Hospital Security

EMERGENCY PREPAREDNESS
2004 NEW JERSEY HOSPITAL ASSOCIATION, 760 Alexander Road, PO Box 1, Princeton, NJ 08543-0001. All rights reserved, No part of this publication may be reproduced in any form without the prior written permission of the publisher, the New Jersey Hospital Association (NJIIA). NJIIA is not responsible for any misprints, typographical or other errors, or any consequences caused as it result of the use of this publication. This publication is provided with the understanding that NJIIA is not engaged in rendering any legal, accounting or other professional services and NJI IA shall not he held liable for any circumstances arising out of its use. If legal advice or other expert assistance is required, the services of a competent professional should be sought. This resource has been produced through a grant supplied by the New ler:sey I )epartrnent of I lera/th and Senior Services,
NJHA
INTRODUCTION
In 2002, the state's Domestic Security Task Force established a Healthcare Infrastructure Advisory Committee (HIAC) to identify and develop best practices that would improve hospitals' readiness in responding to a disaster. The HIAC focused on areas such as security, facility management and information systems among other critical hospital operations. A key component to ensuring that all New Jersey hospitals are secure from unauthorized intrusion is to establish standardized policies and procedures statewide, leaving no single facility more vulnerable than its neighbor. To supplement the recommendations of the HIAC, NJHA's Emergency Preparedness Task Force established a Facility Security Subcommittee comprised of security management experts from the hospital community. The subcommittee examined security policy recommendations from the HIAC as well as other advisory agencies and considered security measures implemented by their own and neighboring healthcare organizations. The expertise, participation and contributions from members of this subcommittee have resulted in a comprehensive checklist that is accompanied by model policies hospitals may use to assess their facility security. The Emergency Preparedness Hospital Security Readiness Assessment Tool is one instrument that can be utilized by hospitals to determine the resources and equipment necessary to ensure an appropriate level of security for their facilities and to feel more confident that the hospital can both prevent and address security incidents. NJHA extends its appreciation to the members of the Facility Security Subcommittee and the hours that they committed to providing guidance to hospitals throughout the state. NJHA also extends its appreciation to the PMK Group for their review of this resource and the development of specific policies.
Emergency Preparedness Hospital Security Readiness Assessment Tool
HOSPITAL SECURITY READINESS ASSESSMENT TOOL FACILITY SECURITY SUBCOMMITTEE
Sarah C. Carnes (formerly) Manager Global & Strategic Assessment Atlantic Health System Victor Rosero Security Manager LibertyHealth Douglas A. Campbell Assistant Vice President of Operations Robert Wood Johnson University Hospital Richard Velardi Chief of Security Saint Michael's Medical Center
Nancy Borzio Safety Officer Solaris Health System Paul R. Calandra Director, Security & Safety St. Joseph's Regional Medical Center Paul M. Lambrecht, MHA Director, Emergency Services Underwood Paramedics Paul Sarnese System Safety Officer Virtua West Jersey Hospital-Voorhees
HOW TO USE THIS TOOL

Members of the Facility Security Subcommittee drew upon their years of experience in security management to identify best practices in policies and operations that all hospitals may want to consider as they evaluate their security protocols. Those best practices are reflected in this assessment tool, which includes both a checklist and model policies to assist in evaluating a security program. The checklist is divided into seven categories, five of which address administrative and operational tasks that facilities will want to evaluate to ensure an appropriate level of security. The two remaining categories focus on access control technology and information security and are included for information purposes only. The five administrative and operational categories address: Developing a security management program Training security staff Educating staff Identifying staff, visitors and vendors Controlling access to the facility.
Under each category is a list of policies facilities may want to have in place - and activities facilities may want to undertake - to protect to the greatest extent possible against potential security incidents. Where available, the checklist will refer to policies included in the back of this book. The policies were provided by subcommittee members as models to guide other healthcare organizations in developing their own policies. The policies can also be used as a basis for hospitals to evaluate their existing policies and determine whether they need to be updated. As NJHA acquires or develops additional policies they will be distributed to hospitals. The Hospital Security Readiness Assessment Tool will be a valuable asset to hospitals as they continue their emergency preparedness efforts.
HOSPITAL SECURITY READINESS ASSESSMENT TOOL
Policy Index
Access Control
Access Control
Building Access
Policy #
HS-23 HS-29 Infant Security
Baggage Check
Visitor and Public Use
Trespassers ED Security ED Signage Key Control
Morgue Security Search and Seizure Security Sensitive Area Access Security of Unoccupied Areas
Locker Inspection
HS-26 HS-27 HS-28 HS-35 HS-50 HS-34 HS-51 HS-30 HS-39 HS-32
General Security Policies

Courtesy Policy ED Security ED Signage General Orders for Security Jump Start / Lockouts Locker Inspection Managing Court Ordered Documents
Narcotic Diversion Non-Solicitation Disruptive Patient / Employee / Visitor Response Guide Bomb Threats
Policy #
HS-40
HS-12
HS-41 HS-28 HS-35 HS-13 HS-43 HS-34 HS-47 HS-36

HS-25
Patient Vehicle Management Physical Force Restraining Orders Search and Seizure Searching Homicidal / Suicidal / Dangerous Patients Terminated Employees
VIP and Media Management Vehicle Inspection
Visiting Hours and Visitor Access Weapons
Policy Index Continued

General Employee Security Awareness & Training
General Employee Awareness and Training
Policy #
HS-17
Identification of Staff Vendors and the Public

Identification - PT, Visitor Staff Vendors Identification- PT, Visitor Staff Vendors Visiting hours Access Control
Identification- PT, Visitor Staff Vendors
Policy #
HS-18 HS-19 HS-20
Physical Plant Security

CCTV System
Fire Watch
Policy #
HS-24 HS-42
Panic Alarm Testing Lighting Inspections Telephone Testing
HS-44 HS-45 HS-49
Security Staff Selection and Training

Security Officer Authority Security Staff Training - Promotion Security Staff Training - Training & Orientation Security Staff Training - Training & Orientation Security Staff Training - Local PD prisoner management
Security Staff Training - Local PD prisoner management
Policy #
HS-16 HS-06 HS-07 HS-08 HS-09 HS-10 HS-22
Uniforming
Standardized Security Management Plans

Hazard Vulnerability Analysis Hazard Vulnerability Analysis Risk Assessment Activities
Policy #
HS-01 HS-02 HS-48 Security Vulnerability Analysis HS-03 Security Management Program Staff Orientation - Performance Evaluations HS-04 Security Management Program Access control - ID - Vehicle access HS-05
A. STANDARDIZED SECURITY
MANAGEMENT PLAN
A key component to ensuring that all New Jersey hospitals are secure from unauthorized intrusion is to establish standardized policies and procedures statewide, leaving no single facility more vulnerable than its ncryhhor. O Has your facility reviewed and determined
Tool
compliance with all JCAHO Environment of Care standards? O Do you conduct a hazard vulnerability analysis on an annual basis or as needed? (JCAHO EC 4.10) O Do you conduct an assessment of your security vulnerability on an annual basis? (JCAHO EC 2.10 and 4.10) O Have you developed a security management plan? (JCAHO EC 2.10) O Have you obtained a copy of your county's emergency management plan from the county Office of Emergency Management? (JCAHO EC 4.10)
Emergency Preparedness Hospital Security Readiness Assessment
Yes / Date
In Process
No
Sample Policy
Appendix A HS-01 HS-02 HS-03 HS 48 HS-04 HS-05
B. SECURITY STAFF SELECTION AND

TRAINING
Io roduco a healthcare organizations Irnhility in the event a security incident occurs hospitals should ensure that their Security staff have undergone criminal history background checks and have received comprehensive training based on rndushy
standards. O If hospital-employed staff provides security, have the following issues been addressed? (JCAHO EC 2.10) o Pre-employment screening, including criminal background check o Standardized hospital-approved orientation and training o Adequate compensation and benefits
to reduce turnover and increase
ability to recruit competent staff o Uniforming O If security is provided by a contract service, have the following issues been addressed? o Pre-employment screening, including criminal background check
o Standardized hospital-approved
orientation and training that is specific to the healthcare setting o Staffing procedures to supplement regular staffing levels in the event of emergency or disaster o Uniforming O Have appropriate staffing levels been determined according to recommendations from the International Association for Healthcare Security and Safety (IAHSS)? o Security staffing levels should not be based solely on a facility's square footage
o Security staffing levels should include
activity and crime rates, overall value of assets, special services required, levels of enforcement and community
concerns
Yes l Date
In Process
No
Sample Policy
HS-06 HS-07 HS-08

HS-22
HS-07
HS-08 HS-22
Continued
Yes t Date
O Have you developed education and training
In Process
No
Appendix
Sample Policy B HS-06 HS-07
programs for Security staff based on the International Association of Health Care Safety & Security (IAHSS) programs? O Does training for Security staff include a counterterrorism program that encompasses the following
issues?
o Threat assessment o National threat levels o Weapons of mass destruction awareness training O Do you have policies governing how Security personnel deal with the following issues? o Weapons o Physical force o Searching of patients, staff and visitors O Do you have policies governing how Security personnel deal with patients, visitors and staff? O Does training include instruction on accommodating law enforcement personnel who are on the premises guarding prisoners or protecting a crime scene? O Do you have policies that lay out the general orders for Security personnel and define their authority? O Do you have a policy regarding fire watch? O Do you have policies regarding the inspection of hospital security vehicles?
O Do you require all Security personnel to
HS-08
HS-11 HS-14 HS-29 HS-30 HS-31 HS-34 HS-12 HS-13 HS-09 HS-10 HS-12 HS-13 HS-16 HS-42 HS-38 HS-06
demonstrate competency with your organization's requirements? JCAHO EC 2.30
C. GENERAL EMPLOYEE SECURITY

AWARENESS &TRAINING
lo r oslrre that the policies acrd procedures developed to protect your
Tool
tacility are followed, all employees should undergo training on the specific procedures so they can respond appropriately to a security ,rrcident O Have you developed a process to ensure all new general staff and volunteers receive
training by Security staff so that they are on alert for suspicious behavior and are aware of the policies and procedures that must be implemented for specific security incidents? (JCAHO HR 2.10) O Do you ensure that each department conducts ongoing awareness training for their staff and volunteers to update them on threat levels, disease surveillance and terror alert advisories issued by the New Jersey Office of Counter-terrorism and other agencies? (JCAHO HR 2.30) O Have you developed a standardized plan for all employees to respond to bomb threats? O Do you hold managers responsible for documenting that staff are trained and are following the facility's security policies and procedures? (JCAHO HR 2.30) o Post security codes, policies and procedures in each department in a
location easily viewed by staff
o Monitor compliance through periodic
testing
Yes / Date
In Process
NO
Sample Policy
Appendix HS-04 HS-17
HS-17
HS-40
I). IDENTIFICATION
Essential to rncuntaining site security is the ability to identify which persons have the authority to be on the premises, either as physician and staff or as a visitor. vendor, volunteer or business associate.
Hospital Security Readiness Assessment Tool
O Do you have an identification card policy that has been approved by the safety committee and the CEO? (JCAHO EC 2.10)
STAFF
Pic following guidelines are designed to assist in developing stondan-lized policies and proced.rres regarding access by staff. O Do you have a policy addressing the issuance
and re-issuance of ID cards for all levels and categories of staff and volunteers? O Do you require staff, including physicians, to wear ID at all times while on facility property
and to show ID upon entering the facility? (JCAHO EC 2.10)
O Do identification cards for staff, volunteers and physicians include a photo, the wearer's name, title or credentials (e.g. M.D; R.N.) and department? O Do ID cards allowing employees access to sensitive areas (e.g. maternity, pharmacy) have distinguishing features, such as a colorcoded background? JCAHO EC 2.10 O Do you have a policy to address consequences for failure to carry/show ID? o Supervisors should be called to authorize
staff that attempt to enter without ID
o Staff and physicians that do not have their ID must sign a log book o After three incidents of signing the log, the staff member should be reported to the department head and/or administration o Report staff and physicians who refuse to show ID to department head and/or to administration o Suspend employee after three occasions
of not producing ID
O Does your policy hold managers accountable for lack of compliance of their employees and for ensuring the imposition of penalties?
Emergency Preparedness -
Yes / Date
In Process
No
Sample Policy
HS-18
HS-19 HS-20 HS-21

Yes I Date In Process No Sample Policy HS-18
HS-19 HS-20
HS-21
HS-18
HS-19 HS-20
HS-18
HS-18
HS-18 HS-19 HS-20 HS-21
Continued
Yes / Date
O Do you have a policy addressing the issuance
In Process
No
Sample Policy
and termination of identification cards that addresses the following? o Handling and storage of blank and terminated cards o Who is authorized to make ID cards (if
electronic system, should be password
HS-18 HS-20
HS-33
protected and tested) o Procedures for lost or stolen cards

(including a replacement fee for all
sui Iiied identification)
VENDORS
The following guidelines are designed to assist Yes / in developing standardized policies and Date procedures regarding access by vendors. In Process No Sample Policy
O Do you have a policy regarding identification of vendors and contractors that addresses consequences for violating access restrictions? O Do you require vendors to report to the main lobby or other standardized designated areas to obtain a pass/badge? o Solicitation
o Badge must be distinct from those
HS-18 HS-19 HS-20 HS-27
provided to visitors and outpatients o Require vendors that visit on a regular basis to wear a special badge, such as a picture ID, the cost of which is covered by the vendor o Require vendor to leave driver's license, which may be retrieved upon departure. 173 Do you require contractors to obtain pass/badge? o Badge must be distinct from that provided to visitors, outpatients and vendors o Use different badges for daily vs.
weekly contractors; contractors that
HS-18
HS-19 HS-20 HS-25
visit on a regular basis (e.g. elevator or other equipment repair) may wear a special badge, such as picture ID, the cost of which is covered by the contractor o Notify Security staff at least 24 hours in advance if contractors will be
working in the facility
HS-18 HS-19 HS-20
o Security staff should be notified as

soon as possible about emergency
repairs to allow the contractor to obtain authorization without delay o Require contractor to leave driver's license, which may be retrieved upon departure.
VISITORS AND PUBLIC USE

The following guidelines are designed to assist in do v eloping standardized policies and prtcerluros regarding access by visitors and the public. O Do you have a policy regarding identification of
Tool
visitors that addresses consequences for violating access restrictions? O Do you require all visitors to sign in and obtain pass/badge? o Require all visitors to obtain passes/badges before proceeding to other areas of facility o Ensure pass/badge is visible for staff to determine at a glance whether the visitor is in the proper areas (colorcoded passes linked to specific floors would achieve this) o Facility staff should escort a visitor that does not have a pass to his/her destination (JCAHO EC 2.10) O Do you require outpatients to obtain a pass that is distinct from those for visitors?
Yes / pate
In
Process No
Sample Policy HS-20
HS-21 HS-27
HS-19 HS-20
HS-18 HS-19
HS-20
E. ACCESS CONTROL
Essential to maintaining site security is the ability to limit access to certain groups or categories of persons, such as staff, visitor or vendors. To be effective senior management should embrace th e
policies.
O Do you have an access control policy that has
been approved by the safety committee and the CEO?

O Do you limit the number of exit and entrance
points? o Equip doors with an electronic system that would alert staff to unauthorized exits and entrances, or if a door has been propped open o If access cannot be limited, ensure Security staff are present at and/or routine) monitor each entrance O Do you have a policy addressing searches of suspicious packages and persons? o Inspect all packages entering the facility with visitors (during threat level
red)
O Do you have a procedure for ensuring the integrity of an electronic access control system (including access card reader and closed circuit TV systems) in the event of a power failure? JCAHO EC 7.20 O Do you control access from clinics and
ambulatory care areas to other areas of the hospital? (JCAHO EC 2.10)
O Have you established a process to rapidly shut down access to the entire facility, or specific areas, e.g. parking garages? (JCAHO EC 2.10) O Do your emergency management plan and security policies and procedures address building access by the media?
(JCAHO EC 2.10)
NOTIFICATION/SIGNAGE
The following guidelines are designed to assist in developing standardized policies and procedures regarding signs that can help control access.
O Do you post signs on exterior and interior of facility informing persons of visiting hours, access to the facility, trespassing, etc.? O Do you post signs informing individuals that their persons or packages may be searched at the facility's discretion?
Yes / Date
In Process
No
Sample Policy
HS-19
HS-20
HS-23
HS-27 HS-29 HS-30 HS-31 HS-34 HS-24 HS-23

HS-28
HS-35
HS-04 HS-15
Yes / Date
In Process
No
Sample Policy
HS-35
Continued
Yes! Date
O Do you post signs at the entrance of restricted
areas indicating "Unauthorized Personnel Not Permitted" or "Authorized Personal Only"? O Do you post signs in the emergency department indicating that the number of visitors will be limited for security or other reasons so that patients and visitors know that staff is not imposing arbitrary limitations on visitors? O Do you post signs at points of access to instruct certain individuals to coordinate their access with specific departments, e.g. the press should call public relations, repair contractors should contact maintenance? O Do you evaluate whether to limit use of public auditoriums and conference facilities by outside organizations during threat level orange and red?
STAFF
Tic following guidelines are designed to assist in Yes / developing standarclired policies and procedures Date regarding access by staff. O Do you limit the areas to which certain employees
have access? (JCAHO EC 2.10) o Card swipe technology or color-coded badges may be used to limit access O Do you have policies regarding access to high-risk areas such as: o Maternity 0 Morgue O Do you give warnings for inappropriate access or trespass? O Do you have a policy regarding searches of employee packages or lockers? O Do access cards have an expiration date? O Do you have a policy regarding restraining orders?
In Process
No
Sample Policy
In Process
No
Sample Policy HS-19

HS-31
HS-34 HS-46 Continued
VENDORS AND CONTRACTORS

The following guidelines are designed to assist you in developing standardized policies and procedures regarding access by vendors. O Do you have a policy regarding deliveries
during and after normal working hours? o Require flower deliveries to be made to the lobby and require volunteers or nurses to deliver to patient rooms o Require food delivered from outside the hospital to be signed for at the front desk and require nurses or other department staff to collect and deliver the food o Require all packages, e.g. UPS/Fed Ex, to be delivered to Central Receiving o Allow only emergency deliveries after 4:30 p.m., or require after-hours deliveries to go to Security O Do you limit access to loading dock, which may be particularly vulnerable to unauthorized
access?
o Use electronic gauges for loading platforms o Monitor loading area with camera and/or alarmed ate O Do you have a policy addressing searches of suspicious packages and persons? o Inspect all packages entering the facility with visitors (during threat level
red)
VISITORS AND PUBLIC USE

The following guidelines are designed to assist in developing standardized policies and procedures regarding access by visitors and
the ptiblic. O Do you have passes for visitors? O Does the pass allow for different levels of access? O Do you restrict access to high-risk areas
(pharmacy, lab, maternity) and assign access
only through special identification card? (JCAHO EC 2.10) O Do you have a policy regarding the handling of individuals that are in areas for which they are not authorized? o Take a photograph of the individual to assist with prosecution should it be necessary at a later date o Arrest the individual
Yes / Date
In Process
No
Sample Policy
HS-18 HS-19 HS-20
HS-29
Yes / Date
In Process
No
Sample Policy HS-19
HS-20
HS-28
HS-29 HS-52
HS-27 HS-41
Continued
Tool
O Do you prohibit use of restrooms and other amenities/facilities by individuals who do not have
business in the facility, i.e. persons who are not visitors, vendors or business associates? O Do you limit the number of visitors to patients in the Emergency Department and other patient care areas (allow case by case exceptions to the stated
limit)?
TRANSPORTATION
The following guidelines are designed to assist in developing standardized policies and procedures regarding controlling access by vehicle. O Have you reviewed transportation routes and
parking areas around the hospital to determine whether the routes allow contact with sensitive areas of the hospital? o Erect barriers to block access to such areas during threat level red O Have you coordinated with local law enforcement to gain understanding of which transportation routes would be blocked during a threat level red? o Determine how traffic will be controlled o Determine hospital's responsibility in helping to control the flow of traffic o Assess the impact of travel restrictions on
hospital deliveries (JCAHO EC 4.10)
O Do you have a policy for transporting staff during inclement weather or a declared state of emergency? o Have staff been educated regarding the travel ban restrictions established by the New Jersey State Police, which requires staff to be listed as "essential personnel" by the hospital and to carry ID on their person O Do you have policies dealing with jump-start and lockout procedures?
Yes / Date
In Process
No
Sample Policy
HS-20 HS-21
Yes / Date
In Process
No
Sample Policy
HS-43
F. TECHNOLOGY AVAILABLE TO ASSIST WITH

IDENTIFICATION AND ACCESS CONTROL
phis list of available technology is provided for your lntormatlon only, re0Ogni7;ng that the ability to
incorporate
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nei,v technology varies
among hospitals.
O Do you have a procedure for ensuring the integrity of an electronic access control system (including access card reader and closed circuit TV systems) in the event of a
power failure? JCAHO EC 7.10
O Is there a closed circuit TV (CCTV) system installed at the facility?

o Is there a policy to address covert camera
o o o o o o O Do you o o o
o Phone Systems
monitoring? Does it monitor high-risk areas? Does it have recording capabilities? Is the system password protected? Is the monitoring station monitored? Is there a training program for the CCTV operators? Can CCTV system including recording devices, monitor screens and cameras - be powered by emergency power? have policies for the use and testing of: CCTV Panic Alarms Lighting Systems
O Do you have video surveillance cameras, including those

that
may be viewed b Security from a desktop computer?
O Do you have systems that produce a visitor/vendor pass by putting a driver's license through a machine? The system verifies whether the license is valid. O Do you have access control systems with locks or cards with computer chips that produce an audit trail - an electronic record of each person entering doors using the key or card? o Swipe card technology is one example O Do you have access control systems that allow role-based access to certain software programs, networks, equipment and departments (e.g. only lab technicians are able to enter the laboratory)? o Proximity cards and smart cards are examples. O Do you have metal detectors? O Do you have policies regarding key control
O Do you have biometrics - eye/palm/thumb scans that permit
access by authorized persons only when the system recognizes their unique preprogrammed features.
Yes 1
Date
In
Process No
Sample
Policy
HS-24
HS-24
HS-24 HS-45 HS-49

HS-49
HS-24
HS-50
G. INFORMATION SECURITY AND ACCESS

CONTROLS REQUIRED UNDER THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA)
Hll='AA security regulations establish standards for the development of policies and procedures related to protecting heath information that is maintained or transmitted electronically. The regulations require that providers implement protections in the following three areas: adrninisirative. physical and technical saleguards. Fora complete overview of compliance requirements review the federal regulations at 45 CFR Part 142.
ADMINISTRATIVE SAFEGUARDS
0 Have you performed a risk analysis?
O Have you established a risk management policy? O Have you established a sanction policy? O Do you conduct information system activity reviews? O Do you assign security responsibility to a single individual (security officer)? JCAHO EC 2.10 O Have you conducted security awareness and training? O Have you developed security incident response and repo rtin procedures?
O Have you established a contingency plan addressing data
backup and recovery?
PHYSICAL SAFEGUARDS
O Have you established facility access controls? O Have you developed policies on workstation use and security? O Have you developed policies regarding device and media
controls that include disposal and re-use policies?
TECHNICAL SAFEGUARDS
O Have you established access controls that include unique user identification and emergency access procedures? O Have you established audit controls? O Have you established mechanisms to authenticate person or entity? O Have you considered transmission security by encryption or other information integrity controls?
Yes / Date
In Process No
Sample Policy
HS-03
HS-48
H. GENERAL SECURITY POLICIES

17 Do you have a procedure for infant security?
Yes / Date
Process
In
T o o l
1771 Do you have a policy regarding narcotics diversion?

O Do you have policies to manage court-ordered documents? O Are your outgoing public mailboxes (U.S. Post Office and Fed Ex) set away from the building?
Terminated employees l ho (olio n irx gurdcUnes are dE.sigood to cl >sist
it) developing
Yes / Process
In standardized policies and procedures regarding access by Date terminated employees. O Do you have a policy and procedure addressing access
restriction for terminated employees? o Require Human Resources to notify Security on a daily, concurrent basis of all terminations or resignations so that Security can restrict access accordingly o Require all employees to turn in equipment/access cards and keys at time of termination/resignation o Require a monetary deposit for an employee's ID at
time of hire; refund the deposit only upon the return
of ID and other materials O Do you terminate access to voice mail, e-mail and health information and patient accounting systems upon termination of the employee?
o Require one department to be responsible for
terminating access to all information/phone systems as well as access to the facility

O Have you developed standard forms and a checklist of steps
for termination to ensure that all appropriate actions are taken? o Require employees to pick up their last paycheck from Security to allow Security staff to ensure that all appropriate steps have been taken upon termination O Do you allow immediate termination of employees 24 hours a day, seven days a week, rather than only when Human Resources is present?
^![i.l
:rrttic.
!"f:,r'li:.,.. ..`;1'..._, i;.77OrV
No
Sample
Policy
HS-26HS-36 HS-47 HS-48
No
Sample Policy
HS-33
HS-33
NJHA
Policy Index
Access Control
Access Control
Building Access
Policy #
HS-23 HS-29 Infant Security
Baggage Check
Visitor and Public Use
Trespassers ED Security ED Signage Key Control
Morgue Security Search and Seizure Security Sensitive Area Access Security of Unoccupied Areas
Locker Inspection

Courtesy Policy ED Security ED Signage General Orders for Security Jump Start / Lockouts Locker Inspection Managing Court Ordered Documents
Narcotic Diversion Non-Solicitation Disruptive Patient / Employee / Visitor Response Guide Bomb Threats
Policy #
HS-40
HS-12

HS-25
Patient Vehicle Management Physical Force Restraining Orders Search and Seizure Searching Homicidal / Suicidal / Dangerous Patients Terminated Employees
VIP and Media Management Vehicle Inspection
Visiting Hours and Visitor Access Weapons
Policy Index Continued

General Employee Awareness and Training
Policy #
HS-17

Identification - PT, Visitor Staff Vendors Identification- PT, Visitor Staff Vendors Visiting hours Access Control
Identification- PT, Visitor Staff Vendors
Policy #
HS-18 HS-19 HS-20

CCTV System
Fire Watch
Policy #
HS-24 HS-42
Panic Alarm Testing Lighting Inspections Telephone Testing
HS-44 HS-45 HS-49

Security Officer Authority Security Staff Training - Promotion Security Staff Training - Training & Orientation Security Staff Training - Training & Orientation Security Staff Training - Local PD prisoner management
Security Staff Training - Local PD prisoner management
Policy #
HS-16 HS-06 HS-07 HS-08 HS-09 HS-10 HS-22
Uniforming

Hazard Vulnerability Analysis Hazard Vulnerability Analysis Risk Assessment Activities
Policy #
HS-01 HS-02 HS-48 Security Vulnerability Analysis HS-03 Security Management Program Staff Orientation - Performance Evaluations HS-04 Security Management Program Access control - ID - Vehicle access HS-05
HAZARD VULNERABILITY
ANALYSIS HS-01
HAZARD VULNERABILITY ANALYSIS

ST. JOSEPH'S REGIONAL MEDICAL CENTER
POLICY
The Joint Commission on Accreditation of Healthcare Organizations requires that institutions conduct regular vulnerability analysis to evaluate risks on the probability of occurrence and how prepared the institution is to deal with them,
PURPOSE
To meet the provisions of the Accreditation Manual for hospitals, management of the
Lnvirotnrnnennt of arEe EC. 1.4,
PROED U R
Fill out all the columns on Vulnerability Analysis .6 Type of emergency In the first column, list all the emergencies that could affect St. Joseph's Regional Medical Center (J .M ), including internal and external possibilities, Include geographic concerns, technology problems, human error, the design of the building, and what disasters you are regulated to deal w Probal:aility
Rate the likelihood of each emergency's occurrence on the kale with the larger
number being the highest probability and lower being the least. This is at
subjective detemilriation.
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Hazard Vulnerability Analysis Page 3
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Human Impact
Assess the potential deaths and injuries from the erner ency, using the saute
scale.
Property impact
Consider potential property damage from the disaster, including costs of repairs using the scale.
Analyze how the emergency could affect business interruption, employees being unable to work, patients being unable to come to the facility, violation of any contracts, potential fines or penalties, and any delay of critical supplies.. nal and external resources
Examine the Medical Center's resources and their ability to respond to the
emer ency, using the scale with the larger number indicating weak resources ,and I showing strong resources. Consider what resources would be needed and ask
whether those resources will be able to respond. as quickly as neeaded. Total

when the form is completed, add the individual columns up for each emergency,
The lower the score, the better. The comparisons among different disaster scenarios should be used to determine planning and resource priorities for
SJRMC, 0 Identified hazards
The identified hazards will then be placed in descending order of their total score, which will prioritize the hazards that JRMC needs to review for emergency planning, The fours of the planning will then be on the hazards of higher priority or score. SJRMC will address all hazards no matter the probability andlor risk of the
event occurring, but will place more emphasis on those scoring six (6) or above after analysis.
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HAZARD VULNERABILITY
ANALYSIS HS-02
HAZARD VULNERABILITY ANALYSIS

UNDERWOOD MEMORIAL HOSPITAL
Po icy:
A Hazardous Vulnerability Analysis
that provisions may be undertaken to lessen the severity and impact of an emergency. Procedure: 1. The HVA identifies all hazards that are most likely to impact the organization, or community, and it includes the vulnerability of the hospital buildings and grounds. The results of the HVA may be used to mitigate potential risks and prepare for managing emergency responses. 2. The HVA and emergency response planning process are performed in concert with local and county emergency management planning processes. 3. Preparedness efforts are prioritized, in part, by the criticality score calculated by the HVA process. The criticality score is calculated by scoring the following indicators for each likely hazard: a. Probability: includes known risk(s), geographic location, historical data, presence of local high-risk industry, manufacturer or vendor statistics, and local emergency management HVA results,
b. Risk:
Officer/Emergency Management Coordinator to identify areas of vulnerability so
(HVA) is performed by the Safety
includes the likelihood of threats to life/health, disruption of services, equipment or facility damage or failure possibilities, loss of community trust and financial impact on the organization.
c. Preparedness: includes the assessment of emergency response plans relative to the identified hazards, the training of hospital staff, exercise and drill outcomes, response to actual emergencies, the availability of back-up and redundant back-up systems, the availability of community resources, and other preparedness issues, 4. The HVA is reviewed by the Environment of Care Committee and recommendations for mitigation and preparedness activities are made to
NJHA
shared with department directors and the leadership of the Medical Staff.
The distribution of HVA results and related education and information is the responsibility of department directors and medical staff leaders. Review Period: The HVA is reviewed, at minimum, on an annual basis and revised accordingly, current or new hazards change.
relevant departments and Administration. The results of the HVA are also
More frequent reviews are conducted as the probability, risk and preparedness of
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RISK ASSESSMENT
HS-03
ENVIRONMENT OF CARE RISK ASSESSMENT

UNDERWOOD MEMORIAL HOSPITAL
POLICY It is the policy of Underwood-Memorial Hospital to conduct an Environment of Care Risk Assessment on at least an annual basis, with reviews and revisions made consistent with identified risk changes, The risk assessment is used to evaluate the impact of the environment of care ability of the organization to perform clinical and business activities. The impact may include disruption of normal functions or injury to patients, visitors and staff. The Safety Officer is responsible for managing the risk assessment process. This responsibility includes: 1. Participating in the selection of Risk Assessment Team members.
2. Training team members
3. Scheduling departmental and area assessments, as needed 4. Managing the annual assessment of the scope of the Environment of Care programs This procedure describes the actions required to initiate and conduct an initial
risk assessment and the actions required to re-evaluate a risk assessment as
part of the annual evaluation of the Environment of Care programs. A risk assessment of all existing programs will be conducted as part of the current annual evaluation of the Environment of Care programs. The risk assessment will be reviewed during each subsequent annual evaluation. A risk assessment of all new services and of all areas undergoing major renovation, alteration, or conversion will be conducted prior to use. The risk assessment findings will be used as a data source for Hazard Surveillance. The risk assessment will be submitted to the Safety Committe
Risk Assessment Page 2
PROCEDURE
An initial risk assessment is required for all areas not having had a risk
assessment conducted within the last 3 years.
2. An initial risk assessment is required: whenever a new building is constructed, an existing building is purchased by the hospital, or an area undergoes significant renovation or conversion of use.
3. Each department or area requiring an initial risk assessment is evaluated using an appropriate risk assessment form(s).
4. The evaluator completes the form by identifying the risks related to the
environment and the activities conducted in the area. Each risk is scored
using the g 4 rating scale included in the form.
5. To determine the appropriate score for each identified risk, the reviewer will consider information obtained through a physical tour of the facility, review of annual incident and accident statistics, review of at least the past twelve (12) months safety committee minutes, hazard surveillance reports, interviews with department heads, and on unit interviews with a representative sampling of staff,
6. The Safety Officer is responsible for identifying an appropriate Risk

Assessment Team and scheduling the evaluation of the affected area (s). 7. The completed risk assessment grids, including the sections on the form
for recommended changes in processes, training, personal protective

equipment, policies/procedures, and comments will be presented to the Safety Committee for review and approval.
8. Should any situations which constitute an imminent danger be discovered
during the course of the risk assessment, they will be reported immediately to the Safety Officer and the appropriate department manager for appropriate follow-up action to resolve the identified issue(s).
SCORING KEY
SCORING CRITERIA A high risk area with possible life-threatening or disabling 4
consequences, as well as some history of associated

incidents with serious injury.
3 2 1
L
0
A high or significant risk area with possible lifethreatening or disabling consequences and no history of associated incidents with serious injury.
A moderate risk of minor injury or inconvenience to
patients, visitors, or staff.
A minimal risk of minor injury or inconvenience to patients, visitors, or staff. Virtually no risk of injury or inconvenience to any one,
NJ NA
NINA
SECURITY MANAGEMENT
PROGRAM HS-04
SECURITY MANAGEMENT PROGRAM

ST. JOSEPH'S MEDICAL CENTER
Sffective Date.
April 1S
2001
Superssradoe s
Kay it 1998
Section B
sections
Page, l-s Pages 1-5
8uhjeet4
Security Hanag
ent Plan
(80.1.2)
St. Jos ph'e Hospital 4 Medical Centersi and S-t: Vixkciantoo Nursing
as
employees, patients and visitors from harsh. A risk assessment is cord determine the elements of the plan and include all off-site locations,
Security management is a function and set of activities focused on 1tedicaal Center's & Nursing tt =e security needs. The objectives of the Security Management Program include,
Security Management Program's scope is to provide a program that shat
protect
ted
to
et.ln
ttie
Provide education to personnel on the elements of the Security r$nagera rst Program... Control access to and egress from sensitive areas Special Care Units, Pharmacy) Reduce the risk of security incident; AS the field Of security management is constantly changing, it is understood that these objectives will achieve et pliance over time, with revisions at (i.e. t eivkaorri o;;seIy. hs .
appropriate to changes in the healthcare environment.
The Medical Center's & Nursing Ham's Security management Plan includes the following: SLR FOR DR pPIAIti, IKPt,Fm:&NT1MG Add t fad rT.o8iso 8
of Executive officer shall appoint a qualified individual to develop, intain and monitor the Security Management Program., The director aiarity is responsible for maintaining a Security Management Program that prepares for and prevents future security incidents by antabl i.shi.ng security procedures, in service orientation and continuing education of all personnel,
and monitoring and evaluation of security incidents for opportunities to Improve
care. S
See security Authority Policy and job Oeacription Director of Security.

PATIR14T8. VXStTO S, RKLOYRRS AM PROPZRTY ARE
Security Page 2
Management
ive Datea suprsraed r
ii is 1 y 1 1l 11 9999 88
$ectica: E
Page: 2
8'ect1
:M
Page, 2.5
Subject Security Management Plan (E
2)
Security i,rnspection vulnerability reports are completed to indicate areas of risk, including security vulnerabilities of sensitive areas, security habits of personnel, staff knowledge and skill of Security Management. An inspection gives a good indication of future danger and i diate steps shall be taken to eliminate the problem. See Security Crime Vulnerability Insp t ton Report and Security Management Policy and Procedure Manual for additional policies,
procedures and forms.
AI t EsCURI INCIDENTS INVOLVING PATIENTS, VISITORS, EMPLOYERS AND PROPERTY ARE REPORTED AND lNVSSTIGAT.EDs
A Security incident Report ias Completed on all incidents inuolvinng par ierss'!=' visitors. employee or property and forwarded to the Security Adtnrti nc rat ! },,,
Offices See Quarterly Report of
X LL PATIENTS.
Security Incidents.
M M PERSO N WILL HAVE APPROPRIA,DE IDENTIFICATION:
The Hospital au4Jor. Nursing , identification badges Shall be worn by all, employees and. staff.. inpatients will wear permanent identification bands and outpatients and 8.D., patients will wear temporary bands. All visitors i.Li obtain a pass from the Information Desk or Security Post. All personnel shall stop and question any unidentifiable person in their area. Any person who is not wearing a recognizable Medical Center's approved identification tag, visitor or vendor tag shall be considered a stranger. SENSITIVE AREAS WILL. kVE CONTROLLED ACES AS D ETER Ttr SY THE FACILITY. Sensitive areas that will have restricted access to and egress from include, but are not limited to Emergency care Areas, Newborn Nursery; Labor & Delivery, Special Care units, Pharmacies. Behavioral Health Units, Medical Records, Cashier, Outpatient Clinics and' Specialty Outpatient Clinics, See Security Manaage nt policy and Procedure manual for additional policies, procedures forms .
,cm To uRaE1rt cAIBE AREAS IS PR
Security will keep the limited Emergency Depart nt parking clear for authorised vehicles only, Security will be on hand for traffic control and will attempt to clear Urgent Care and ergency r'tment parking areas of infractions.
"NINA
Security Page 3
Management
ffectiva Dates up,r'aedeaa
April 15.2001 May 1, 1908
Sections 8
Page:
Page
Security management plan J C, 1.2.)
CRI A IO A EDUCA"fZON P FL VIACNX
EP7, rs i
REGARDING sgct3T.ITY Is IN
The Director of Security wilt provide security related education to all employees at orientation and annually thereafter. Education programs shall includeWhat emergency procedures to take during security incidents. How to report security incidents in property. sling patients, personnel, v si Corn and
to minimize security risks in security sensitive areas.

G CS ST MARL:
summaries of all activities shall be forwarded to the Administration. Quality Assessment and improvement Department, Organizational Performance improvement
committee, Risk Management and department directors as appropriate, The following perforaaafce tandarda are utilized to evaluate the Security Management Plan.
Rte
S9
stab' x,nowledge loot compliance by
by
Security
Quarterly
safety committee
employee wearing ID badges 4 understanding pal icy 95% know.Security's telephone It quarterly safety Committee Security
Staff
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Security Page 4
Management
Ef.f+ tine Date: Supersedes s
April 15, 2001 may 1, 1998
Section: a Section: M
Pager 4-S Page: 4-'S
subiect: Seeutity
,i.2)
-Aire,
ZarsArA security security will respond
Fr=sfta
RMEL
xAU49AU= Quarterly Committee

Security
to :tallsi incidents
within 3 minutes
See monitoring Summary Pormat, Safety Program Indicators, Staff Safety

Questionnaire and Security Management Policy and Procedure Manual
for
pool i. ies, procedures nd orms .

EP.GE CT SECURITY PROCEDUR'
addiu+
There are provisions made for the security of the phyai a.t plant, patients, visitors and personnel of this Medical Center and Nursing Rome during disaster situations.
personnel are trained in the actions to be taken in the event of a security

incident, i.e., infant abduction, attempted robbery, workplace violence, civil disturbance. All VIPs entering the hospital will enter through the Emergency Department and be met by a Triage Team. If the patient is to be, admitted, he/she will be
admitted to ICU. Any inquiry from the news media will be directed to the
Director of Community Relations.
The medical Center shall seek to maintain a cooperative relationship with the news media which balances the public need for infcrnmation with the responsibility to safeguard the patient's right to privacy. ease of information to the media will be by authorized personnel only. See Release of Information to New Media; Security Measures Involving VIP(S) policy, Riot or Civil Disturbance Procedure Policy; Emergency Preparedness Security policy and security Management Pol y and Procedure manual for additional policies, procedures and form,
Security Page 5
Management
fac cttive r
Suparsetlei t
April 15, 2001

(ay 1, 1998
section 2
Section. x
Pager S-5, Page; 5 5
Subject t security t+ nasemen:t Plan (1c:.1.2)
ARMIL EThLUADIC OF TUN URM 1 RJOE1t PR*FOR EFFECTI $;
oa ECTIVEL.
=PR,
The annual evaluation of the Seourity Mena
nt Program will include a review of the scope and objectives by the Security Department, The performance and effectiveness of the Security Management Pr rant shall be reviewed by the Director of security, Organizational Performance Improveme nt Committee and r1m. organizational Performance Improvement COt m ttee. (see Securit y N4anage nt Program Annual Evaluation Form.)
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SECURITY MANAGEMENT
PROGRAM HS-05
SECURITY MANAGEMENT PROGRAM

ATLANTIC CITY MEDICAL CENTER
MISSION STATEMENT The Atlantic City Medical Center Security Department will provide a system of safeguards designed to protect all persons interacting within the Medical Center and its environment. The system will also be designed to prevent the destruction or theft of the medical Center assets.
PURPOSEIOOJECTIYES: The safety and securitys of the patients, visitors, employees and property is of vital importance and is essential in providing safe patient care as part of the medical center's mission. The potential for the occurrence of incidents that can impact on the safety and security of an organization cannot be ignored, but must be recognized and appropriate remedial measures taken to prevent or at least reduce the sometimes destructive resu Its of such occurrences, The objectives of the Security Management Program are: Establishing, supporting, and maintaining a Security Management Program, To provide a safe and secure physical environment for the patients, visitors and employees of Atlantic City Medical Center. To monitor the physical environment of the facility for actual or potential hazards, To address and correct the concerns/hazards that are discovered through monitoring and surveillance activities. ucate all. persons concerned with the continued operations of the facility vci.th the importance of aining an effective and efficient security program..
SCOPE:
The security Management Plan applies to all employees and departments in the medical center, other sites owned by the medical center, and all areas of the medical center grounds. Security coverage is provided by a proprietary security force which provides for security on a 24 hour a day, seven days a week basis at both Medical Center divisions, whose officers are qualified to perform duties customarily undertaken by security guards, with the expressed stipulation that the security force will be unarmed and will not engage in any type of police actions. In the event that such police actions are needed, assistance will be sought from local law enforcement agencies..
Security Page 2
Management
tESPCINSIRI L ITY: A collaborative effort between management and staff is needed to maintain the Security Program and to ensure that the program functions in an effective and efficient manner. It is the responsibility of the Chief Executive ility to ensure: that the Security Program meets the needs of the facility. The Security Program will be under the direct supervision of the Director of Security and Safety. There is one
supervisor and/or lead officer pcr shift in the city division, one site supervisor and two lead officers at the mainland division to oversee the, lady operations of the security force.
SECURITY MANAGEMENT PROGRAM INCLUDES:

I Addressing security issues concerning patients, visitors, personnel, and property.
Implementation: a. Monitoring and patrolling designated perimeters, areas, structures and activities of security interest to the medical center. b. Checking designated areas and buildings during other than normal working hours to determine that they are properly locked or are otherwise in order. Perform essential escort duties during after hour's
d.
e.
Responding to protective alarm signals or other hazard indicators,. Acting as necessary in the event of situations affecting the safety and security of the facility including responding to fire and emergency codes.
f.
Providing staff information on responding to violence in the workplace.

Ntaintaining an open line of communication with the Corporate Director of Safety and Security
g.
for the purpose of keeping the Director informed of situations that will impede upon the safety and/or security of the facility..
2. Reporting and investigating aft security incidents that involve patients, visitors, personnel, or
property-
Implementation-
During normal operating hours, the security supervisor/lead officer in-charge will notify the Corporate Director of Safety and Security or the On-Call Administrative person of any unusual occurrences, breeches of security or safety/security problems that are identified during their rounds. The Corporate Director of Safety and Security or the On-Call Administrative person will assess the situation, give farther directions to security personnel and notify the Division Administrator of the facil ity/designee and local law enforcement agencies as deemed necessary. During after hour's periods, the security supervisorlin.chharge lead officer will notify the Nursing
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Security Page 3
Management
Supervisor on duty of any unusual occurrences, breeches of security or safetyls unity problens identified during their rounds. The Nursing Supervisor will assess the situation, give further direction to security personnel and notify the Corporate Director of Safety and Security, the Division Administrator fdeesignee and law
enforcement agencies as deemed necessary.

Providing identification, as appropriate, for patients, visitors, and staff, I mplementa tion:: All employees and volunteers will be required to wear a picture identification name badge at all times while on duty. Visitors will be issued visitor passes by the information desk. Patients will be required to wear identification armbands. Contractors/vendors and students: will be required to wear approved medical center name badges. Controlling access to (traffic control) and egress from sensitive areas. (ER:, OR, Nursery, Pediatrics, Pharmacy, Mental health, Medical Records I mplementa flan: Emergency. Room: Access to the ER is controlled by security staffed 24 hours a day. Access control and CCTV are used to monitor and control access to the Emergency department. Operating Room Suite: an ID Card Access System controls Access to the OR Suite. The staff in the department is responsible for traffic control in the department, Nursery: Access to the nursery is controlled by surveillance cameras, access control, disci Nursery If) badges, and entry of only authorized personnel into the Nursery. Pediatri
security guard rounds control Access to Pediatrics.
: surveillance cameras, access control wal
exit doors with alarms, and
Pharmacy: doors locked at all times control Access to the Pharmacy and entry by only authori zed personnel.
Mental health: Access to Mental Health is controlled by locked entrance doors, exit doors with alarms, entry by authorized personnel, and security guard rounds. Medical Records: Access to Medical Records is controlled by an access control system. The staff in the department i : responsible for traffic control in the department. Egress: Staff in all sensitive areas are responsible for maintaining clear eg at all times. exit rem
5.
Leadership's designation. of personnel responsible for developing, implementing; and monitoring the security management plan. Implementation: David Tilton, CEO, Atlantic City Medical Center has designated Larry Swe ne ey as Corporate Director
tip
Security Page 4
Management
of Safety and Security. Emergency security procedures that address, a. Actions taken in. the event of a security incident or failure Implementation: Any employee who witnesses or hears of an occurrence requiring security will immediately notify medical center communications (city 1.2222, mainland 2-2222). Upon receiving the call the operator will call "Security STAT" and the location on the overhead paging system. Weapons: Employees, patients, visitors, and medical staff of the medical center are not permitted to bring weapons into the medical center. It is against the law, In the event that it is discovered that a
person has a weapon in their possession, the Corporate Director of Safety and Security or the security supervisor, roust be notified. The Corporate Director of Safety and Security or the
security supervisor will inform the person(s) possessing the weapon of the medical center's weapon policy and request that person(s) remove the weapon from the medical center premises immediately. If an illegal weapon is found, security will immediately notify local law enforcement The person(s) will be asked to either take the firearm and lock it in their vehicle or unload the firearm and lock it in the safe. If the person(s) refuses, the police department will be notified. The only time firearms may be carried in the medical center is by law enforcement officers, b. handling of civil disturbances
Implementation.
Individuals: If it is determined that a visitor is creating a civil disturbance, the person will be
escorted out of the medical center by the security. If the person objects, the security officer will notify the security supervisor who will notify the police. If assistance is needed, the security officer may page "Security STAT" until the police arrive.
Groups: If it is de termine I that a group of individuals are in the medical center on other than
fficial or medically related business, and are creating a civil disturbance, all entrances to the r should be secured, and where possible, the group should be isolated be activating the fire doors and preventing them from circulating through the rest of the medical center. The security supervisor will immediately notify the police, It is important that security try to keep the group calm and not aggravate the situation, as much as possible, until the police arrive.
C.
I Iandling of situations involving VIPs or the media Implementation: Situations involving VIPs or the. media will be handled in the following manner. The Corporate Director of Safety and Security will be responsible for securing the building if necessary and implementing the neceYssary security of the medical center. The Corporate Director of Safety and Security will also designate parking for media vehicles so that normal patient, visitor, and
emergency traffic are not interrupted. The Administrator will be responsible for designating
Security Page 5
Management
an area for any press conferences, and the time and content of such press conferences. The VIP patient will be placed in a private room with security in attendance, if necessary.
d.
Staffing for human and vehicle control during disasters
Implementation.
T1te Press will be directed to the designated pre" area Family members coming tc pick up discharged patients will be directed to the main lobby. Security is responsible for monitoring traffic coming through the main lobby of the medical center. Only families of disaster victims, families picking up discharges, physicians, and individuals assisting with the treatment of victims will be allowed in these entrance doors. All authorized persons seeking entrance to the medical center will be directed to the rear employee entrance. All others seeking entrance to the medical center will be turned away. Security is responsible for monitoring traffic through the Emergency Department ambulance entrance, Only disaster victims, physicians, and individuals assisting with the treatment of victims will be allowed in these entrance doors.
7,
Providing vehicular access to urgent care areas. Implementation: Vehicular access is provided to the ER by surveillance cameras outside the ambulatory and ambulance entrance and staffviewing of the ambulance access area. Anyone pulling a vehicle into the ambulance area for patient unloading will be assisted and instructed to move the vehicle to an authorized parking area. In the event that construction occurs in this area, an alternate ambulancejvehicle entrance will be assigned and temporary signage will be provided to direct traffic to the alternate area. An orientation and education program that addresses: a. Processes for minimizing security risks for personnel in sensitive areas b, Reporting procedures for security incidents Emergency procedures followed during security incidents c, Implementation: All employees will be provided education regarding security management at the facility and departmental level. It will be accomplished in the following manner: a. All new employees will be provided with facility security management education during
8.
Medical Center wide Orientation. They will also be oriented to departmental security
management responsibilities during their initial three months of employment by the Department
Manager,
All employees will receive at least annual medical center wide and department-specitie security management education. c. The departmental programs will be based on employee needs, either requested or assessed, and
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Security Page 6
Management
are coordinated by the respective de .artment. managers. The Corporate Director of Se Security will assist in providing information for departmental programs. q.
y d
Ongoing monitoring of performance regarding actual or potential risks related to one or more of the following: Implementation:
Performance improvement standards for Security Management will be monitored on an ongoing basis
and reported to the Safety Committee and will include: at least one of the following: Staff knowledge and skills Valuable Procedures Monitoring and inspection activities Emergency and incident rcpctri n Inspection, preventive rayinte:n<ance, and testing of equipment
ANNUAL EVALUATION OF THE SECURITY MANAGEMENT PROGRA

plan shall be evaluated on an ongoing basis to assure that it meets the security needs of the institution. At least annually the objectives, scope, performance, and eflT ctiiveness of the plan shall be reviewed, and revised if necessary by the Safety Committee, with input and assistance from other committees,, Administration, Medical Staff Departments and Medical Center Departments. Approval of revisions will be made by the Safety Committee, Medical Staff:, and the Board ofTrusts. COMMUNICA [. IO1 IREPORTIN[k
'l'he findings, conclusions, recommendations, actions taken, and follow-up by the Safety Committee, as a result of the monitoring and evaluation of the Security Management Plan, are reported at least quarterly to the Safety
Committee, the Quality Council, which includes nursing, departmental and administrative reprise z titaaz,
Medical Executive Committee, and the Board of Trustees.
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Security Page 7
Management
CORPORATE DIRECTOR OF SAFETY AND SECURITY 2 SAFETY SPECIALISTS 3 HEALTHPLEX OFFICERS
OPERATIONS MANAGER CITY
OPERATIONS MANAGER CITY
THREE LEAD OFFICERS
THREE LEAD OFFICERS
4 OFFICERS
4 OFFICERS
3 OFFICERS
3 OFFICERS
3 OFFICERS
1 OFFICER
1 OFFICER BBRH
1 OFFICER BBRH
1 OFFICER BBRH
NJHA
APPENDIX A
Joint Commission Resources. CAMH. 2004 Comprehensive Accreditation Manual for Hospitals. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare
Organizations, 2004, 19 pages. Reprinted with permission.
Orientation, Training, and Education
Compliant
Not Compliant
Standard HR210
Orientation provides initial job training and information.
Rationale for HR.2.10

Staff members, students, and volunteers are oriented to their jobs as appropriate and the work environment before providing care, treatment, and services.
Elements of Performance for HR.2.10

As appropriate, each staff member, student, and volunteer is oriented to the following (EPs 1-5):
cC
C F0 C
NA NA NA
1. The hospital's mission and goals
2. Hospitalwide policies and procedures (including safe ty and infection control) and relevant unit, setting, or program-specific policies and procedures Specific job duties and responsibilities and unit, setting, or program-specific job duties and responsibilities related to safety and infection control 4. Not applicable
CL C 0
2 2
NA NA
5. Cultural diversity and sensitivity 6. Persons are educated about the rights of patients and ethical aspects of care, treatment, and services and the process used to address ethical issues.
7. Not applicable
Mactui;enu'rtf oflhxnctu I'i'scutrecs
Scoring Grid
0 nsufficient compliance I Partial compliance 2 Satisfactory (ompliance NA Not applicattlo
8.
Orientation and education for forensic staff include how to interact with patients; procedures for responding to unusual clinical events and incidents; the hospital's channels of clinical, security, and administrative communication; and distinctions between administrative and clinical seclusion and restraint. The hospital assesses and documents each person's ability to carry out assigned responsibilities safely, competently, and in a timely manner upon completion of orientation.
Q 9.
Standard HR.2.20
Staff members, licensed independent practitioners, students, and volunteers, as appropriate, can describe or demonstrate their roles and responsibilities, based on specific job duties or responsibilities, relative to safety
U Compliant J Not Compliant
Rationale for HR.2.20

The human element is the most critical factor in any process, determining whether the right things are done correctly The best policies and procedures for minimizing risks in the environment where care, treatment, and services are provided are meaningless if staff, LIPs if applicable, and volunteers do not know and understand them well enough to perform them properly It is important that everyday precautions identified by the health care organization for minimizing various risks, including those related to patient safety and environmental safety,' be properly implemented, It is also important that the appropriate emergency procedures be instituted should an incident or failure occur in the environment.

Staff members, LIPs, students, and volunteers, as appropriate, can describe or demonstrate the following:
Q 1. Risks within the hospital's environment

2. Actions to eliminate, minimize, or report risks 3. Procedures to follow in the event of an incident
C
C
L!I?J"I]
2__LN7
4. Reporting processes for common problems, failures, and user errors

Standard HR.2.30
Ongoing education, including in-services, training, and other activities, maintains and improves competence.
C _0
iU Compliant i] Not Compliant

The following occurs for staff, students, and volunteers who work in the same capacity as staff providing care, treatment, and services:
1.
Training occurs when job responsibilities or duties change
C LL1C O .I. C C 0
2T 2_ NA _kA 2 NA)
Q 2. Participation in ongoing in-services, training, or other activities occurs to increase staff, student, or volunteer knowledge of work-related issues
Q 3.
Ongoing in-services and other education and training are appropriate to the needs of the population(s) served and comply with law and regulation
4. Ongoing in-services, training, or other activities emphasize specific job-related aspects of safety and infection prevention and control
The Mann event of the' Environment of Care" c halrlcr in this mtuurrl identifies risks t ksociated with the followin categories.
safely, security, hazardous materials and waste, emeryenc,y manas;emenl, laltexatory/uicdicerl equipment, and utility mainuferrtent.
HR-8
2004 CAMH Core
Refreshed
Scoring Grid
0 Insufficient compliance
C'vrrrpr<rhrtnsir r> A(s reedrieition Manual for Hospitals. The Of/ic/al 1/anclhnok
Partial compliance
2 Satisfactory compliance NA Not applicable
C C C 0 0
1
Ongoing in-services, training, or other education incorporate methods of team training,

when appropriate 2 2 NA NA
6. Ongoing in-services, training, or other education reinforce the need and ways to report
unanticipated adverse events Q 7. Ongoing in-services or other education is offered in response to learning needs identified through performance improvement findings and other data analysis (that is, data from staff surveys, performance evaluations, or other needs assessments)
NA
Ongoing education is documented
2004 C;AMI I Refreshed Cure
HR - 9
Scoring Grid
0 i%uf}iclpni :omplianco 1 P11101 compliance 2 Satisfactory compliance NA Notapplicahle
Comprehensive A(('ieril(llir)ii Manurd !or Ilnspilcrls: The Ollirial llunrlhooh
Standards, Rationales, Elements of Performance, and Scoring
Planning and Implementation Activities

No hospital can ensure that patients, staff, and others coming to the hospital's facilities will never suffer an accidental injury. However, hospitals can minimize avoidable risks and injuries through sound planning, resource allocation (see "Leadership" chapter), effective training (see "Management of Human Resources" chapter), implementation, and ongoing monitoring and improvement of risk reduction activities. These activities can be accomplished through management process, staff activitiee,s, and/or technology
J Compliant
J Not Compliant
Standard EC.1.10
The hospital manages safety risks.
Rationale for EC. 1.10

Each hospital has inherent safety risks associated with providing services for patients, the performance of daily activities by staff, and the physical environment in which services occur. It is impor tant that each hospital identifies these risks and plans and implements processes to minimize the. likelihood of those risks causing incidents.
Elements of Performance for EC.1.10

B (_o L112 1. The hospital develops and maintains a written management plan describing the processes it implements to effectively manage the environmental safety of patients, staff, and other people coming to the hospital's facilities. 2. The hospital identifies a person(s), as designated by leadership, to coordinate the developnlent, irnpleinentation, and monitoring of the safety management: activities. 2 _N NA 3. The hospital identifies a person(s) to intervene whenever conditions immediately threaten life or health or threaten damage to equipment or buildings.
A r0
T1j
A L0
L1. .
B [0J- 1
1.
The hospital conducts proactive risk assessments that evaluate the potential adverse impact of buildings, grounds, equipment, occupants, and internal physical systems on the safety and health of patients, staff, and other people coming to the hospitals facilities.
5. The hospital uses the risks identified to select and implement procedures and controls to achieve the lowest potential for adverse impact on the safety and health of patients, staff, and other people coming to the hospital's facilities. C 0 1 2 NA 6. The hospital establishes safety policies and procedures that are distritbnuted, practiced, enforced, and reviewed as frequently as necessary, but at least every three years. 7. Not applicable B L-O=t _= NAJ C 2 TNA S. The hospital ensures responses to product safety recalls by appropriate hospital representatives. g. `flae hospital ensures that all grounds and equipment are maintained appropriately
U Compliant
U Not Compliant
Standard EC.1.20
The hospital maintains a safe environment.
4lanagement of The Environment of Care
Scoring Grid
0
t
Insufficient compliance
Partial compliance
2 NA
Satisfactory compliance Not applicable
Rationale for EC.1.20

It is essential that the hospital conducts periodic environmental tours to determine if its current processes for managing patient, public, and staff safety risks are being practiced correctly and are effective. These tours can also be used to assess staff knowledge and behaviors, identify new or altered risks in areas where construction or changes in services have occurred, and identify oppor tunities to improve the environment.

1. The hospital conducts environmental tours to identify environmental deficiencies, hazards, and unsafe practices. 2. The hospital conducts environmental tours at least eve ry six months in all areas where patients are served. 3. Not applicable 4. The hospital conducts environmental tours at least annually in areas where patients are not served.
C 0
B A
0 0
NA
NA
NA
Standard EC.1.30
The hospital develops and implements a policy to prohibit smoking except in specified circumstances.
C7 Compliant O Not Compliant

This standard is intended to reduce the following risks: To people who smoke, including possible adverse effects on care, treatment, and se rvices Passive smoking for others Fire The standard prohibits smoking in all areas of all building(s) under the hospital's control, except for patients in circumstances specified in the EPs below

1. The hospital develops a policy regarding smoking in all areas of all building(s) under the hospital's control. 2. The hospital's policy prohibits smoking in all areas of all building(s) under the hospital's control (no medical exceptions allowed) for the following: All hospital-based outpatients All children or youth 3. The hospital's policy may permit patients to smoke in the hospital's buildings under the following circumstance(s): A patient is residing in long term care settings (that is, longer than thirty days' length of stay) A patient is granted permission that has been authorized by a licensed independent B 0_ 2 2 NA NA
NA
practitioner (LIP), based on criteria developed by the medical staff

4. When patients are permitted to smoke in the hospital's buildings, they smoke only under the following circumstance(s): In designated locations environmentally separate from care, treatment, and service areas* C 0 2 NA
After the hospital has taken measures to minimize fire risks

5. Patients who do smoke in the hospital's buildings are discouraged from doing so and are provided education, including information about options for smoking cessation. C
NA
Note: This does not require that a designated smoking area be a specific, distance morn care, treatment, and service areas. A physically
separate, well-ventilated room (a designated area for authorized smoking by patients that is exhausted 1o the outside) is acceptable.
EC
("AMII Update 1, February 2004
Scoring Grid
0 1 Ir wfficienr compliance Pavia) cnrnpliance
(.'onrprehenshw A( CYCdiluNioo 49ruruul lur llvspiluk: Pic Olli( rid IG:mdirur,k
2 iarisfacrory comp) ance NA Piotapphcable
2 NA C 1 2. NA
Q G. The hospital identifies and implements a process(es) for monitoring compliance with the
policy
Q 7. T1ae hospital develops strategies to eliminate the incidence of policy violations wheel identified.
J Compliant
J Not Compliant
Standard EC.2.10 hTe hospital identifies and manages its security risks.
Rationale for EC.2.1 0

It is essential that a hospital manages the physical and personal security of patients, staff (including addressing the risks of violence in the workplace), and individuals corning to the hospital's facilities. In addition, security of the established environment, equilarneirt, supplies, and information is also important.
Elements of Performance for EC.2.10 B 0...1..1

2 NA] 1. The hospital develops and maintrains a written management plan descrilting the processes it implements to effectively manage the security of patients, staff, and other people coming to the hospital's facilities. 2. The hospital identifies a person(s), as designated by leadership, to coordinate the develofanment, implementation, and monitoring of the security management activities. 3. The hospital conducts proactive risk assessments that evaluate the potential adverse impact of the external environment and the services provided on the security of patients, staff, and other people coming to the hospital's facilities. Q 4. The hospital uses the risks identified to select and irrlplement procedures and controls to achieve the lowest potential for adverse impact on security. 5. The hospital identifies, as appropriate, patients, staff, and other people entering the hospital's facilities.
A [_0[ T.2.-INA DI? NA
C r0 C C
NA
[- _
1 1
2 2
NA NA NA
Q b. The hospital controls access to and egress from security-sensitive areas, is determined by the hospital. 7. 'floe hospital identifies and implements security procedures that address actions taken in the event of a security incident. The hospital identifies and implerneuts se curity procedures that address handling of an infant or pediatric abduction as applicable.
A [_0 A LO' J
1. _-2
CL
2 2 NAJ
9. hTe hospital identifies and implements security procedures that address handling of situations involving VIPs or the media. 10. The hospital identifies and implements security procedures that address vehicular access to emergency care areas.
:E1
J Compliant J Not Compliant
Standard EC.3.10
The hospital manages its hazardous materials aril waster risks.
' re polonlial for workpl; e violence is ronsid, wd dnring 11w rir>Ir nsses.tiinent.
Hazardous materials (IIAZMA'r) and w:Lste Malorinls Whose handling, use, anti sh r, ge ar'e' aide f or defined by local, slate', or
focloral repirlnlion-for rxample, the Or e'upalional Sufrrrv rind I icaltlr Adminislrrlion's i r'l;ulaliorrs for filcurril ornc Nrrlturl;rpns regarding the dispus,rl of blood :rid Hood Soaked atenrs; trot Nuclear konulalorv Commission's rcf;uhrlirnr, for the handlhir. and
disposal of radioaclivc' wnsle, hazardous vapors (for ('satnll)In, gluferrldehvde, elhylr,'iw oxide, rrilrois oxide), and hazardous onerrfy
sourcts (for r'xaulpfc, ionizing or nonionizing radiation lasers, microwave, ulrrasowr(l). Allhounh inn Joint Commission says infr r lions waste falls into IN,; each'{ory of mrth'rials, federal rf;ul Lions do rent define infrrction.s or medirvrl waste as hazirrdous waste.
2004 CAMH Refreshed Core
EC - 9
,Haan /emenl of Mc I,rU ! UUmc ut of Core
Scoring Grid
0 1 2 Iruufticient compliance Partin! Compliance
Satisfactory compliance NA Not appilcable.

Hospitals must identify materials they use that need special handling and implement processes to minimize the risks of their unsafe use and improper disposal.

1 The hospital develops and maintains a written management plan describing the processes it implements to effectively manage hazardous materials and waste. The hospital creates and maintains an inventory that identifies hazardous materials and waste used, stored, or generated using criteria consistent with applicable law and regulation (for example, the Environmental Protection Agency [EPA] and the Occupational Safety and Health Administration [OSHA]). The hospital establishes and implements processes for selecting, handling, storing, transporting, using, and disposing of hazardous materials and waste from receipt or generation through use and/or final disposal, including managing the following: Chemicals Chemotherapeutic materials Radioactive materials Infectious and regulated medical waste, including sharps 4. The hospital provides adequate and appropriate space and equipment for safely handling and storing hazardous materials and waste. The hospital monitors and disposes of hazardous gases and vapors. C A 1=2 NAi NA C J. 1 7-2 NA
5.
6. The hospital identifies and implements emergency procedures that include the specific precautions, procedures, and protective equipment used during hazardous materials and waste spills or exposures. 7. The hospital maintains documentation, including required permits, licenses, and adherence to other regulations.
S. The hospital maintains required manifests for handling hazardous materials and waste.
L2 NA 2 NA
9.
The hospital properly labels hazardous materials and waste.
C [0 .f 1
10. The hospital effectively separates hazardous materials and waste storage and processing areas from other areas of the facility
NA
Standard EC.4.10
The hospital addresses emergency management.
CI Compliant t' Not Compliant

An ernergency* in the hospital or its community could suddenly and significantly affect the need for the hospital's services or its ability to provide those services. Therefore, a hospital needs to have an emergency management plan that comprehensively describes its approach to emergencies in the hospital or in its community
Emergency A natural or maimiade rwvenl that significtuilly disrupts the onvirounient of care (,for examl)I+, danut,gC toll ' hospi tal's but IdingIsl and grounds clue to severe winds, storms, or earlhquakcs) that sif;nificanlly disru jts care, Ireatmenl, and services (for example, loss of utilities such as power, water, or teIophones its a result of IIoods, civil disturb aces, accidents or emergencies within the hospital or ill its cornnrunityl'. or Ih0l results in sudden siguific,antly changed, or increased demands for the hospitals serviceeS (for example, biote rrorist attack, I iling collapse, piano rraslt in the hospital's conununilyj. Some ernurgem ies are called "disasters" or "potential injury crealim events" (PI("f s)
EC - 10
2001 CAMI I Cow
Refreshed
Scoring Grid
0 IrrSUncCrenl compliance 1 Partial compliance 2 Satisfactory compliance NA Not appu_able
unrpre/renstvo itccreclilatiort rhlarrual for l/uspilols: The Official /limclhook

A A 0 1 2 NA 1. ?. The hospital conducts a hazard vulnerability analysis' to identify potential emergencies that could affect the need for its services or its abili ty to provide those services. The hospital establishes the following with the communi ty:
Priorities among the potential emergencies identified in the hazard vulnerabili ty analysis
0=1T NA
The hospital's role in relation to a cornniunitywide emergency management program An "all-hazards" command structure within the hospital that links with the community 's command structure
g _LI?_LNA
A [01_112[NJ
I 0 B 1
3.
The hospital develops and maintains a written emergency management plan describing the process for disaster readiness and emergency management, and implements it when appropriate. At a minimum, an emergency management plan is developed with the involvement of the hospitals leaders including those of the medical staff. The plan identifies specific procedures that describe mitigation,' preparedness, l response, and recovery strategies, actions, and responsibilities for each priority emergency The plan provides processes for initiating the response and recovery phases of the plan, including a description of how, when, and by whom the phases are to be activated. The plan provides processes for notifying staff when emergency response measures are initiated. The plan provides processes for notifying external authorities of emergencies, including possible community emergencies identified by the hospital (for example, evidence of a possible bioterrorist attack).
4. 5.
LL?:_LNJ _? I NAl
L._---1--
2 2
NA
----
9.
The, plan provides processes for identifying and assigning g staff to cover all essential staff ( identifying n
B 1 07- 1
NA
functions under emergency conditions. 10. The plan provides processes for managing the following under emergency conditions: Activities related to care, treatment, and services (for example, scheduling, modifying, or discontinuing services; controlling irrformatioii about patients; referrals; transporting patients) Staff support activities (for example, housing, transportation, incident stress debriefing) Staff family support activities Logistics relating to critical supplies (for example, pharmaceuticals, supplies, food, linen, water) Security (for example, access, crowd control, traffic control) Communication with the news media 1 1. Not applicable 12. The plan provides processes for evacuating the entire facility (both horizontally and, when applicable, vertically) when the environment cannot support adequate care, treatment, and services.
NA
13. The plan provides processes for establishing an alternative care site(s) that has the c:apabilities to meet the needs of patients when the environment cannot support adequate care, treatment, and services including processes for the following:
Hazard vulnerability analysis The identification of poterdral enren,encies arid the direct and indirect effects these cmaer,gen c.ies tray have on the health care crgauiratiorr's opr'rations and the demand for its .sercices, 1Mitigation activities I-base activities ar hospital undertakes in aatternlrliuty to lessen the severity and impact of a Iorlential elnervency. } Preparedness activities Those activities a hospital undertakes to build capacity and identify resources That may be us'd if an gremeency uecurs.
2004 CAMH Refreshed COW
EC-11
Mannq(tnerr! of the Environmenf of Cow
Scoring Grid
0 1 2 NA lnsuffiiientcompliance Partial compliance Sati,factoiycomplianic
Not ipplicahle
Transporting patients, staff, and equipment to the alternative care site(s) Transferring to and from the alternative care site(s), the necessities of patients (for example, medications, medical records) Tracking of patients Interfacility communication between the hospital and the alternative care site(s) 14. The plan provides processes for identifying care providers and other personnel during emergencies. 1 5. processes for cooperative planning among health care organizations' tI iat together provide services to a contiguous geograpllic area (for example, among hospitals serving a town or borough) to facilitate the timely sharing of information about the following: o Essential elements of their command structures and control centers for emergency response Names and roles of individuals in their command structures and command center telephone numbers Resources and assets that could potentially he shared in an emergency response Names Of patients and deceased individuals brought to their hospitals to facilitate identifying and locating victims of the emergency B NA
The plan provides B 0 2 NA
1 G, Not applicable
17. Not applicable lt? The plan identifies backup internal and external communication systems in the event of failure during emergencies. 19. The plan identifies alternate roles and responsibilities of staff during emergencies, including to whom they report in the hospital's command structure and, when activated, iii the community's command structure. B B 0
20. The plan identifies an alternative means of meeting essential building utility needs when
the hospital is designated by its emergency management plan to provide continuous service during an emergency (for example, electricity, water, ventilation, fuel sources, medical gas/vacuum systems). 21. The plan identifies means for radioactive, biological, and chen-tical isolation and deco iitamination.
1`
? I NA
B [ 0._L
Standard EC.4.20
The hospital conducts drills regularly to test emergency ianagement.
a Compliant
_] Not Compliant

1. The hospital tests the response phase of its emergency management plan twice a year, either ii i response to an actual emergency or in planned drills. Note 1: Staff in each freestanding building classified as a business occupancy (as defined by the Life Safety Code") that does not offer emergency services nor is cornmunitydesignated as a emergency
NA
disaster-receiving station needs to participate in only One
preparedness drill annually. Staff in areas of the building that the hospital occupies Hurst participate in this drill. Note 2: Tahletop exercises, though usehil in planning or training, are acceptable substitutes only for conununityiuide disaster drills. 2. Drills are conducted at least four months apart and no more than eight months apart.
" Effective imrnediately:
1
Refreshed
NA
EC - 12
2004 CAMI Core
Note: llrills (hat iniolner purdruhes of inrormnlinrt lhat siondate In'llirrrts, 111cir krntilies, urtd the puhiir are arrc'r lob/e.
Scoring Grid
0
1
Comprehensive Accreditation Manual for Hospitals: The Official Handbook
Partial compliance
2 NA
Satisfactory compliance Not applicable
NA
3. Hospitals that offer emergency services or are community-designated disaster receiving stations must conduct at least one drill a year that includes an influx of volunteers or simulated patients. 4. The hospital participates in at least one communitywide practice drill a year (where applicable) relevant to the priority emergencies identified in its hazard vulnerability analysis. The drill assesses the communication, coordination, and effectiveness of the hospital's and community's command structures.
NA
Note 1: "Comrnunitywide " may range from a contiguous geographic area served by the same health care providers, to a large borough, town, city, or region.
Note 2: Tests of EPs 3 and 4 may be separate, simultaneous, or combined. 5. Not applicable NA 6. All drills are critiqued to identify deficiencies and opportunities for improvement.
J Compliant
'-A Not Compliant
Standard EC.5.10
The hospital manages fire safety risks.
...t.
Rationale for EC.5.1 0

All facilities are designed, constructed, maintained, and operated to minimize the possibility of a fire emergency requiring the evacuation of occupants. Because the safe ty of occupants cannot be ensured adequately by dependence on evacuation of the building, their protection from fire shall be provided by appropriate arrangement of facilities; adequate, trained staff; and development of operating and maintenance procedures composed of the following: Design, construction, and compartmentalization Provision for detection, alarm, and extinguishment Fire prevention and the planning, training, and drilling programs for the isolation of fire, transfer of occupants to areas of refuge, or evacuation of the building

B C I NA 1. The hospital develops and maintains a written management plan describing the processes it implements to effectively manage fire safety. 2. The hospital identifies and implements proactive processes for protecting patients, staff, and others coming to the hospital's facilities, as well as protecting property from fire, smoke, and other products of combustion. The hospital identifies and implements processes for regularly inspecting, testing, and maintaining fire protection and fire safetysystems, equipment, and components. 4. The hospital develops and implements a fire response plan that addresses the following: Facilitywide fire response Area-specific needs including fire evacuation routes Specific roles and responsibilities of staff, licensed independent practitioners (LIPs),
C B
NA
2 NA
and volunteers at a fire's point of origin Specific roles and responsibilities of staff, LIPs, and volunteers away from a fire's point of origin
Specific roles and responsibilities of staff, LIPs, and volunteers in preparing for building evacuation C 2 NA 5. The hospital reviews proposed acquisitions of bedding, window draperies, and other curtains, furnishings, decorations, and other equipment for fire safety.
CAMH Update 1, l'ebruary 200.1
EC - 13
Manacernert of the linurrzrnmerrf of Car
Effecti ve July 1, 2004.
Standard EC.5.20
Newly constructed and existing environments are designed Life .Safely Code`". *
and maintained to comply with the

The LSC requires that a building is designed, constructed, and maintained with the capabili ty of being fire safe- When undertaking the design of a newly remodeled building, the hospital should also satisfy any requirements of others (local, state, or federal) that may be more stringent than the .LSC. Note: This standard does not apply to the follotvirrg facilities: Classified as a business occupancy by the LSC that are freestanding buildings Classified cis a business occupancy by the l: SC that are connected to a health care occupancy but are separated by a two-hour rated fire barrier and do not serve as a required means of egress from the health care occupancy Housing three or fewer patients

1.Each building in which patients are housed or receive care, treatment, and services coni-
plies with the LSC, NFP\ lilt

or
2000
Each building in which patients are housed or receive care, treatment, and services does not comply with the LSC, but the resolution of all deficiencies is evidenced through the following. o An equivalency approved by the Joint Commission or w Continued pn.)gress in completing an acceptable Plan For Improvement (Statement of Conditions''"', Part 4) 2. A current, hospitalwide Statement of C:nrditions'M (SOC) ! compliance document has been prepared. 3. and 4. Not applicable 5. The organization is making sufficient progress toward the corrective actions described in a previously approved Statement of Conditionsl"' Note: You can obtain a copy of the SOC from our Web site at http: //www. jcoho. org or by calling Customer Service at 630/7.92-5800. You may make as marry copies of this SOC as you Wish. fHowever remember to keep the original blank for future copying.
Standard EC.5.30
The hospital conducts fire drills regularly.

The development of a fire response plan is an important part of achieving a fire-safe environment (see standard EC.5.10). It is important that this plan be regularly evaluated during implementations (in drill scenarios or actual fire situations) for performance of the fire safety equipment and staff.
laid.SrrlnrvCude is a repisto red tradern;urk of the National Fire Protection Association, Quincy, Massachu.sells.
to dr'lermine your r ornpli;rnCe wilh FT I, please see the sc:orirrg docuuuerll on pages EC28-F.C-1 I .
Statement of Conditions- (SOC) compliance document A proactive document that helps; hospital do a critical self nsscssmenl of its current level of coinplrance and desccribe how to resolve oily 1S'Cdelic iencies.'Ihe SOC was created to be a living, ongoing management tool Ih;ht should be used in a ruani process that continually identifies, asses,es, ,rod resolves LSC deficiencies.
EC
14
CAMH Update 1, February 2004
Scoring Grid
0 1 2 NA Insufficient compliance Partial compliance Satisfactory compliance Not applicable
ii Compliant
U Not Compliant
J Compliant U Not Compliant
Scoring Grid
0 1
Corrrpre/rensirre Accredfiation Manual /orlluspifats: I/re Official Ihmc/book
Insu(ficlent compliance
Partial compliance
2 Satisfaacry campmate NA Not appl,cable
Implementation of the plan should be realistic and held at varied times. An implementation held at shift change may present an unrealistic picture as to the number of staff likely available any time a fire occurs. Actual evacuation of patients during the drills is not required.

NA 1. Fire drills are conducted quarterly on all shifts in all buildings defined by the I_SC as the following: Ambulatory health care occupancy Health care occupancy 2. Fire drills are conducted annually in all freestanding buildings classified as a business occupancy as defined by the LS( 'where patients are seen or treated.
A I1
NA
occupies must participate in such drills.

Not applicable
Note: In leased or rented facilities, only staff in areas of the building that the hospital
cL A
C
NA
4. At least 50"-, of the required drills are unannounced. 5. All staff in all areas of eve ry building where patients are housed or treated participates in drills to the extent called for in the facility's fire plan (see standard K.5. 10 for required
z 1 NA
0 1
2
content of fire response plan).*
B A
NA NA
6. All fire drills are critiqued to identify deficiencies
art(] opportunities for improvement.
The effectiveness of fire response training according to the fire plan is evaluated at least annually During fire drills, staff knowledge is evaluated including the following: When and how to sound fire alarms (where such alarms are available) When and how to transmit for off-site fire responders Containment of smoke and fire Transfer of patients to areas of refuge Fire extinguishment Specific fire response duties Preparation for building evacuation
J Compliant
J Not Compliant
Standard EC.5.40
The hospital maintains fire-safety equipment and building features. Note 1: This standard does not require hospitals to have the types of tire-safety equipment and building features discussed below However, if these types of equipment or features exist within the hospital, then the following maintenance, testing, and inspection requirements apply
Note 2: Hospitals that offer care, treatment, and services in leased facilities need to communicate maintenance expectations for building equipment not under their control to
their landlord through contractual language, lease agreements, memos, and so forth. These hospitals are not required to possess maintenance documentation, but must only have access to such documentation as needed and during survey. It is also important that the landlord communicate to the hospital any building equipment problems identified that could negatively affect the safety or health of patients, staff and other people coming to the hospital, as well as the landlords plan to resolve such issues.

1. Documentation is available that for initiating devices, fire detection and alarm equipment is tested as follows: All supervisory signal devices (except valve tamper switches) are tested at least quarterly
When drills are cvmducted betwcc.n 9 00I N. and ((:00 ,A.mt., a1 coded aril loll ncernent will be perrnitlc:d to be used Instead 01 audible alarms.
CAMH Update 1, February 2004

For additional uidanc'm . nc r' NFI'A 72 1999 edition ('fable 73.2
EC
15
Nlonafrement of the Lnuironment of Care
Scoring Grid
0
1
Partial compliance
2 Satisfactory comphance NA Not applicable
o All duct detectors, electromechanical releasing devices, heat detectors, manual fire alarm boxes, and smoke detectors are tested at least annually
2. 3. 4. 5. 6.
Documentation is available that occupant alarm notification devices, including all audible devices, speakers, and visible devices, are tested at least annually* Documentation is available that off-premises emergency forces notification transmission equipment is tested at least quarterly* Documentation is available that for water-based automatic fire-extinguishing systems, all fire pumps are tested at least weekly under no flow condition.' Documentation is available that for water-based automatic fire-extinguishing systems, all water-storage tank high- and low-water level alarms are tested at least semiannually. Documentation is available that for water-based automatic fire-extinguishing systems, all water-storage tank low-water temperature alarms (during cold weather only) are tested at least monthly Documentation is available that for water-based automatic fire-extinguishing systems, main drain tests are conducted at least annually at all system risers. Documentation is available that for water-based automatic fire-extinguishing systems, all fire department connections are inspected quarterly
C A C C C 0 F1 0 1
-2 2 2 2
NA NA NA NA NA
7.
C C 0
2 NIA NA 2 1 L2 1 2 2 2 NA NA NA NA NA
9.
For water-based automatic fire-extinguishing systems, all fire pumps are tested at least annually under flow
A F6
A C 0 0 I0
10. Kitchen automatic fire-extinguishing systems are inspected for proper operation at least semiannually (actual discharge of the fire-extinguishing system is not required). 11. Carhon dioxide and other gaseous automatic fire-extinguishing systems are tested for proper operation at least annually (actual discharge of the fire-extinguishing system is not required). 12. Documentation is available that all portable fire extinguishers are clearly identified, inspected at least monthly, and maintained at least annually 13. Documentation is available that all standpipe occupant hoses are hydrostatically tested five years after installation and at least every three years thereafter-, and systems receive water-flow tests at least every five years. * 14. Documentation is available that all fire and smoke dampers are operated at least every four years (with fusible links removed where applicable) to verify that they fully closer t 15. Documentation is available that all automatic smoke-detection shutdown devices for airhandling equipment are tested at least annually t 16. Documentation is available that all horizontal and vertical sliding and rolling fire doors are tested for proper operation and full closure at least annually.
c
C
11
C A C 0 OQ 1
2 2 2
NA NA NA
For additional guidance, see NFPA 72-1999 edition (Table 7-3.2). For additional guidance, see NFPA 251998 edition. For additional guidance, see NFPA 10-1998 edition (sections 1-6, 4-3, arid 4-1). For additional guidance, see NFPA 1962-1998 edition (section 2-3). For additional guidance, see NFPA 25,-1998 edition. rr For additional guidance, see NFPA 90A-1999 edit ion (section 347). t1 For additional guidance, see NFPA 90A-1999 edition (section 4-4.1). For additional guidance, see NFPA 80 1999 edition (section 15-2.4).
EC
16
CAM If Update 1, February 2004
Scoring Grid
0
CoIII/ rrehe'nsir)e ,lccreditatiort Alaimo/ to, h ospltals: Thra official hlarrdhooh
Irsuftioem comp) ance Partial (omp;iarice
2 Satisfi Cory compliance NA Not apphcahle
fJ Compliant
Not Compliant
Standard EC.5.50
The hospital develops and implements activities to protect occupants during periods when a building does not meet the applicable provisions of the Life Safety Coderl0, Note: This standard does riot apply to facilities classified as a business occupancy by the [SC.

When building code deficiencies are identified and cannot be immediately corrected or during renovation or construction activities, the safety of patients, staff, and other people corning to the hospital's facilities is diminished. Hospitals need to proactively identify administrative actions (for example, additional training, additional inspections, additional fire drills, and so on) to be taken if these scenarios arise.
B 191-1BB o 1
L NA
;NA

1. Each hospital develops a policy for using interim life safety measures (ILSMs). 2. The policy includes written criteria for evaluating various deficiencies and construction hazards to determine when and to what extent one or more of the following measures apply: Ensuring free and unobstructed exits. Staff receives additionalinformation/communication when alternative exits are designated. Buildings or areas under construction mast maintain escape routes for construction workers at all times, and the means of exiting construction areas are inspected daily Ensuring free and unobstructed access to emergency services and for fire, police, and other emergency forces. Ensuring that fire alarm, detection, and suppression systems are in good working order. A temporary but equivalent system must be provided when any fire system is impaired. 'temporary systems must be inspected and tested rnonthly.* Ensuring that temporary construction partitions are smoke-tight and built of noncombustible or limited combustible materials that will not contribute to the development or spread of fire. Providing additional fire-fighting equipment and training staff in its use. Prohibiting smoking throughout the hospital's buildings and in and near construction areas. Developing arid enforcing storage, housekeeping, and debris-removal practices that reduce the building's flammable and combustible fire load to the lowest feasible level. Conducting a minimum of two fire drills per shift per quarter. Increasing surveillance of buildings, grounds, and equipment, with special attention to excavations, construction areas, construction storage, and field offices. Training staff to compensate for impaired structural or compartrnentalization1 features of fire safety, Conducting hospitalwide safety education programs to promote awareness of firesafety building deficiencies, construction hazards, and ILSMs. Each hospital implements ABMs as defined in its policy.
iL Compliant
Not Compliant
Standard EC.6.10
The hospital manages medical equipment risks.
The t rk .Nu/0 y Code ", N1 TA 101 2000 edition, requires that the municipal fire department is notified (or applicable emergency forces group) and a lire watch is provided whenever am approved fire alarm ur automatic sprinkler system is out of service for more than 4 hours in a 21-hour period in an occupied building. Compartmentalization The concept of using various boilifing components (fir(, walls and doors, smoke barriers, fire-rated floor slabs, and so forth ) to prevent the spread of fire and the production's combustion, and to provide a safe mean s of egress to an approved exit. 11tc presence of these features varies depending upon the building occupancy classification.
2004 CAMI I Refreshed Core
EC - 17
Monngernent of the Environment of Core
Scoring Grid
0
Partial compliance
2 Satisfactory compliance NA Not applicable

Medical equipment is a significant contributor to the quali ty of care. It is used in treatment, diagnostic activities and monitoring of the patient. It is essential that the equipment be appropriate for the intended use; that staff, including LIPs, be trained to use the equipment safely and effectively; and that the equipment be maintained appropriately by qualified individuals.
Elements of Performance for EC.6.1 0

1. 2. 3. The hospital develops and maintains a written management plan describing the processes it implements to manage the effective, safe, and reliable operation of medical equipment. The hospital identifies and implements a process(es) for selecting and acquiring medical equipment. * The hospital establishes and uses risk criterial for identifying, evaluating, and creating an inventory of equipment to be included in the medical management plan before the equipment is used. These criteria address the following: Equipment function (diagnosis, care, treatment, and monitoring) Physical risks associated with use Equipment incident history The hospital identifies appropriate strategies for all equipment on the inventory for achieving effective, safe, and reliable operation of all equipment in the inventory The hospital defines intervals for inspecting, testing, and maintaining appropriate equipmeet on the inventory (that is, those pieces of equipment on the inventory benefiting from scheduled activities to minimize the clinical and physical risks) that are based upon criteria such as manufacturers' recommendations, risk levels, and current hospital experience The hospital identifies and implements processes for monitoring and acting on equipment hazard notices and recalls. The hospital identifies and implements processes for monitoring and reporting incidents in which a medical device is suspected or attributed to the death, serious injury, or serious illness of any individual, as required by the Safe Medical Devices Act of 1990. The hospital identifies and implements processes for emergency procedures that address the following: What to do in the event of equipment disruption or failure When and how to perform emergency clinical interventions when medical equipment fails Availability of backup equipment How to obtain repair services B 50 B B [0 2 1 2 NA NA NA
4. 5.
B B
NA 1 NA
__0_F
6. 7.
B B
NA NA
8.
NA
Standard EC.6.20
Medical equipment is maintained, tested, and inspected.
Compliant
fJ Not Compliant

1. The hospital documents a current, accurate, and separate inventory of all equipment identified in the medical equipment management plan, regardless of ownership. C 0 2 NA
*The. acquisition process includes initially evaluating the condition and function of the equipment when received and evaluating the training of users before use on patients. The hospital may choose not to use risk criteria to limit the types of equipment to be included in the medical ey uiprnent management plan, but rather include all medical equipment,
'
t f lospitals may use different stralegies as appropriate. For example, strategies such as predictive maintenance, interval-based inspections, corrective maintenance, or teetered maintenance may be selected to ensure reliahle performance.
EC
18
2004 CAMII Core
Refreshed
Scoring Grid 0
1 2 NA
Crnnpreher'sioe Acrerli[ntion llkrnun( for 1/ospitu(s "/'he l)/G(-iol llunrlbook
Insuffioent complian(e
i'amal compliance
Satisfactory compliance
Not appllrable
2. The hospital documents performance and safety testing of all equipment identified in the medical management program before initial use. 3The hospital documents maintenance of equipment used for life support that is consistent with maintenance strategies to minimize clinical and physical risks identified in the equipment management plan (see standard EC.6. l0).
2222
NA] Q 4. The hospital documents maintenance of non-life support equipment on the inventory that is consistent with maintenance strategies to minimize clinical and physical risks identified in the equipment management plan (see standard EC.6.10).
5. The hospital documentsperformance testing of all sterilizers usedThe hospital documents chemical and biological testing of water used in renal dialysis and other applicable tests based upon regulations, manufacturers' recommendations, and hospital experience.
J Compliant
_,I Not Compliant
Standard EC.7.10
The hospital manages its utility risks.

Utility .systerns* are essential to the proper operation of the environment of care and significantly contribute to effective, safe, and reliable provision of care to patients in health care hospitals. It is important that hospitals establish and maintain a utility systems management program to promote a safe, controlled, and comfortable environment that does the following: Ensures operational reliability of utility systems Reduces the potential for hospital-acquired illness to be transmitted through the utility systems Assesses the reliability and minimizes potential risks of utility system failures

1. Through 6. Not applicable
)J 2 j1A
7. The hospital develops and maintains a written management plan describing the processes it implements to manage the effective, safe, and reliable operation of utili ty systems. 8. The hospital designs and installs utility systems that meet the patient care and operational needs of the services in the hospital's buildings. 9. The hospital establishes and uses risk criteriat for identifying, evaluating, zinc] creating an inventory of operating components of systems before the equipment is used. These criteria address the following: Life support Infection control Support of the environment Equipment support
C L0
NA AF-A
Communication
B 10. The hospital develops appropriate strategies for all utility systems equipment on the inventory for ensuring effective, safe, and reliable operation of all equipment in the inventory. t
Utility Systems Maly include electrical distribution; emergency power; vertical an<I horizontal transport; heating, ventilating, and air conditioning, plurnbiug. hoiler, and steam; piped gases; vacuum systc ms; or c inununication systems including data-exchtinge systemise The hospital may choose rot to use risk criteria to Ifmit the types of utility systems to be included in the utility management plan. brit rather include all utility systems. Hospitals may use' difh'.rent strategies as appropriate. Nor c'xampte, strategies such as predictive maintenance, interval-based inspections, corrective maintenance, or metered maintenance may be selected to ensure reliable performance.
EC-19
Mciticgerrtirnl o/ I/?(, Erluir()ItInenI vlCare
Scoring Grid
0 1 2 NA Insufficient compliance Partial compliance Satisfactory compliance
Not appli( able
11. The hospital defines intervals for inspecting, testing, and maintaining appropriate utility systems equipment on the inventory (that is, those pieces of equipment on the inventory benefiting from scheduled activities to minimize the clinical and physical risks) that are based upon criteria such as manufacturers' recommendations, risk levels, and current hospital experience. 12. The hospital identifies and implements emergency procedures for responding to utility system disruptions or failures that address the following: What to do if utility systems malfunction Identification of an alternative source of hospital defined essential utilities Shutting off of the malfunctioning systems and notifying staff in affected areas How and when to perform emergency clinical interventions when utility systems fail Obtaining repair services 1 distribution of utility systems and labeling controls for a partial or complete emergency shutdown. 14. The hospital identifies and implements processes to minimize pathogenic biological agents in cooling towers, domestic hot/cold water systems, and other aerosolizing water systems. 15. The hospital designs, installs, and maintains ventilation equipment to provide appropriate pressure relationships, air-exchange rates, and filtration efficiencies for ventilation systems serving areas specially designed* to control air-borne contaminants (such as biological agents, gases, fumes, and dust).
NA
NA
3. The hospital maps the C 1 NA C 1_J NA
2 'NA
Standard EC720
The hospital provides an emergency electrical power source.
IJ Compliant
IJ Not Compliant

The hospital properly installs an emergency power source that is adequately sized, designed, and fueled, as required by the ISC occupancy requirements and the services provided.

The hospital provides an emergency electrical power source, as required by the LSC occupancy requirements, that supplies electricity to the following areas when normal electricity is interrupted: 1. Alarm systems A F0 2 2 2 1 2 NA NA NA NA
2. Exit route illumination 3. Emergency communication systems 4. Illumination of exit signs The hospital provides a reliable emergency power system, as required by the services provided and patients, that supplies electricity to the following areas when normal electricity is interrupted:
A 1Y
C 0
cC
5. Blood, bone, and tissue storage units

6. Not applicable
NA
7. Emergency/urgent care areas

8. Elevators (at least one for nonambulatory patients) 9. Medical air compressors
Areas specially designed Include spaces such as operating rooms, special pnx_edure r :,i.>rns, delivery rooms for patients diagnosed or Suspected of having airborne communicable diseases, (for example, pulmonary or laryngeal tuberculosis), p Bents in "protective environinent" rooms (for example, those receiving bone marrow transplants), laboratories, pharmacies, acid sterile supply rooms.
1 2 2 2
NA NA NA
A CJ1 A 0 1
CC- 20
2004 Core
CAMH
Refreshed
Scoring Grid
0 1 2 Insufficient compliance Partial compliance Satisfactory cornpilance
Cornprehertsirre Acrreclitali(m Marmot for l/ospitols. i/ie 0110101 llow1hook
NA Not applicable
A
A
NA 2 1NA'
10. Medical and surgical vacuum systems 11. Areas where electrically powered life-support equipment is used
12. Not applicable 13. Not applicable

14. Operating rooms 15. Postoperative recovery rooms 16. Obstetrical delivery rooms 17. Newborn nurseries
J Compliant
J Not Compliant
Standard EC.7.30
The hospital maintains, tests, and inspects its utility systems. Note: Hospitals that offer care, treatment, and services in leased facilities need to communicate maintenance expectations for building equipment not under their control to their landlord through contractual language, lease agreements, memos, and so forth_ These hospitals are not required to possess maintenance documentation, but must only have access to such documentation as needed and during survey It is also important that the landlord communicate to the hospital any building equipment problems identified that could negatively affect the safety or health of patients, staff and other people coming to the hospital, as well as the landlords plan to resolve such issues.

C L L0 21NA A 0 11 2 NA NA (ail 1. The hospital maintains documentation of a current, accurate, and separate inventory of utility components identified in the utility management plan.
2. The hospital maintains documentation of performance and safety testing of each critical component identified in the plan before initial use. 3. The hospital maintains documentation of maintenance of critical components of life support utility systems/equipment consistent with maintenance strategies identified in the
A CZ1 [2
utility management plan (see standard EC.7.10).

AF-O1 1
NA
4. The hospital maintains documentation of maintenance of critical components of infection control utility systems/equipment for high-risk patients consistent with maintenance strategies identified in the utility management plan (see standard EC.7. 10). (u1 5. The hospital maintains documentation of maintenance of critical components of non-life support utility systems/equipment on the inventory consistent with maintenance strategies identified in the utility management plan (see standard EC.7.10),
C LO L1
NA
Compliant
L) Not Compliant
Standard EC.7.40
The hospital maintains, tests, and inspects its emergency power systems. Note: This standard does not require hospitals to have the types of emergency power systems discussed below. However, ifa hospital has these types of systems, then the following maintenance, testing, and inspection requirements apply

1 Z NA 1. The hospital tests each generator 12 times a year with testing intervals not less than 20 days and not more than 40 days apart. These tests shall be conducted for at least 30 continuous minutes under a dynamic load that is at least 30% of the nameplate rating of the generator.
EC
21
'ffv,tty cv+ltzoi of tht' Littrirunmenf of Corer Scoring Grid 0 Insufficient compliance

I Partial compliance 2 Satisfactory compliance NA Not applicable
Note: Hospitals may choose to test to less than 30% of the emergency generators nameplate. However, these hospitals shall (in addition to performing a test for 30 continuous minutes under operating temperature at the intervals described above) revise their existing documented management plan to conform to current NFPA 99 and NM 110 testing and maintenance activities. These activities shall include inspection procedures for assessing the prime movers' exhaust gas temperature against the minimum temperature recommended by the manufacturer. If diesel-powered generators do not meet the minimum exhaust gas temperatures as determined during these tests, they shall be exercised for.30 continuous minutes at the intervals described above with available Emergency Power Supply Systems (EPSS) load, and exercised annually with supplemental loads of 53; ofname plate sting for 30 minutes, folloured by 5030 of name plate rating for 30 minutes, followed by 75`1, ofname plate toting for 60 minutes for a total of two continuous hours 2. The hospital tests all automatic transfer switches 12 times a year wit) i testing intervals not less than 20 days and not more than .'10 clays apart. 3_ The hospital tests all battery-powered lights required for egress. Testing includes the following: a. A functional test at 30-day intervals for a minimum of 30 seconds h. An annual test for a duration of 1.5 hours The hospital tests Stored Emergency Power Supply Systems (SEPSS) whose malfunction may severely jeopardize the occupants' life and safety* Testing includes the following: a. A quarterly functional test fors minutes or as specified for its class,' whichever is less b. An annual test at full load for 60"b of the full duration of its class c C
Fol-i
0
NA 2 jNA
c 1 L2
NAI
Standard EC.7.50
The hospital maintains, tests, and inspects its medical gas and vacuum systems. Note: This standard does not require hospitals to have the medical gas and vacuum systems discussed Mon.,, However, if a hospital has these types of systems, then the following maintenance, test ing, and inspection requirements apply
Compliant J Not Compliant

1. The hospital inspects, tests, and maintains critical components of piped medical gas sy.sterns including master signal panels, area alarms, automatic pressure switches, shutoff valves, flexible connectors, and outlets. Cut 2. The hospital tests piped medical gas and vacuum systems when the systems are installed, modified, or repaired including cross-connection testing, piping purity testing, and pressure testing. 3. The hospital maintains the main supply valve and area shut-off valves of piped medical gas and vacuum systems to be accessible and clearly labeled. A NA NA
'Stored Emergency Power Supply Systems (SEPSS) Inlernded to antonralic:ally supply iflunrinalion or power ter critical areas and equipment gssenhal forsafely to human life. Indudod u"e syrslt ms that supply c mc n;ency (rower for such him-lions as illuminoLion for salt' exiiini;, v enlil,ii oil wlrcn it is 'ssenlial to inainlain lilt' fax' dctrrclion and alarm systems, puhhc safr'ly comniunlcations s}stctms, and Irroc cssrs Where Ihe currcnl i rrte'rruption would produce si'iiewti life safety or hrlatlttt hazards to potir'nts, the puhlic, or staff. Note: C)Mrer rtorr.llil'S.S buttery h0c'k-op crntergencyprrrc.er syskms 1Au1 a ltospilul1)11,5 dc'u>rrrrined to Sc' crilictll fin oper0Goris durnt, n pourer /niGire (i)reanmple', lahorolore' erqutpr en!, ides sonic nnedi(al re'c'ords) should be ptoperlt feshed and muintvined in oi't urdnrtt e trill) A7unftutti 1o'y,s r(-'Ci1lrlmendalfOi L$.
EC
22
Clerss l ie/ines Ihe nrininwm lime for which Ihi tional r; ridance, see NJI'A 111 1 FVrrnerSysS ins ).
51-i /iS is designed to operate at its dried load wlthoul hein.G recharged (for addi 199ti i fitionI .Slurritard on.Srorrrd k7eo It nl Enemy 1;nrerge it untl Standby
This res our ce has bee n pro duc ed thro ugh a gra nt sup plie d by the New ler:s ey I ) epa rtrn ent of I lera /th and Seni or Ser vice s,
2004 NEW JERSEY HOSPITAL ASSOCIATION, 760 Alexander Road, PO Box 1, Princeton, NJ 08543-0001. All rights reserved, No part of this publication may be reproduced in any form without the prior written permission of the publisher, the New Jersey Hospital Association (NJIIA). NJIIA is not responsible for any misprints, typographical or other errors, or any consequences caused as it result of the use of this publication. This publication is provided with the understanding that NJIIA is not engaged in rendering any legal, accounting or other professional services and NJI IA shall not he held liable for any circumstances arising out of its use. If legal advice or other expert assistance is required, the services of a competent professional should be sought.
EC
23
NJHA
APPENDIX B
TRAINING PROGRAMS
For Healthcare Security Officers
The IAHSS currently has three programs directed to the functions of the line healthcare
security officer and one program directed to the responsibilities of the healthcare security supervisor. These programs are: Basic Training for the Healthcare Security Officer Advanced Training for the Healthcare Security Officer Health and Safety Training for the Healthcare Security Officer Supervisory Training for Healthcare Security Personnel
The basic, advanced and supervisory training programs offer a progression in knowledge and skills that concludes with eligibility to sit for a certification examination in each of these areas.
A training manual and study guide is available for each of these programs.
Progression from one level to the next requires holding certification at the previous level with
the exception of the Health and Safety Certification that stands independently. Certification at
the highest level attained is renewable every three years.
BASIC TRAINING CERTIFICATION FOR SECURITY OFFICERS This program is intended to give the student a solid foundation of basic healthcare security concepts on which to build further training required for specific facility programs. Basic Training certification is based on a forty-hour (unit) IAHSS training standard. The required training units are:
Introduction to Healthcare Security (2) Security as a Service Organization (1) Public/Community/Customer Relations (1) Employee/Labor Relations (1) Patrol and Post Procedures/Techniques (3) Public Safety Interactions/Liaison (1) Self Protection / Defense (1) Professional Conduct and Self Development Crisis Intervention (2)
Interview and Investigation (2)
(1)
Report Preparation / Writing (2) Report Utilization (1) Judicial / Courtroom Procedure/Testimony (1) Nursing Units (2) Business Office (1) Security Interactions with Patients, Visitors, Employees (1)
Pharmacy (1) Emergency and Mental Health Units(1) Support Units/Ancillary Services (1) Healthcare Vulnerabilities/Risks (1) Access Control Concepts/Systems (1) Physical Security Measures (1) Equipment Usage/Maintenance (1) Basic Safety Concepts (1) Fire Prevention (2) Fire Control/Response (1) Bomb Threats/Procedures (1) Disaster Control/Response (1) Civil Disturbances (1) Criminal and Civil Law (2) Narcotics and Dangerous Drugs (1)
ADVANCED TRAINING CERTIFICATION PROGRAM This program is the next in the progressive certification process for persons who have achieved Basic Training Certification. Persons who have not been awarded the Basic Training
Certification by the Association are not eligible to sit for the Advanced Training Certification
exam. The Advanced training program is based on a twenty-hour (unit) IAHSS training standard. The number shown in parenthesis indicates the number of required units:
Security Awareness & Crime Prevention (2) Enhanced Customer Services (2) Premise Liability (1) Methods of Patrol (1) Investigative Techniques, Reports & Procedures (2) Off Campus Security and Safety (1) Workplace Violence (2) Patient Risk Groups (2) Security and Patient Interactions (2) Special Security Concerns (1) Security I n Sensitive Areas (1) Security Technology (1) Critical Incident Response (1) Advancing Professionalism Definition (1)
SECURITY SUPERVISOR TRAINING CERTIFICATION PROGRAM This program is intended to provide training for security personnel who are supervisors and those persons who wish to further prepare themselves in anticipation of achieving the supervisor role. In addition it is also helpful for the line personnel to understand the concepts of the supervisory function in fostering better relationships between all members of the security team. The Supervisory training program is the last or third component of the progressive certification process. The Supervisory training program is based on a twenty-hour (unit) IAHSS training standard. A supervisor certification examination in is available and may be renewed every three years. The number shown in parenthesis indicates the number of required units:
Introduction to Supervision (1) Contemporary Issues in Healthcare (1) Supervisory Responsibilities (2) Employee Relations & Employee Appraisals (2) Authority and Control (1) Leadership (2) Handling Complaints and Grievances (2) Effective Communications/ Management skills (2) Self Improvement (2) Civil Liability and the Supervisor (1) Safety (2) Budgeting/Cost Control (1) Principles of Customer Relations (1) Professionalism and Ethics (1)
HEALTH AND SAFETY TRAINING CERTIFICATION PROGRAM This program is intended to provide training for line personnel who require a specific knowledge of safety aspects of the healthcare environment. The Health and Safety training program is based on a twenty-hour (unit) IAHSS training standard. A certification examination in Health and Safety is available and may be renewed every three years. The number shown in parenthesis indicates the required units:
Regulatory Agencies (1) Healthcare Safety Programs (2) Accidents and Injuries (2) Fire Safety (2) Emergency Preparedness (2)
Hazardous Materials and Emergency Response (1)
Infection Control Programs (1) Special Healthcare Settings (2) Radiation Safety (1) Construction/Renovation Safety (1)
Hazardous Surveillance (1)
Hazardous Materials/Waste Management (2)
TRAINING PROGRAM ADMINISTRATION INFORMATION All forms must be complete and legible. Print all information and sign forms as required. Choose the electronic (available for the Basic Exam only) or paper version of the appropriate certification exam. Allow up to three weeks for receiving and processing ordered materials Each exam is assigned to a specific individual. Do not change the name on the examination answer sheet unless prior approval is received from the IAHSS office. Exams and answer sheets or the electronic email answer file must be returned to the IAHSS office within 45 days of issue. After 45 days, these materials become invalid. If the examination cannot be completed within the 45 day requirement, please return the unused material to IAHSS. A credit for the returned examinations will be posted. No actual dollar refunds will be issued. Allow up to four weeks for test results and processing of certificates. Please do not call the office for test results, as they will be communicated by mail to the proctor and test taker as
soon as they are available.
TIPS FOR TAKING THE IAHSS BASIC EXAMINATION You should take this written exam fully prepared by being totally familiar with the subject matter, adequately rested, and completely confident. Begin preparing for the exam as soon as you start reading the text material. The exam is based on the basic manual and is 100 multiple choice questions. In order to effectively study: STUDY ALONE When you work by yourself in a comfortable, well-lighted spot, you will be able to concentrate better. You can exchange ideas at a joint review before the test with others who may be preparing for the
same test.
AVOID DISTRACTIONS Study in a private room without disturbances from family, visitors, t.v. programs, and phone calls.
STUDY EFFECTIVELY
Do not try to digest everything at one study period. Take short breaks when necessary and return quickly to the material. Make a regular daily study schedule and stick to it. REVIEW THE MATERIAL The next day, thoroughly go over what you have studied to ensure that it is familiar to you. REVIEW ALL OBJECTIVES The objectives in the text are purposely included to help you monitor your knowledge of the material. Most objectives will form the content of test questions in the exam. BE PHYSICALLY FIT Physical health promotes mental functioning. If you are tense, uncomfortable, or have a headache, you will not absorb and retain information from the text. Select only the best answer. Read all the choices for answers very carefully and eliminate the obviously incorrect ones. Your odds will increase with the elimination of incorrect answers and will strengthen your probability if you are making an "educated guess". Read each question very carefully and be sure you know what it asks. Then try to answer it before you look over the answers presented. Qualifying words like: only, least, most, best, definitely, probably, not, all, every, & except should warn you that you must choose your answer with caution. Answer each question in order do not skip any guessing does not hurt. Do not look for easy questions since it could very well cause you to answer a question in the wrong position on the answer sheet. Basically, the wrong answer itself does not work against you. It is better to "guess" incorrectly than to avoid answering a question. Never mark more than one answer as that question will be marked as wrong. Mark the questions that you cannot answer immediately. The mark (in pencil) will assist you in coming back to it later. Correct any answers if your review suggests a more appropriate selection. Erase any marks on the answer sheet so they are not counted. Do not cross anything out. You must manage your time. Make your best educated guess, mark the question, and return to it after completing the test to give it some more attention and thought. You may read another question that will refresh your recollection and assist you in answering something elsewhere in the exam. You can pass the exam if you properly prepare for it by reading and understanding the text as well as having the confidence in yourself which will diffuse anxiety.
APPLICATION FOR BASIC TRAINING

J
3
aF
S
CERTIFICATION EXAMINATION
3rd
Edition
For Office Use Only
Applicant Information (print clearly): Social Security Number Name (first, last) Mailing Address City State ZIP Telephone Senior Member Information (print clearly): Name (first, last) Mailing Address
City State ZIP Telephone Fax
I request to be examined by written test for the award of certification for the IAHSS Basic Training Program. I have contacted the Senior Member above who has agreed to administer this time limited closed book examination to me. I understand I must achieve a score of at least 75%, correct answers to be certified for a three year period. The fee of $70.00 (U.S. Funds) is enclosed with this completed application form. I understand there is no refund of this fee should I fail to obtain a passing score to be certified and that new application form and fee must be submitted for re-examination. Applicant Signature Date Senior Member Signature Date
Note: Examination is only valid for 45 days from date of issue. Fax (630) 871-9938
Send completed application and fee to: IAHSS PO Box 5038 Glendale Heights IL 60139 Telephone (888) 353-0990 (630) 871-9936
DO NOT WRITE BELOW THIS LINE Date Received Examination Serial Number Senior Member Status Verified By Date Sent
THIS APPLICATION MAY BE REPRODUCED
International Association for Healthcare Security & Safety

Training Program Order Form
PO Box 5038 Glendale Hgts IL 60139 888-353-0990
Name:
Date: __ Telephone:_____
Title:
Organization: Street Address: (No P.O. Box Numbers) City:
State:
Zip:___
Item Ordered Basic Training Manual and Study Guide 1 10-14 manuals @ $31.95 each 15+ manuals @ $28.95 each
Quantity
Total Price
-9 manuals @ $34.95 each # $ # # $ $
New.......Instructor's Basic Training Manual I free with purchase of 10 or snore Basic Training Manuals Instructor's Basic Training Manual @ $28.95 each # $
Advanced Training Manual and Study Guide 1-9 manuals @ $34.95 each
1
15+ manuals @$28.95 each Health and Safety Training Manual and Study Guide 1-9 manuals @) $34.95 each 10-14 manuals @ $31.95 each 15+ manuals @$28.95 each Supervisory Training and Study Guide 1-9 manuals @ $34.95 each 10-14 manuals @ $31.95 each 15+ manuals @ $28.95 each 4 Volume Set (Basic, Advanced, Safety and Supervisory) $127.80/set Pins & Patches Basic Certification Lapel/Tie Tack Pin @ $5.00 each Basic Certification & Supervisory Pin @ $5.00 each Basic Certification & Safety Pin @ $5.00 each Basic Certification, Supervisory & Safety Pin @ $5.00 each Basic Certification & Advanced Pin @ $5.00 each Basic Certification, Advanced, Supervisory & Safety Pin @$5.00 each Cloth Uniform Patch @ $3.00 each Basic Certification, Advanced, Supervisory & Safety Pin @ $5.00 each IL Resident add 7% Sales Tax
1/04
# $ 0- 14 manuals @ $31.95 each # $ # $
# # #
$ $ $
# # # # sets
$ $ $ $
# # # # # # #
$ $ $ $ $ $ $

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EMERGENCY PREPAREDNESS

Emergency Preparedness Hospital Security Readiness Assessment Tool

Emergency Preparedness Hospital Security Readiness Assessment Tool

HOW TO USE THIS TOOL

Emergency Preparedness Hospital Security Readiness Assessment Tool

Trespassers ED Security ED Signage Key Control

General Security Policies

HS-41 HS-28 HS-35 HS-13 HS-43 HS-34 HS-47 HS-36

Visiting Hours and Visitor Access Weapons

Emergency Preparedness Hospital Security Readiness Assessment Tool

Policy Index Continued

Identification of Staff Vendors and the Public

Physical Plant Security

Panic Alarm Testing Lighting Inspections Telephone Testing

HS-44 HS-45 HS-49

Security Staff Selection and Training

Standardized Security Management Plans

Emergency Preparedness Hospital Security Readiness Assessment Tool

Emergency Preparedness Hospital Security Readiness Assessment

Appendix A HS-01 HS-02 HS-03 HS 48 HS-04 HS-05

B. SECURITY STAFF SELECTION AND

Emergency Preparedness Hospital Security Readiness Assessment Tool

HS-06 HS-07 HS-08

Sample Policy B HS-06 HS-07

demonstrate competency with your organization's requirements? JCAHO EC 2.30

Emergency Preparedness Hospital Security Readiness Assessment Tool

C. GENERAL EMPLOYEE SECURITY

lo r oslrre that the policies acrd procedures developed to protect your

o Monitor compliance through periodic

Emergency Preparedness Hospital Security Readiness Assessment

Appendix HS-04 HS-17