ML12089A554

Entergy Pre-Filed Evidentiary Hearing Exhibit ENT000292 - 10 CRR-NY 405.24, Official Compilation of Codes, Rules and Regulations of the State of Ny, Title 10, Chapter V. Subchapter A. Medical Facilities - Minimum Standards, Article 2. Hospi

ML12089A554
Person / Time
Site:	Indian Point
Issue date:	09/15/2011
From:	State of NY, Dept of State
To:	Atomic Safety and Licensing Board Panel
SECY RAS
Shared Package
ML12089A551	List: ML12089A553 ML12089A554
References
RAS 22122, 50-247-LR, 50-286-LR, ASLBP 07-858-03-LR-BD01
Download: ML12089A554 (4)

Text

NYDe partmentofState

-DivisionofAdministrativeRulesHome Search Hel p © WelcometotheonlinesourcefortheNewYorkCodes,RulesandRegulations10CRR-NY405.2410CRR-NY405.2410CRR-NY405.24OFFICIALCOMPILATIONOFCODES,RULESANDREGULATIONSOFTHESTATEOFNEWYORKTITLE10.DEPARTMENTOFHEALTHCHAPTERV.MEDICALFACILITIESSUBCHAPTERA.MEDICALFACILITIES--MINIMUMSTANDARDSARTICLE2.HOSPITALSPART405.HOSPITALS--MINIMUMSTANDARDSCurrentthroughSeptember15,2011*Section405.24.*Environmentalhealth.Thehospitalshallbeoperatedandmaintainedtoensurethesafetyofpatients.(a)Buildingandgrounds.Facilitygroundsandphysicalplantshallbemaintainedinamannertoassureasafeandsuitableenvironmentforpatients.(1)Groundsandbuildingsshallbemaintainedinfunctionalconditionandtomeetdesignintent,freeofsafetyhazards,excessivenoise,odorsandenvironmentalpollutantsasmayadverselyaffectthehealthorwelfareof patients.(2)Thereshallbefacilitiesforemergencyprovisionofadequatefuelandwatersuppliesduringanyperiodinwhichthesupplyoffueland/orwaterfromusualsourcestemporarilybecomesdisrupted.(b)Lifesafetyfromfire.(1)Buildingsandequipmentshallbesomaintainedastopreventfire.

(2)Thehospitalshallhaveawrittenmasterfireplanthatcontainprovisionsforpromptreportingoffires;extinguishingfires;protectionofpatients,personnelandvisitors;evacuation;andcooperationwithfirefighting authorities.(3)Personnelshallbetrainedinprocedurestobefollowedinemergencies,includingbutnotlimitedtotheuseoffirefightingequipment,evacuationofpatientsandpersonnelandallotherdutiesinthemasterfireplan.(4)Firedrillsshallbeconductedatirregularintervalsatleast12timesperyearcoveringallshifts.

(5)Thehospitalshallensurethethoroughinvestigationofallfires.Awrittenreportoftheinvestigationshallbeproducedandshallremainonfilefornotlessthansixyears.

(c)Engineeringandmaintenance.(1)Watersuppliesofmedicalfacilities.AllwaterusedinoperationshallbeprovidedinconformancewithPart5oftheStateSanitaryCodeandsection702.1(a)ofthisTitle.(2)Preventivemaintenance.Awrittenpreventivemaintenanceprogramshallbeestablishedandimplementedtoinsurethatallequipmentandbuildingsareoperative,safe,sanitaryandmaintainedingoodrepair.(i)Hospitalsshalldevelopandadheretoschedulesfortesting,maintenanceandcalibrationofallpatientcareandlifesafetyequipment.Suchmaintenanceschedulesshall,ataminimum,beconductedinaccordancewithmanufacturer'sspecifications.(ii)Writtenreportsdocumentingsuchtests,maintenanceandcalibrationshallberetainedonfilefornotlessthanthreeyearsafterthedateofsuchtests,maintenanceorcalibration.(d)Waste.Hospitalsshalldevelopandimplementinfectiouswastemanagementprogramsasrequiredbytheflflfhbllh provisionso ftit leXIIIo fartic le13o f t hePu blicHea l t hLaw.(e)Housekeeping.(1)Theentirefacility,includingbutnotlimitedtothefloors,walls,windows,doors,ceilings,fixtures,equipmentandfurnishings,shallbekeptcleanandmaintainedingoodrepair.(2)Thefacilityshallbekeptfreeofinsectsandrodents.(3)Allcleaningshallbedoneinamannerwhichwillnotspreaddustorotherparticulatematter.(4)Suppliesandequipmentforhousekeepingfunctionsshallbeprovidedwithcleaningcompoundsandhazardoussubstancesproperlylabeledandstored.(f)Linenandlaundry.(1)Cleanlinenshallbeprovidedtomeettherequirementsofpatients.(2)Alllinenshallbehandled,stored,launderedandprocessed,andtransportedinamannerthatwillpreventinfectionandassurethemaintenanceoflinenthatiscleanandingoodrepair.Thehospitalshallensurethatanyuseofinksordyescontainedanilineoil(aminobenzene)oroilofmirbane(nitrobenzene)orotherbenzenederivativesbysuchhospital,laundryordiaperserviceconformstotherequirementsinsection12.10oftheStateSanitaryCode.(3)Alllinen,includingblankets,shallbelaunderedbetweenpatientuse.(4)Topreventthespreadofinfection,allsoiledlinenshallbeenclosedincontainerswithinthepatientcareunitfortransportationtothelaundry.(5)Alllinenfromisolationrooms,infectiouspatientsandthepathologyserviceshallbeenclosedinidentifiablecontainersdistinguishablefromotherlaundry.(g)Emergencyanddisasterpreparedness.Thehospitalshallhaveawrittenplan,rehearsedandupdatedatleasttwiceayear,withprocedurestobefollowedforthepropercareofpatientsandpersonnel,includingbutnotlimitedtothereceptionandtreatmentofmasscasualtyvictims,intheeventofaninternalorexternalemergencyordisasterarisingfromtheinterruptionofnormalservicesresultingfromearthquake,flood,bombthreat,chemicalspills,strike,interruptionofutilityservices,nuclearaccidentsandsimilaroccurrences.Personnelresponsibleforthehospital'saccommodationtoextraordinaryeventsshallbetrainedinallaspectsofpreparednessforanyinterruptionofservicesandforanydisaster.(h)Animals.Animals,exclusiveofthoserequiredforlaboratorypurposes,shallonlybeallowedinahospitalinthefollowinginstances:(1)servicedogsorotherserviceanimalswhichhavebeenindividuallytrainedtodoworkorperformtasksforthebenefitofanindividualwithadisabilitywhenthepresenceofsuchanimalwillnotposeasignificantrisktothehealthorsafetyofothersthatcannotbeeliminatedbyreasonableaccommodationandisnotmedicallycontraindicated.However,ifthesafeoperationofthehospitalwouldbejeopardized,aserviceanimalneednotbeallowedtoenter.Afindingbyappropriatemedicalpersonnelatthehospitalthatthepresenceoruseofaserviceanimalwouldposeasignificanthealthriskincertaindesignatedareasofahospitalmayserveasabasisforexcludingserviceanimalsinthoseareas;(2)whenahospitalchoosestoinitiateandoperateanorganizedanimalvisitationoranimal-assistedtherapyprogramthatisjointlydeveloped,approvedandmonitoredbythehospital'squalityassurance,riskmanagementandinfectioncontrolcommitteesordesignees.Ineachsuchapprovedprogram,thehospitalmustataminimumensurethat:(i)participatinganimalsmeetthequalificationssetbythehospitalincluding:(a)certificationofcurrentvaccinationsandbeingfreeofcommunicablediseasesorinfections;(b)documentationofhavingtrainingandtemperamentacceptabletothehospital;(ii)eachparticipatingpatientsignsapatientconsentformthatincludesanassessmentoftherisksandbenefitsofprogramparticipation;(iii)hospitalpersonnelandnon-participatingpatientsinproximitytotheprogramarenotnegativelyimpactedbythepresenceofsuchanimals;(iv)thewell-beingoftheparticipatinganimalsisconsideredandmaintained;(v)patientandstaffsatisfactionisassessed,ensuringthatparticipatingpatientsandstaffaswellasarepresentativesampleofnon-participatingpatientsandstaffareroutinelysampledforfeedback;and(vi)infectioncontrolprotocolsestablishedfortheprogramincludeacomparativeassessmentofinfectionsforparticipatingandnon-participatingpatients.(i)Centralsupplyservices.Thehospitalshallensuretheprovisionofcentralsupplyservicesforthepreparation,storage,handlinganddistributionofsterilesuppliesandotherpatientcareitems.Thehospitalshallconformtocurrent,acceptablestandardsofpracticeforcentralservices.(1)Centralservicesshallbeunderthedirectionofanindividualqualifiedbyeducation,trainingandexperiencetosupervisethepersonnelandfunctionsofcentralservices,andwhoshallberesponsibletothechiefexecutiveofficereitherdirectly,orthroughadesignateddepartmenthead.(2)Ctlihllbltdtfthhitl'ilit

((g)Emergencyanddisasterpreparedness.Thehospitalshallhaveawrittenplan,rehearsedandupdatedatleast twicea y ear ,with procedurestobefollowedforthe p ro percareof patientsand personnel ,includin gbutnotlimitedt othereceptionandtreatmentofmasscasualtyvictims,intheeventofaninternalorexternalemergencyordisasterarisingfromtheinterruptionofnormalservicesresultingfromnuclearaccidents (2)C en t ra lserv icess h allbeeva l ua t e daspar t ofth e hosp it a l'son g o i n gqualityassurancepro gram.(3)Thefunctionaldesignandworkflowpatternsincentralservicesshallprovidefortheseparationofsoiledandcontaminatedsuppliesfromthosethatarecleanandsterile.(4)Thereshallbewrittenpoliciesandproceduresforthedecontaminationandsterilizationactivitiesperformedincentralservicesandelsewhereinthehospital,andforrelatedrequirements.Thesepoliciesandproceduresshallinclude,butnotbelimitedtoprovisionsfor:(i)thedecontamination,cleaning,preparationandsterilizationofpatientcaresuppliesandequipment;(ii)theseparationofsoiledorcontaminatedsuppliesandequipmentfromcleanandsterilizedsuppliesandequipment;(iii)theassembly,wrapping,storage,handlinganddistributionofsterilesuppliesandequipmentincentralservicesandallotherareasofthehospitalasapplicable;(iv)requirementsforaerationofgas-sterilizeditems;(v)maintainingandrecordingtimeandtemperatureforeachsterilizationcycleandaerationcycle,ifany,withprovisionsforrecordstobekeptatleastoneyear;(vi)thelabelingofeachsterilizeditemwiththedatesterilized,cycleandexpirationdateindicatingtheshelflifeofthesterilizeditemifthehospitalchoosestousetime-relatedsterilitycriteriawithestablishedexpirationdatingofin-housereprocessedandsterilizedsuppliesandequipment;(vii)event-relatedsterilityassuranceifthehospitalchoosestousesuchcriteriaforsterilityassurance.Suchsterilityassuranceshall:(a)complywithgenerallyacceptedstandardsforsterilityassurancesuchasthoseendorsedbytheAssociationfortheAdvancementofMedicalInstrumentation,theJointCommissionontheAccreditationofHealthcareOrganizationsorothersuchentitiesrecognizedasappropriatebythecommissioner;(b)bebasedontheresultsofanevaluationofcurrenthospitalpoliciesandproceduresforhandlingsterilesupplies;(c)bereflectedinthehospital'swrittenpolicieswhichdetailtheprocessandresponsibilitiesandwhichhavebeenapprovedbytheinfectioncontrolofficerandInfectionControlCommittee,ifany;(d)beaddressedthroughinserviceeducationofstaff;and(e)provideforqualityassurancemonitoringtoevaluateeffectiveness;(viii)theuseofchemicalindicatorswitheachcycleandweeklybacteriologicalsporemonitoringforallsterilizers;(ix)therotationandreprocessingofsterileequipmentandsupplies;and(x)theroutinecheckingandremovalofoutdatedordamagedsterilesuppliesandequipmentorsuppliesorequipmentwhichnolongermeetthesterilitystandardsoftheevent-relatedsterilityassurancecriteriaandtherecallofsuchsuppliesandequipmentfromallareasofthehospital.(j)Injurycontrol.Thehospitalshall:(1)haveasafetyeducationprogramwhichshallincludebothorientationofnewemployeesandcontinuinginservicetrainingprograms;(2)developandimplementprogramsdesignedtoeliminatesafetyhazards;and(3)maintain,duringanyconstruction,alterationsorrepairs,asafeenvironmentandsafeaccess.10CRR-NY405.2410CRR-NY405.242011WL7413668910CRR-NY405.24ENDOFDOCUMENT©2012ThomsonReuters.NoClaimtoOrig.U.S.Govt.Works.AdobeReaderisrequiredtoviewPDFimages.

Westlaw,partofThomsonReuters

©2012WestlPrivacylAccessibility