Helping Washington Hospitals With L&I Audits and Inspections
 

SB 6485 (Chapter 261, Statutes of 2004) initiates a pilot project under the coordination of the State of Washington Department of Health, in cooperation with the Washington State Hospital Association, to implement and evaluate strategies intended to reduce the regulatory burden on hospitals and to improve the quality and efficiency of hospital surveys or audits conducted by multiple agencies.

Under the requirements of the bill, each state agency which conducts hospital surveys or audits shall post to its agency website a list of the most frequent problems identified in its hospital inspections along with information on how to avoid or address the identified problem.

Several divisions within the Department of Labor & Industries perform surveys, audits, examinations or inspections in hospitals. Each has compiled a list of most frequent problems identified in hospitals, and how hospitals may avoid or address the problems.

For most questions related to WISHA and hospitals please contact John Furman at (360) 902-5666 or by e-mail at furk235@Lni.wa.gov. You may also contact a WISHA safety and health consultant. A listing of WISHA consultation contacts is found at: http://www.lni.wa.gov/Safety/Basics/Assistance/Consultation/consultants.asp

The following items represent common problems found during L&I inspections and audits in Hospitals, and how to address them.

Problem Remedy

a)Signage which restricts entry and directs employees to the nurses station was not posted to prevent the employee from entering the suspected Tuberculosis (TB) patient’s room.

b)HVAC Engineers were not required to wear respirators when they worked inside of TB isolation room exhaust air ducts while the isolation room housed suspect or confirmed TB patients.

c)Air from the exhaust ventilation for TB isolation rooms was not exhaustd away from populated areas.

d)The exhaust ventilation for TB isolation rooms shared common ducts with other rooms/areas of the facility and was not filtered.
  • Protect employees from biologic hazards as required by WAC 296-800-11045
  • Institute policies and procedures based on current CDC recommendations. See WRD 11.35
  • Contact John Furman at (360) 902-5666 or furk235@lni.wa.gov for all tuberculosis-related questions.
The employer did not ensure that an employee wore eye protection such as safety goggles or a face shield when working with corrosive chemicals .
A written energy control program (also know as lock out tag out program) was not included and implemented in the employer’s existing program.
The accident prevention program did not include a section on workplace violence prevention.
  • The accident prevention program did not include a section on workplace violence prevention.
  • A written respiratory protection program for was not developed.
An asbestos good faith survey was not performed.
  • Perform a survey as required by WAC 296-62-07721 and RCW 49.26.13.
  • Communicate survey results to affected employees and contractors.
  • Contact John Stebbins at (360) 902-5514 or stjo235@lni.wa.gov for all
    asbestos related questions.
An effective bloodborne pathogens (BBP) exposure control plan was not established for the hospital.
  • Develop and implement an exposure control plan for your hospital that follows the requirements of WAC 296-823-110.
  • Update the plan at least annually to reflect new or modified tasks or procedures that affect occupational exposure and to reflect new or revised employee positions with occupational exposure.
  • Contact John Furman at (360) 902-5666 or furk235@lni.wa.gov
Personal protective equipment (PPE) for potential exposure to bloodborne pathogens (BBP) or other potentially infectious material (OPIM) was either not provided or not used properly. In addition, a general assessment for hazards requiring the use of PPE was not effectively performed.
  • Perform a PPE assessment as required by WAC 296-800-160
    and
  • Follow the specific requirements for providing and using PPE, such as those requirements found in WAC 296-823-150.
  • Documentation of your PPE hazard assessment may be included in the BBP exposure control plan or other external document as long as it is referenced in the exposure control plan.
  • Contact John Furman at (360) 902-5666 or furk235@lni.wa.gov
An effective program for communicating the hazards of chemicals to employees was not established.
An emergency washing facility was not provided in areas where employees mix toxic chemicals.
  • Identify areas where chemical usage requires an emergency shower and/or eyewash facility to be and make sure appropriate emergency washing is provided (see WAC 296-800-15030 through –15040).
  • Contact John Stebbins at (360) 902-5514 or stjo235@lni.wa.gov for all
    asbestos related questions.
A safety committee with employee representation was not established.
Frequent problems identified in hospital elevator inspections:
  • Phones: inoperative, stating wrong location
  • Test logs: missing, incomplete
  • Failure to test smoke alarm system annually
  • Operating Permits: not posted, expired
  • Wet pits
  • Emergency lights/alarm inoperative
  • Door detector edges not functioning properly
  • Materials stored in machine rooms
  • Keys for elevator operation not on job site
  • Intercom not working properly

Frequent problems identified in inspections of boilers and pressure vessels at hospitals:

  • Boiler Controls
  • Boiler Piping and Other Systems
  • Boiler Manufacturing Data
  • Report/Nameplate
  • Boiler Components
  • Pressure-Relieving Devices for Boilers
  • Pressure Vessels
  • Repairs and Alterations
  • Failure to obtain inspection and failure to pay inspection fees.
  • Careful professional attention to and maintenance of the areas of concern and timely and complete inspections can actually prevent accidents by identifying problems and enforcing repairs prior to adverse conditions occurring.
  • Contact the Boiler program

Frequent problems identified in inspections at hospital construction sites:

1. Contractor not registered, bonded and insured in Washington.

  • A general contractor must maintain a $12,000 bond. A specialty contractor, such as a painter, must maintain a $6,000 bond. Dissatisfied consumers may pursue restitution with civil action in Superior Court against a contractor’s bond.
  • All registered contractors must carry general liability insurance coverage ($50,000 property damage and $200,000 public liability or $250,000 combined single limit).

2. Contractor does not have a current business license.

  • Contractors are also required to have a current business license.

3. Contractor is not up-to-date on workers' comp premiums for any employees.

  • If the contractor has employees, he or she must have a federal employer identification number (EIN) and industrial insurance. (The identification number is optional for a sole proprietorship with no employees.)

4. Medical Gas and Vacuum systems.

  • Medical gas Systems and Equipment must be installed by qualified Journeyman Plumbers who have been issued a Medical gas endorsement by the Department of Labor and Industries.
  • Visit L&I’s Construction Compliance web site,
  • Visit your local L&I office or call the toll-free contractor registration hotline (1-800-647-0982) to learn:
    • If a contractor is currently registered.
    • How long the contractor has been registered.
    • If action against the contractor’s bond is pending or has been taken in the past.
    • Other business names under which a contractor may have operated.
    • Whether a contractor has industrial insurance coverage for his or her employees.
  • Contact the Contractor program

Frequently written Electrical Corrections issued at hospitals and other identified issues:

See attached document.
  • It’s apparent that some of the issues that are found upon inspection of actual installations at Hospitals; might be avoided by properly submitting all new installations, and alterations to existing installations, to Electrical Plan Review. This is already a requirement, but not always adhered to. Full adherence to the rule would help avoid potentially unsafe situations and could save time and dollars as well, if costly repairs are needed.
  • It is also apparent that from Electrical Inspection’s perspective, having at least one person that could serve as a point-of-contact, would help immensely. Ideally that person would have not only the responsibility of interfacing with electrical inspection, but also the authority to ensure that all electrical installations or modifications at a facility were done in a code compliant manner.
  • Contact the Electrical Program
  • Call the Electrical Plan Review section – Bill Eckroth, (360) 902-5246.