ME Compliance

Sr # Standard # Description
M PM NM NA
Facility Management and Safety (FMS)

The hospital complies with relevant laws, regulations, building and fire safety codes, and facility inspection. ✓

Hospital leadership and the facility management and safety structure understand and implement the
1 1 national and local laws, regulations, building and fire safety codes, and other requirements applicable ✓
to the hospital’s facilities.

Hospital leadership and the facility management and safety structure document corrective actions
2 2 taken to meet the conditions of external facility reports or citations from inspections by national and ✓
local authorities.
Standard
FMS.1 Hospital leadership plans and budgets for replacing or upgrading facilities, systems, and equipment
3 3 needed to meet applicable requirements and for the continued operation of a safe, secure, and effective ✓
facility.

4 4 Hospital leadership approves and allocates budgeted resources or implements alternative strategies to ✓
reduce risks until the resources can be allocated.

When the hospital is located inside a multiuse building, hospital leadership obtains evidence of compliance
5 5 with relevant laws, regulations, codes, facility inspection reports, utility maintenance requirements, ✓
and other requirements related to shared systems and building issues.

A qualified individual oversees the facility management and safety structure to reduce and control risks in the care
environment.
Oversight and direction of the facility management and safety structure is assigned to an individual
6 1 qualified by experience and training, and evidence of the experience and training is documented.

The qualified individual is responsible for elements a) through f ) of the intent. a)Recommendations for space,
medical equipment, technology, and other resources to support the
facility management and safety structure are provided to hospital leadership.
b) Facility management and safety programs are planned and developed for the following: safety, security,
hazardous materials and waste, fire safety, medical equipment, utility systems, emergency and disaster
Standard management and construction and renovation.
7 2
FMS.2 c) The facility management and safety programs are current and fully implemented.
d) Staff and others are trained on the program.
e) The programs are evaluated and monitored.
f ) The programs are reviewed and revised at least annually, or more frequently if needed (for example,
when there are changes to requirements in the country’s laws and regulations; changes to the hospital’s
facilities, systems, or equipment; and so on).

8 3 The qualified individual is responsible for coordinating and managing risk assessment and risk reduction
activities for the facility management and safety structure.

9 4 When independent business entities are present within the organization, the entities comply with the
facility management and safety programs, as applicable.
 The hospital develops and documents a comprehensive risk assessment based on facility management and
safety risks identified throughout the organization, prioritizes the risks, establishes goals, and implements
improvements to reduce and eliminate risks.

The risk assessments from all eight facility management and safety programs listed as a) through h) in
the intent are integrated to develop and document a comprehensive, facility-wide risk assessment, at
least annually. a) Safety
Standard b) Security
c) Hazardous materials and waste
10 FMS.3 1 ✓
d) Fire safety
e) Medical equipment
f ) Utility systems
g) Emergency and disaster management
h) Construction and renovation

The hospital prioritizes the risks, identifies goals and improvements, and implements improvements
11 2 ✓
to reduce and eliminate risks.

12 3 The hospital evaluates the effectiveness of the improvements, and based on the results, the hospital ✓
updates the applicable facility management and safety programs.

Data are collected and analyzed from each of the facility management and safety programs to reduce risks
in the environment, track progress on goals and improvements, and support planning for replacing and ✓
upgrading facilities, systems, and equipment.

Monitoring data are collected and analyzed for each of the facility management and safety programs
13 1 and used to reduce risks in the environment and support planning for replacing or upgrading facilities, ✓
systems, and equipment.
Standard Monitoring data for the facility management and safety programs are documented and integrated
14 2 ✓
FMS.4 into the hospital’s quality and patient safety program.
The individual who oversees the facility management and safety structure provides monitoring data
15 3 reports that address the effectiveness of each program and progress on goals to hospital leadership on a quarterly ✓
basis, and leadership takes action.

The individual who oversees the facility management and safety structure provides the comprehensive,
16 4 facility-wide risk assessment and planned and implemented improvements to hospital leadership ✓
at least annually.
Hospital leadership provides an annual report to the governing entity on the effectiveness of the facility
17 5 ✓
management and safety programs, and the governing entity takes action.
 The hospital develops and implements a program to provide a safe physical facility through inspection and
planning to reduce risks. ℗ ✓

18 1 The hospital develops and implements a written program to provide a safe physical facility. ✓
19 Standard 2 The hospital has a documented, current, accurate inspection of its physical facilities. ✓
FMS.5
The results from the facility inspection are reviewed and addressed in a safety risk assessment that
20 3 is conducted and documented annually, and safety risks are identified and prioritized from the risk ✓
assessment.

21 4 The hospital identifies goals, implements improvements, and monitors data to ensure that safety risks are reduced or ✓
eliminated.

The hospital develops and implements a program to provide a secure environment for patients, families, staff, ✓
and visitors. ℗

22 1 The hospital develops and implements a written program to provide a secure environment. ✓

23 2 A security risk assessment is conducted and documented annually throughout the facility, and security ✓
Standard risks are identified and prioritized from the risk assessment.
FMS.6 The security program identifies all security risk areas and restricted areas and ensures they are monitored
24 3 ✓
and kept secure.
The security program ensures that all staff, students, trainees, contract workers, volunteers, vendors,
25 4 ✓
and individuals associated with independent business entities are identified.
The hospital identifies goals and implements improvements in the security program, and monitors
26 5 ✓
data to ensure that security risks are reduced or eliminated.

The hospital develops and implements a program for the management of hazardous materials and waste.℗ ✓

The hospital develops and implements a written program for the management of hazardous materials
27 1 ✓
and waste.
Standard
FMS.7 A hazardous materials and waste risk assessment is conducted and documented annually throughout
28 2 the facility, and risks related to hazardous materials and waste are identified and prioritized from the ✓
risk assessment.

29 3 The hospital identifies goals, implements improvements, and monitors data to ensure that risks ✓
related to hazardous materials and waste are reduced or eliminated.
 The hospital’s program for the management of hazardous materials and waste includes the inventory, handling,
storage, and use of hazardous materials. ℗ ✓

The hazardous materials and waste program identifies the type, quantities, and locations of hazardous
30 1 materials and has a complete inventory, which is updated at least annually, to reflect changes in the
hazardous materials used and stored in the organization.
The hazardous materials and waste program establishes and implements procedures for safe handling,
31 2 ✓
storage, and use of hazardous materials.
Standard
The hazardous materials and waste program establishes and implements the proper protective equipment
32 FMS.7.1 3 ✓
required during handling and use of hazardous materials.
The hazardous materials and waste program establishes and implements proper and clear labeling of
33 4 ✓
hazardous materials that is consistent with information from the safety data sheets (SDS).
The hazardous materials and waste program establishes and implements procedures for the management
34 5 of spills and exposures, including the use of proper protective equipment and reporting of spills ✓
and exposures.

35 6 Information about the hazardous materials related to safe handling, spill-handling procedures, and ✓
procedures for managing exposures are up to date and available at all times.

The hospital’s program for the management of hazardous materials and waste includes the types, handling, ✓
storage, and disposal of hazardous waste. ℗

The hazardous materials and waste program establishes the types of hazardous waste generated by the
36 Standard 1 hospital and how they are identified. ✓
FMS.7.2
The hazardous materials and waste program establishes and implements procedures and the proper
37 2 protective equipment required for safe handling and storage of hazardous waste. ✓

When required by local laws and regulations, the hazardous materials and waste program documents
38 3 the quantities of hazardous waste generated by the hospital. ✓
 The hospital establishes and implements a program for fire safety that includes an ongoing assessment of risks
and compliance with national and local codes, laws, and regulations for fire safety. ℗ ✓

The hospital develops and implements a written program for fire safety to protect all occupants of the
39 1 ✓
hospital’s facilities from fire, smoke, and non-fire emergencies.

The hospital performs and documents an ongoing fire safety risk assessment related to at least a)
through k) in the intent, and fire safety risks are identified and prioritized from the risk assessment. a) Fire
separations
b) Smoke separations/compartments
c) Hazardous areas (and spaces above the ceilings in those areas) such as soiled linen rooms, trash
collection rooms, and oxygen storage rooms
Standard d) Fire exits
40 2 ✓
FMS.8 e) Kitchen grease-producing cooking devices f ) Laundry and trash chutes
g) Emergency power systems and equipment
h) Medical gas and vacuum system components
i) Storage and handling of potentially flammable materials (for example, flammable liquids,
combustible gases, and oxidizing medical gases such as oxygen and nitrous oxide)
j) Procedures and precautions to prevent and manage surgical fires
k) Fire hazards related to construction, renovation, or demolition projects

The fire safety program includes implementing interim measures, when necessary, to ensure that
41 3 the safety of the hospital’s patients, staff, and visitors is maintained when fire safety risks cannot be ✓
immediately addressed.
The hospital identifies goals, implements improvements, and monitors data to ensure that fire safety
42 4 risks are reduced or eliminated. ✓

The fire safety program includes the early detection, suppression, and containment of fire and smoke.℗ ✓

43 1 The fire safety program includes equipment/systems for the early detection and alarm notification of ✓
fire and smoke.

Standard
FMS.8.1
44 2 The fire safety program includes equipment/systems for the suppression of fire. ✓

When required by local laws and regulations, the fire safety program includes containment of fire and
45 3 ✓
smoke, and these features are maintained to ensure effectiveness and safety.
The fire safety program includes measures to ensure safe exit from the facility when fire and non-fire
✓
emergencies occur.℗
The fire safety program includes the safe exit from the facility through free and unobstructed access
46 Standard 1 ✓
to exits.
FMS.8.2
The fire safety program includes clearly visible exit signage that is understandable to the hospital’s
47 2 occupants. ✓

48 3 The fire safety program includes lighting for emergency exit corridors and stairs. ✓
 All fire safety equipment and systems, including devices related to early detection, alarm notification, and
suppression, are inspected, tested, and maintained.℗ ✓

All fire safety equipment and systems, including those for smoke and fire detection and suppression,
49 Standard 1 are inspected, tested, and maintained according to manufacturers’ recommendations or as required ✓
FMS.8.3 by local codes, laws, and regulations, whichever sets the more stringent requirement.
Inspection, testing, and maintenance of all fire safety equipment and systems are documented,
50 2 ✓
including results and corrective actions.
Any deficiencies identified in fire safety equipment and systems are immediately corrected, or interim
51 3 ✓
measures are implemented to reduce fire risk until deficiencies can be fully corrected.
The hospital involves staff in regular exercises to evaluate the fire safety program.℗
Staff from all shifts, including the night shift and weekends, annually participate in an exercise to
52 1 evaluate the fire safety program. ✓
Standard
53 FMS.8.4 2 Staff are knowledgeable of the fire safety program and can describe how to bring patients to safety. ✓

54 3 Results of exercises to evaluate the fire safety program are documented, and staff who do not pass are ✓
reeducated and retested on the fire safety program.

The fire safety program includes limiting smoking by staff and patients to designated non–patient care areas of ✓
the facility.℗

55 1 The fire safety program addresses eliminating or limiting smoking within the hospital facility. ✓
Standard
56 2 The program applies to patients, families, visitors, and staff. ✓
FMS.8.5
The program identifies who may grant patient exceptions for smoking and when those exceptions
57 3 apply. ✓

58 4 Smoking is prohibited in all areas under construction or renovation. ✓

The hospital develops and implements a program for the management of medical equipment throughout the
organization.

The hospital develops and implements a written program for the management of medical equipment
59 Standard 1
throughout the hospital.
FMS.9
A medical equipment risk assessment is conducted and documented annually throughout the hospital,
60 2
and medical equipment risks are identified and prioritized from the risk assessment.
The hospital identifies goals, implements improvements, and monitors data to ensure that medical
61 3 equipment risks are reduced or eliminated.
 The medical equipment program includes inspection, testing, preventive maintenance, and documenting the
results. ℗

The medical equipment program addresses hospital-owned and nonhospital-owned medical equipment
62 Standard 1 in the organization, such as equipment that is leased, rented, brought in by physicians and
FMS.9.1 other health care practitioners, brought in by patients, and so on.
63 2 The medical equipment program includes an inventory of all medical equipment.
Medical equipment is inspected and tested when new and according to age, use, and manufacturers’
64 3 recommendations thereafter.

65 4 The medical equipment program includes preventive maintenance and calibration as applicable.

The hospital has a process for monitoring and acting on medical equipment hazard notices, recalls, reportable
incidents, problems, and failures. ℗

The hospital has a process for monitoring and acting on medical equipment and implantable device
66 Standard 1 hazard notices, recalls, reportable incidents, problems, and failures.
FMS.9.2
The hospital reports any deaths, serious injuries, or illness that are a result of medical equipment
67 2
through the hospital’s incident and adverse event reporting process.
The medical equipment management program addresses the use of any medical equipment with a
68 3 reported problem or failure, or that is the subject of a hazard notice or is under recall.

The hospital develops and implements a program for the management of utility systems throughout the
organization.

The hospital develops and implements a written program for the management of utility systems
69 Standard 1 throughout the hospital. ✓
FMS.10
The hospital conducts and documents the utility systems risk assessment annually throughout the
70 2 hospital and prioritizes the utility systems risks that are identified from the risk assessment. ✓

The hospital identifies goals, implements improvements, and monitors data to ensure that the utility
71 3 systems risks are reduced or eliminated. ✓
 The utility systems program includes inspection, testing, and maintenance to ensure that utilities operate
effectively and efficiently to meet the needs of patients, staff, and visitors. ℗ ✓

72 1 The hospital inventories its utility systems components and maps the current distribution of them. ✓

Standard The hospital identifies, in writing, the activities and intervals for inspecting, testing, and conducting
73 2 preventive and routine maintenance on all operating components of the utility systems on the inventory, ✓
FMS.10.1 based on criteria such as manufacturers’ recommendations, risk levels, and hospital experience.
The hospital updates or replaces utility systems and components when the need for improvement is
74 3 ✓
identified through inspection, testing, and maintenance.

75 4 The hospital labels utility system controls to facilitate partial or complete emergency shutdowns. ✓

The hospital utility systems program ensures that essential utilities, including power, water, and medical gases,
are available at all times and alternative sources for essential utilities are established and tested. ℗ ✓

The hospital identifies the areas and services at greatest risk when essential utilities (including power,
76 1 ✓
water, and medical gas) become unavailable.

The hospital ensures backup availability/continuity of essential utilities (including power, water, and
77 2 ✓
medical gas) 24 hours a day, 7 days a week.

Standard
78 FMS.10.2 3 The hospital assesses for and reduces the risks of interruption, contamination, and failure of essential ✓
utilities (including power, water, and medical gas).
The hospital tests the availability and quality of the alternative source(s) of water at least annually or
79 4 more frequently if required by local laws and regulations or conditions of the source of water. The ✓
hospital documents the results of the tests.

The hospital tests alternative sources of power at least quarterly or more frequently if required by
80 5 local laws and regulations, manufacturers’ recommendations, or conditions of the source of power. ✓
The hospital documents the results of the tests.
When emergency sources of power require a fuel source, the hospital establishes and has available the
81 6 ✓
necessary amount of on-site fuel stored.
 Designated individuals or authorities monitor water quality regularly. ✓

Quality of potable water is tested at least quarterly or more frequently based on local laws and regulations,
82 1 conditions of the sources for water, and previous experience with water quality problems. The ✓
testing results are documented.

Quality of non-potable water is tested at least every six (6) months or more frequently based on local
83 Standard 2 laws and regulations, conditions of the sources for water, and previous experience with water quality ✓
FMS.10.3 problems. The testing results are documented.
Preventive measures and strategies are implemented to reduce the risks of contamination and growth
84 3 ✓
of bacteria in water.

85 4 Actions are taken and documented when water quality is found to be unsafe. ✓

Dental unit waterlines are treated and tested according to manufacturer’s guidelines, and treatments
86 5 ✓
and testing are documented.

Quality of water used in hemodialysis is tested for chemical, bacterial, and endotoxin contaminants, and ✓
processes for hemodialysis services follow professional standards for infection prevention and control.℗

Hemodialysis services in the hospital follow industry standards and professional guidelines for maintaining
87 1 ✓
water quality and implementing infection prevention and control measures.
Standard
FMS.10.3.1 Water used in hemodialysis is tested monthly for bacterial growth and endotoxins and tested annually
88 2 ✓
for chemical contaminants. The testing results are documented.
89 3 The hospital performs routine disinfection of the hemodialysis water distribution system. ✓
The hospital conducts testing on all hemodialysis machines annually, including machines not in use,
90 4 and testing results are documented.

The hospital establishes and implements procedures for reprocessing dialyzers, including, as applicable,
91 5 frequency for reusing/replacing dialyzers and processes for cleaning and testing dialyzers.
 The hospital develops, maintains, and tests an emergency management program to respond to internal and
Y
external emergencies and disasters that have the potential of occurring within the hospital and community.℗

The hospital develops, evaluates, and maintains a written emergency and disaster management program
that identifies its response to likely emergencies and disasters, including items a) through i) in
the intent.) a) determining the type, likelihood, and consequences of hazards, threats, and events;
b) identifying the structural and nonstructural vulnerabilities of the hospital’s patient care environments
and how the hospital will perform in the event of an emergency or disaster; c) planning for alternative sources of
power and water in emergencies and disasters; (Also see FMS.10.2)
d) determining the hospital’s role in such events;
92 1 Y
e) determining communication strategies for events;
f ) managing resources during events, including alternative sources;
g) managing clinical activities during an event, including alternative care sites;
h) identifying and assigning staff roles and responsibilities during an event (including contract staff,
vendors, and others identified by the hospital); (Also see FMS.13) and
i) managing emergencies and disasters when personal responsibilities of staff conflict with the hospital’s
responsibility for providing patient care. (Also see MOI.13)

Standard
FMS.11
The hospital has identified the major internal and external emergencies and/or disasters such as community
93 2 emergencies, and natural or other disasters that pose significant risks of occurring, taking into
consideration the hospital’s geographic location.

The hospital identifies the probable impact that each type of disaster will have on all aspects of care
94 3 and services. y

The entire program, or at least critical elements c) through i) of the program, is tested annually. c) planning for
alternative sources of power and water in emergencies and disasters; (Also see FMS.10.2)
d) determining the hospital’s role in such events;
e) determining communication strategies for events;
f ) managing resources during events, including alternative sources;
95 4 Y
g) managing clinical activities during an event, including alternative care sites;
h) identifying and assigning staff roles and responsibilities during an event (including contract staff,
vendors, and others identified by the hospital); (Also see FMS.13) and
i) managing emergencies and disasters when personal responsibilities of staff conflict with the hospital’s
responsibility for providing patient care. (Also see MOI.13)

96 5 At the conclusion of every test, debriefing of the test is conducted. Y

97 6 Follow-up actions identified from testing and debriefing are developed and implemented. Y
 When planning for construction, renovation, and demolition projects, or maintenance activities that affect
patient care, the organization conducts a preconstruction risk assessment.℗ ✓

When planning for construction, renovation, or demolition projects, or maintenance activities that
affect patient care, the hospital conducts a preconstruction risk assessment (PCRA) for at least a)
through j) in the intent. a) air quality;
b) infection prevention and control; (Also see PCI.11)
c) utilities;
Standard d) noise;
98 1 e) vibration; ✓
FMS.12
f ) hazardous materials and waste;
g) fire safety;
h) security;
i) emergency procedures, including alternate pathways/exits and access to emergency services; and
j) other hazards that affect care, treatment, and services.

The hospital takes action based on its assessment to minimize risks during construction, renovation,
99 2 ✓
and demolition projects, and maintenance activities that affect patient care.
100 3 The hospital ensures that contractor compliance is monitored, enforced, and documented. ✓

Staff and others are trained and knowledgeable about the hospital’s facility management and safety programs ✓
and their roles in ensuring a safe and effective facility.

All staff receive annual training and testing on each facility management and safety program
101 1 to ensure they can safely and effectively carry out their responsibilities, and testing results are ✓
documented.
Training on the facility management and safety programs includes vendors, contract workers, volunteers,
102 2 students, trainees, and others, as applicable to the individuals’ roles and responsibilities, and as ✓
Standard determined by the hospital.
FMS.13
103 3 Staff can describe and/or demonstrate their roles in response to a fire. ✓
Staff can describe and/or demonstrate actions to eliminate, minimize, or report safety, security, and
104 4 other risks. ✓

Staff can describe and/or demonstrate precautions and procedures for handling and managing
105 5 medical gases and hazardous materials and waste, as applicable to the staff member’s role and ✓
responsibilities.
Staff can describe and/or demonstrate procedures for and their roles in internal and community
106 6 ✓
emergencies and disasters.
Total 30 56 12 2
300 280 0 20
Grand Total 34.72
 Comments

working on Fire Exits and signages to be done.

documentation to be maintained

Proper plan is to be implement.

Total Experience/HR
Documentation to be done for risk assesment policy
is ready for review and implementation

EOC committee minutes and KPI monitoring

 Documents needs to be approved

Hospital wide Waste Management Policy to be

approved by ICC

Risk Assessment Policy is prepared and ready for

review and implementation.
Waste Management policy is met while Hazardous
material policy need to be implemented by MMD
Manager

chemial spill kit is not available

information to be displayed
highlighted ones are not being followed , needs to
plan.

risk assessment policy and activity to be planned for

2021 annual

nursing hostel, AHU room or newly constructed

areas/rooms smoke detectors are pending.

Sprinklers system not available

Fire doors and assemblies inspection procedure
missing.
Automatic smoke management systems (smoke
extraction system not available)

Identify local codes laws, and regulations include

requirements for inspection, testing.

Working on OPD fire exit. And D5 Ramp provision

review the local guidelines as per specs.

 subcontract for services.

escape plan sign is in process. Drills and exercise plan

to be developed

only signage is missing

contractor Management document and construction

policy and checklist
Maintenance schedules and procedures are develop
and implemented.
Risk Assessment is carried out but documentation is
pending.

Documentation required
 Min/Max are ready to be demanded. MMD's
compliance is required.

All the maintenance schedules are ready and being

implemented as per recommendations.

Being done as per requirement.

Labelling for mechanical and electrical systems is

pending in some areas. Plumbing pipe lines and
some of HVAC is missing

Areas are identified they just need to be added in

the policy.
Water Backup: PAFL Line
Power Backup: Diesel Genset (No Backup in case of
power outage)

Risk assessment is being done not yet documented.

Not Done yet.

Met and documented

Main fuel source and diesel filling line required.

 Planned, yet to be implemented.

Water Culture reports are made.

Flushing is done on regular basis

Schedule for Flushing of all areas was made. RO

filters' chlorination was done.

No dental unit available.

Proper water supply is provided in dialysis, yet the

documentation for standards is yet to be made.

Biomedical.

Biomedical.
meeting with Disaster Management Committee
documentation of Trainings and training plan to be
develop.
 8 Policy /program for fire safety with risk assessment with national laws
fire safety/ disaster management program
fire fighting policy
risk assessment and priorities
interim measure
data monitoring

8.1 policy/program fire detection,alarm,firefighting policy

fire suppression equipment and system
containment of fire

8.2 polic/program of safe exit

unobstructed exit
exit signs
lighting of exit and stair case and corridor

8.3 all fire reelated system and equipment testing

39 1

Standard
40 FMS.8 2

41 3

42 4

43 1

Standard
FMS.8.1
44 2

45 3

Standard
FMS.8.2
46 Standard 1
FMS.8.2
47 2

48 3

49 Standard 1
FMS.8.3

50 2

51 3

52 1
Standard
53 FMS.8.4 2

54 3

55 1
56 Standard 2
FMS.8.5
57 3

58 4
The hospital establishes and implements a program for fire safety that includes an ongoing assessment of risks
and compliance with national and local codes, laws, and regulations for fire safety. ℗

The hospital develops and implements a written program for fire safety to protect all occupants of the
hospital’s facilities from fire, smoke, and non-fire emergencies.

The hospital performs and documents an ongoing fire safety risk assessment related to at least a)
through k) in the intent, and fire safety risks are identified and prioritized from the risk assessment. a) Fire
separations
b) Smoke separations/compartments
c) Hazardous areas (and spaces above the ceilings in those areas) such as soiled linen rooms, trash
collection rooms, and oxygen storage rooms
d) Fire exits
e) Kitchen grease-producing cooking devices f ) Laundry and trash chutes
g) Emergency power systems and equipment
h) Medical gas and vacuum system components
i) Storage and handling of potentially flammable materials (for example, flammable liquids,
combustible gases, and oxidizing medical gases such as oxygen and nitrous oxide)
j) Procedures and precautions to prevent and manage surgical fires
k) Fire hazards related to construction, renovation, or demolition projects

The fire safety program includes implementing interim measures, when necessary, to ensure that
the safety of the hospital’s patients, staff, and visitors is maintained when fire safety risks cannot be
immediately addressed.
The hospital identifies goals, implements improvements, and monitors data to ensure that fire safety
risks are reduced or eliminated.

The fire safety program includes the early detection, suppression, and containment of fire and smoke.℗

The fire safety program includes equipment/systems for the early detection and alarm notification of
fire and smoke.

The fire safety program includes equipment/systems for the suppression of fire.

When required by local laws and regulations, the fire safety program includes containment of fire and
smoke, and these features are maintained to ensure effectiveness and safety.
The fire safety program includes measures to ensure safe exit from the facility when fire and non-fire
emergencies occur.℗
The fire safety program includes the safe exit from the facility through free and unobstructed access
to exits.
The fire safety program includes clearly visible exit signage that is understandable to the hospital’s
occupants.
The fire safety program includes lighting for emergency exit corridors and stairs.

All fire safety equipment and systems, including devices related to early detection, alarm notification, and
suppression, are inspected, tested, and maintained.℗

All fire safety equipment and systems, including those for smoke and fire detection and suppression,
are inspected, tested, and maintained according to manufacturers’ recommendations or as required
by local codes, laws, and regulations, whichever sets the more stringent requirement.
Inspection, testing, and maintenance of all fire safety equipment and systems are documented,
including results and corrective actions.
Any deficiencies identified in fire safety equipment and systems are immediately corrected, or interim
measures are implemented to reduce fire risk until deficiencies can be fully corrected.
The hospital involves staff in regular exercises to evaluate the fire safety program.℗
Staff from all shifts, including the night shift and weekends, annually participate in an exercise to
evaluate the fire safety program.
Staff are knowledgeable of the fire safety program and can describe how to bring patients to safety.
Results of exercises to evaluate the fire safety program are documented, and staff who do not pass are
reeducated and retested on the fire safety program.

The fire safety program includes limiting smoking by staff and patients to designated non–patient care areas of
the facility.℗

The fire safety program addresses eliminating or limiting smoking within the hospital facility.
The program applies to patients, families, visitors, and staff.
The program identifies who may grant patient exceptions for smoking and when those exceptions
apply.

Smoking is prohibited in all areas under construction or renovation.

✓

highlighted ones are not being followed , needs to

✓ plan.

risk assessment policy and activity to be planned for

✓
2021 annual

nursing hostel, AHU room or newly constructed

✓ areas/rooms smoke detectors are pending.

Sprinklers system not available

Fire doors and assemblies inspection procedure
✓ missing.
Automatic smoke management systems (smoke
extraction system not available)

Identify local codes laws, and regulations include

✓ requirements for inspection, testing.

✓
 ✓ Working on OPD fire exit. And D5 Ramp provision

✓ review the local guidelines as per specs.

✓ subcontract for services.

escape plan sign is in process. Drills and exercise plan

✓
to be developed
✓

✓ only signage is missing

✓

contractor Management document and construction

✓
policy and checklist
Risk Assesmenet
Local laws
Smoke separation/compartment
Storage Area's
Fire Exits and signs
interim measures
Smoke detectors in Nursing Hostel and New areas/