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Cashins & Associates Blog

Hospital Safety and Health - The 7 Most Common Vulnerable Areas

Posted by Mike Cashins on Thu, Jan, 03, 2013 @ 11:01 AM

Medical SymbolOf the hundreds of inspections that the Joint Commission performs they have tallied the seven most common vulnerable areas that face hospitals. We have summarized the key components of each area commonly found to be deficient.  

Decontamination Plan

(EC 1.4) Hospitals will have a written decontamination plan but will seldom deal with all types hazards.  Written Decontamination Plans must deal with radiological, biological and chemical exposures.  These plans should also include:

  • Identify various zones of hazards (Red, Yellow, Green)
  • Establish donning procedures for Personnel Protective Equipment.
  • Outline communication during emergency.
  • Specify how hazardous waste will be collect and disposed. 

Proper Chain of Command

(EM 01.01.01) Most hospital facilities will agree that a proper chain of command during emergency or disaster situation aids in communication and correction of the problem.  The clear line of communication should be document between facilities/engineering and clinical staff.  When creating this procedure ask yourself:

  • Who will represent the hospital to government, cities, and towns?
  • Who will represent the hospital to local authorities?
  • Who will represent the hospital to staff members?

Alternate Care Site (ACS) Plan

(EM.02.01.01) Hospitals must identify and set up Alternative Care Sites (ACS) during disaster times. Joint Commission Surveyors will often requests specific details for these alternate locations:

  • Who has the authority to active/de-active the ACS Plan?
  • What are the ACS Locations?
  • What staff is located in these areas?
  • Are there adequate medical supplies?
    • IV Poles, Fluids, Equipment, etc.
    • Adequate pharmacy
    • Sufficient food, water, trays, cups, utensils
    • Personnel Protective Equipment
    • Who will be responsible for inspecting and restocking all items?

All items above must be documents according to EM.02.01.01.

Fire Penetrations

(LS.02.01.10) A building should be designed, constructed, and maintained in order to minimize danger from the effects of fire, including smoke, heat, and toxic gases. The structural characteristics of the building, as well as its age, determine the types of fire protection features that are needed. When remodeling or designing a new building, the hospital should also satisfy any requirements of other codes and standards (local, state, or federal) that may be more stringent than the Life Safety Code.

When new construction or remodeling occurs penetrations in fire rated wall are seldom over looked due to cost.  Penetrations must be properly sealed and inspected according to the Life Safety standard. (LS.02.01.30, NFPA 101-2000: and

Contractor Training

Contractors are often the most over looked for training requirements. Under EC.02.01.01 all contractors will learn the following information:

  • The location of fire alarm stations and how to shut off fire alarms
  • How to dial 911 in the event of a fire
  • How to page a fire
  • How emergency codes are called in the hospital and appropriate initial actions
  • Actions to be taken during fire and other emergency drills

According to the Emergency Care standard training will occur annually.


(LS.02.01.20) Exits, exit accesses, and exit discharges are the most common areas that need to be kept clear of obstructions or impairments to the public way, such as clutter (for example, construction equipment, carts, furniture).  The Joint Commission will often request documentation, policy and procedure for reconcile of this most commonly cited item.  This policy should include:

  • Tracking/Documentation System
  • Responsible Individual
  • Inspection Routine

96 Hour Stability Plan

(EC.4.13-4.18) Prior to Hurricane Katrina in 2005, the general rule of thumb regarding disaster preparedness in hospitals was all hospitals should be prepared for a minimum of 72 hours.  However, the aftermath of Hurricane Katrina strongly indicated that being prepared for 72 hours was inadequate and is now 96 hours.  It does not require hospitals to be sustaining for 96 hours, but it requires hospitals to assess their capability of being sustained for 96 hours. If the facility cannot be sustained for 96 hours, then you must have a contingency plan in place to adequately serve the facility to meet the 96 hour Joint Commission requirement. 

The written plan must not only state “Yes, the hospital has enough water, fuel and staff to sustain for 96 hours.” You must be more specific with how many gallons you have of fresh water, how much water per person per day will be provided, and does this number include staff members drinking rationed water.

If you require assistance in complying with the Joint Commission standards Cashins & Associates, Inc. can help. Click the button below and contact us today to see how we can be a benefit to your hospital or medical facility.

 Free Hospital EHS Assistance Inquiry

Topics: health & safety, Hospital

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