EOC Documentation

Q: I am starting the Environment of Care (EOC) program here at a hospital and was wondering if you could give any advice on how to organize binders for all of the different areas of the EOC program so it’s easy to find documents when surveyed by Joint Commission or CMS? Thank you.

A: My approach has always been to be as obvious and practical as possible - and logical, too. Being an engineer, logic seems to be at the forefront of most of what I do, which generally drives my wife crazy.

I would recommend having a separate 3-ring binder for each Joint Commission Environment of Care subject, such as:

• Safety

• Security

• Hazardous Material and Waste

• Fire Safety

• Medical Equipment

• Utilities

• Emergency Management

• EOC Committee meeting agendas and minutes

I know Emergency Management is no longer an EOC subject, but it will still be evaluated during the EOC/EM review session, so it is best to have it part of the binder program.

Start with having the management plan for each respective EOC subject. Then have separate tabs for additional requirements found in the Joint Commission manual, such as for Safety, you would have EC.02.01.01, EP 1 which says, “The organization implements its process to identify safety risks associated with the environment of care that could affect patients, staff, and other people coming to the organization’s facilities.” So, after that description, I would explain how the hospital meets that requirement. In this particular standard, I would insert all of the inspections made during the semi-annual rounds of the facilities. Be sure to include written messages you made to others regarding the safety of their areas and any follow-up correspondence as well. If the surveyor takes the time to read some of the inspection reports, you want to make sure you have follow-up documentation of anything you wrote (Not all the surveyors take the time to read in depth the EOC management plans and how the organization meets the requirements). Other EPs may not have physical documentation, so it falls on you to write an explanation that clearly identifies how the organization meets this requirement.

Do this for each of the different EPs that apply to each subject. I’m a believer in including the Joint Commission standard number and EP (i.e. EC.02.01.02, EP 4) as this helps you in making sure you covered all of the required elements of the EOC subject. I know that Joint Commission has said they don’t like it, as they believe you are just regurgitating back the standard (and you are, it’s just that you are using it to explain what your reply is), but so what? As long as there is no standard that prohibits you from doing this, it is better to use a method that helps you write the response as best you can.

I would recommend having separate binders for each of the features of life safety that require inspections and/or testing activities. This is for everyone’s convenience. Some of the requirements for inspecting/testing these features of life safety are found in the Safety standard (EC.02.03.05), Utilities standard (EC.02.05.01), and the Life Safety standards (LS.02.01.35). It makes it difficult when the surveyor wants to look at a specific test report and you have to go searching in which EOC binder it is in. Have separate binders for the different testing/inspection documents. Some subjects may need a binder of their own due to the thickness of the reports, and some subjects can be group together in the same binder due to the thinness of the reports. But the documentation for testing/inspecting of the following subjects should be included in these binders that are separate from the EOC management plans:

• Fire alarm system

• Fire extinguishers

• Alternative fire suppression systems

• Sprinkler system

• Generators

• Automatic transfer switches

• Medical gas and vacuum systems

• ILSMs

• Fire/smoke dampers

• Overhead rolling fire doors

• Side-hinged swinging fire doors

• EXIT signs

• Elevator recall

• Kitchen hood cleaning

• NFPA 99 risk assessment

• GFCI tests

• LIM test

• Emergency shower

• Emergency eyewash

• Battery powered emergency lights

• Fire drills

• Waste/line chute doors

Part of the reason for this separate binder issue is some of the above subjects don’t even have a Joint Commission standard number or EP. These tests/inspections are required even though Joint Commission does not have a standard on them.

And last but not least, have a separate binder for your EOC committee meeting minutes and agendas. If the minutes says someone is going to do something, make sure there is follow-up documentation that is was addressed properly. Surveyors will likely read these notes and minutes.

Yes, this gets into a lot of binders, but it is logical and organized. Live long and prosper.

Readers, if you would like a free copy of the list for Life Safety Documentation requirements for hospitals, send an email to info@keyeslifesafety.com and put "LS Doc" in the subject line.