Facility Management and Safety Surveyor Exit Report

Report Contents:
I. Essential Safety Requirements
II. Significant Findings

I. Essential Safety Requirements (ESR)

FMS.24 The hospital and its occupants are safe from fire and smoke.
FMS.24.5 Fire rated doors are available according to the hospital zones with no
separation between walls and ceiling to prevent smoke spread between
rooms and areas.
---Not Met---
Findings: FMS Observation - Fire rated doors were not available. There was no zones layout.

FMS.32 The hospital ensures proper maintenance of the medical gas system.
FMS.32.3 Compressed medical air is regularly tested for humidity and purity.
---Not Met---
Findings: FMS Document Evidence - Compressed medical air was not regularly tested for humidity
and purity.

FMS.32.8 The hospital keeps standby oxygen and medical air cylinders enough for forty
eight hours of average consumption.
---Not Met---
Findings: FMS Observation - The hospital did not keep standby oxygen and medical air cylinders
enough for forty eight hours of average consumption but only for twenty four hours only.

II. Significant Findings

FMS.1 Hospital Leaders establish and support a facility management and safety program.
FMS.1.3 The program includes regular inspection, testing, and maintenance of all the
operating components of the program.
Findings: FMS Document Review - The safety program was not supported by indicators
to check and verify its progress. There were no PPM achieved indicator, OVR
reported nor HAZMAT levels.
FMS.18 The hospital has a system for scheduling and conducting fire drills regularly.
FMS.18.1 Fire drills are scheduled and conducted regularly in all departments.
Findings: FMS Document Review - Fire drills were not scheduled to be conducted
regularly in all departments.
FMS.18.2 Fire drills are conducted during different shifts to test:

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Facility Name: Ballahmar General Hospital | Date of Survey: 14/09/2022 | Specialty: Facility Management and Safety
 FMS.18.2.1 Using Rescue, Alarm, Confine, Extinguish/Evacuate (RACE) procedure.
FMS.18.2.2 Using Pull, Aim, Squeeze, Sweep (PASS) procedure.
FMS.18.2.3 The ability to contain the fire when it starts.
FMS.18.2.4 Staff performance in the event of fire.
FMS.18.2.5 Evacuation procedures.
FMS.18.2.6 Whether the oxygen and electricity supplies were shut off at the right time.

Findings: FMS Document Evidence - Fire drills were not scheduled to be conducted
during different shifts. There was no test on all related requirements during the
fire drills.
FMS.18.3 All staff participate in the fire drills.
Findings: FMS Document Evidence - There was no document presented to show that
all hospital staff participate in the fire drills.
FMS.18.4 All fire drills’ results and corrective actions are documented and integrated
into the quality improvement program.
Findings: FMS Document Review - Fire drills that were conducted had no results and
corrective actions documented.
FMS.18.5 A full fire drill is conducted for the internal disaster plan once a year and this
drill is evaluated.
Findings: FMS Document Review - A full annual fire drill document for the internal
disaster plan was not presented.
FMS.19 The hospital supports fire prevention.
FMS.19.2 The hospital ensures separating all dangerous materials or flammables from
heat generating areas.
Findings: FMS Observation - storage of flammable materials was not in the fire safety
cabinet. The hospital did not ensure separating all dangerous materials or
flammables from heat generating areas.
FMS.19.3 The hospital ensures installing fire rated walls as appropriate, especially in high
risk areas like the laboratory, electrical rooms, and kitchen.
Findings: FMS Document Review - The hospital did not ensure installing fire rated walls
as appropriate, especially in high risk areas like the laboratory, electrical rooms,
and kitchen. There was no fire zoning layout nor fire rated doors hence the walls
were tampered.
FMS.34 There is a periodic preventive maintenance plan for heating, ventilating, and air-
conditioning.
FMS.34.4 HEPA filters are monitored on a monthly basis and the results are
documented.
Findings: FMS Document Evidence - HEPA filters were monitored on a monthly basis.
FMS.34.5 Air change per hour is maintained as per national and international guidelines
(e.g., American Society of Heating, Refrigerating & Air-Conditioning Engineers,
ASHRAE).

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Facility Name: Ballahmar General Hospital | Date of Survey: 14/09/2022 | Specialty: Facility Management and Safety
 Findings: FMS Document Evidence - Air change per hour was not maintained as per
national and international guidelines (e.g., American Society of Heating,
Refrigerating & Air-Conditioning Engineers, ASHRAE).
FMS.36 The hospital provides appropriate control of temperature and humidity in the required
locations.
FMS.36.1 Temperature and humidity are controlled and regularly monitored in
operating and recovery room(s).
Findings: FMS Observation - Temperature and humidity were not controlled and
regularly monitored in operating and recovery room(s).
FMS.36.3 Temperature and humidity are controlled and regularly monitored in critical
care unit(s).
Findings: FMS Observation - Temperature and humidity were not controlled and
regularly monitored in critical care unit(s).

----- End of Exit Report -----

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Facility Name: Ballahmar General Hospital | Date of Survey: 14/09/2022 | Specialty: Facility Management and Safety

Page: 3 of 3
Facility Name: Ballahmar General Hospital | Date of Survey: 14/09/2022 | Specialty: Facility Management and Safety