) item generated every six months.
  • Checks are preformed by Engineering Technicians using a supplied checklist to verify the proper operation and condition of the buildings’ life safety features.
  • An annualfull assessment/update of the e-SOC™is preformed by Department staff and/or in conjunction with an outside contractor familiar with the hospital and with knowledge of the 2000 edition of NFPA 101(Life Safety Code).
  • All other agency inspections related to life safety, such as local and state agencies, will be documented, and if applicable, included in this process.

Correction:

  • Deficiencies that are identified from the PM program that can be immediately corrected are noted directly on the PM document.
  • Deficiencies that require additional resources and have an expected completion date of 45 days or less are entered as a Life Safety Improvement work order in the PM program.
  • Deficiencies that require extensive resources (major repairs) are entered into the ElectronicStatement of Condition™ (e-SOC™) intranet site and an Electronic Plan for Improvement (e-PFI™).
  • All plans for improvement created will be assessed for any Interim Life Safety Measures (ILSM) that may need to be implemented. If so, the ILSM policy will be followed.

Monitoring:

  • Items in PM program are periodically monitored for accuracy and on-time completion.
  • Open e-PFI™ items in the e-SOC™ program are submitted to the Safety Committee quarterly until completion.

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