ASHE Healthcare Facility Safety Questions and Answers 1 — Questions and Answers
Question 1: A hospital is establishing a new water management program to comply with The Joint Commission standards. Which of the following is a mandatory initial step in developing this program?
- Immediately begin chemical treatment of the entire water system.
- Create a comprehensive diagram of the water system and conduct a risk assessment. (Correct answer)
- Purchase and install point-of-use filters on all patient-use faucets and showers.
- Test all water outlets for Legionella and other waterborne pathogens.
Correct answer: Create a comprehensive diagram of the water system and conduct a risk assessment.
According to The Joint Commission's Environment of Care (EC) standard EC.02.05.02, a foundational requirement for a water management program is to first understand the system. This involves creating a basic diagram showing water sources, treatment systems, and key points of use, and then using this to conduct a risk assessment to identify where pathogens like Legionella could grow and spread.
Question 2: Per NFPA 99 and CGA C-9 standards for medical gas piping, what are the primary identifiers required on a pipe label?
- The installation date and the name of the certified installer.
- The pipe material specification and maximum pressure rating.
- The name of the gas or vacuum system and its corresponding standard color code. (Correct answer)
- The room numbers served and the location of the nearest shut-off valve.
Correct answer: The name of the gas or vacuum system and its corresponding standard color code.
NFPA 99 requires that medical gas and vacuum piping be clearly labeled. The standard specifies that these labels must, at a minimum, indicate the name of the gas or vacuum system (or its chemical symbol) and include the appropriate color code as designated by the Compressed Gas Association (CGA) standard C-9.
Question 3: A facility manager is reviewing the safety protocols for fire-rated door assemblies. According to NFPA 80, Standard for Fire Doors and Other Opening Protectives, how often must these assemblies be inspected and tested?
- Every three years.
- Only after a fire event has occurred.
- On an annual basis. (Correct answer)
- Every six months.
Correct answer: On an annual basis.
NFPA 80, which is referenced by NFPA 101 and adopted by CMS, mandates that fire door assemblies must be inspected and tested at least annually. The standard also requires inspections after installation and after any maintenance work is performed on the assembly.
Question 4: A hospital's safety committee is developing a workplace violence prevention program based on OSHA guidelines. Which of the following is considered a core component of such a program?
- Hiring a dedicated, armed security force for every hospital unit.
- Implementing a zero-tolerance policy for verbal abuse from patients.
- Conducting a worksite analysis to identify existing or potential hazards. (Correct answer)
- Ensuring all clinical staff complete advanced self-defense training.
Correct answer: Conducting a worksite analysis to identify existing or potential hazards.
OSHA's 'Guidelines for Preventing Workplace Violence for Healthcare and Social Service Workers' outlines five key building blocks for an effective program. A fundamental component is the worksite analysis, which involves a step-by-step assessment to find existing or potential hazards that may lead to violence. The other core components are management commitment/employee participation, hazard prevention and control, safety and health training, and recordkeeping/program evaluation.
Question 5: A hospital is performing required testing on its Essential Electrical System (EES). According to CMS and The Joint Commission, compliance for testing emergency power supply systems (EPSS) is primarily referenced from which standard?
- NFPA 70, National Electrical Code
- ANSI/ASHRAE/ASHE Standard 170
- NFPA 110, Standard for Emergency and Standby Power Systems (Correct answer)
- NFPA 101, Life Safety Code
Correct answer: NFPA 110, Standard for Emergency and Standby Power Systems
Both CMS and The Joint Commission require routine maintenance and operational testing of a facility's Essential Electrical System (EES). The specific requirements for the emergency power supply system (EPSS), which is part of the EES, are detailed in NFPA 110. This standard covers performance, maintenance, and testing criteria for the EPSS.
Question 6: As part of The Joint Commission's Environment of Care (EOC) standards, a hospital must have a Security Management Plan. Which of the following elements must this plan specifically address?
- A procedure for vetting all third-party vendors and contractors.
- A process for responding to and managing infant and pediatric abductions. (Correct answer)
- A protocol for managing media inquiries during a security incident.
- A policy for the use of social media by staff members.
Correct answer: A process for responding to and managing infant and pediatric abductions.
The Joint Commission's Environment of Care (EOC) standard for Security Management (EC.02.01.01) requires the organization to manage security risks. A specific element of performance under this standard mandates that the Security Management Plan must address the prevention of and response to infant and pediatric abductions.
ASHE Healthcare Facility Safety Questions and Answers 1
A hospital is establishing a new water management program to comply with The Joint Commission standards.
Which of the following is a mandatory initial step in developing this program?