Safety Fact Sheet

Applicable Accreditation Standards

The physical facility(s) used by the facility complies with all required standards, regulations and codes for construction, fire safety and building codes applicable in the jurisdiction where the facility is located and appropriate to the facility type.

The facility must demonstrate compliance with all applicable OSHA requirements as well as appropriate state authorities. This includes but is not limited to:

  1. Access to safety data sheets for hazardous materials used in the sleep facility; and
  2. Availability of personal protective equipment.

The facility disposes of all hazardous materials in compliance with the manufacturer’s recommendations and applicable laws and regulations.

The facility must complete and document an analysis of safety risks to patients related the procedures performed by the facility. This analysis must be updated periodically and no less frequently than every five years. The risk analysis must be reviewed, and the review documented, on an annual basis. Examples of risks may include: patient falls after receiving hypnotics, slippery shower surfaces, and uneven ground to/from the facility. The facility must implement policies and procedures to mitigate risks identified.

Within the facility, the facility director must document the occurrence of significant adverse events for its patient population. At a minimum, the following events must be considered significant adverse events:

  • Patient or staff death
  • Permanent loss of function or of a body part by a patient or staff
  • An event that leads to the hospitalization of a patient or staff
  • An event that requires activation of an emergency medical response
  • Sexual or physical assault of a patient or staff or allegations thereof
  • Release of a minor or a patient lacking capacity or competency to an unauthorized individual
  • Elopement of a patient
  • Complications arising from the effects of hypnotics used for the purpose of sleep testing
  • Any event required by the applicable jurisdiction to be reported to a government agency

The facility must create a policy and procedure for performing a root cause analysis of any significant adverse events. Consistent with the policy, the facility must conduct an investigation of all significant adverse events that occur.

Recognizing the unique vulnerability of patients and staff in a sleep testing environment, facilities must have explicit policies and procedures to minimize the risk for assault or allegations of inappropriate behavior during the attended sleep testing encounter. This may include the use of continuous video monitoring in high risk areas during the attended sleep testing encounter (patient bedrooms, hookup areas) and/or specific training for the use of chaperone during interactions between patients and staff.

Purpose of Safety Plans

Sleep policies and procedures are necessary to ensure the safety of patients and staff.  Policies and procedures provide guidelines for establishing and implementing procedures that will reduce work place hazards, protect lives and promote health.

Safety Compliance Requirements

Occupational Safety

The facility is to maintain policies and procedures specific to the sleep facility that describe state and federal regulations for OSHA and hazardous material storage, handling and disposal. This includes the use of personal protective equipment (PPE) as well as access and maintenance of safety data sheets for hazardous material (SDS) if the facility maintains hazardous material.

Safety Risk Analysis

A sleep facility is to maintain a policy that indicates it conducts an assessment of all areas within the sleep environment.  The assessment should be conducted annually and updated every 5 years. Once the assessment of the sleep areas is completed the facility should analyze any potential risks identified and implement mechanism to correct issues to prevent future safety problems.

  • Examples: broken cement on entrance to the building; slippery shower services; uneven floors; cleaning supplies are maintained separate from food sites, medications are stored properly, etc.

Significant Adverse Event Management                

A sleep facility should maintain a Significant Adverse Event Policy that addresses the procedure for investigating, reporting, documenting, and analyzing the significant adverse event.  This needs to include conducting a root cause analysis which is to be reviewed by the facility director.

  • Root Cause Analysis is a method used to arrive, discover, and understand why problem occurred and develop a solution to prevent future problems from reoccurring.

The policy should at least list include the minimum recommended events identified in standard K-5

Safety Risks Unique to In-Center Sleep Testing

Patients and staff are vulnerable during the sleep testing encounter; therefore, the facility is to develop policies and procedures that would minimize the risk of inappropriate behavior and allegations of assault. Risks can be reduced by the use of chaperones or the use of continuous video monitoring; minimally, in hook up areas and/or patient bedrooms.

Key Things to Keep In Mind

  • Facility Safety is met for standard K-1 by submitting evidence of Certificate of Occupancy or Permit within the application. If those are not available evidence of a Fire Marshall Inspection report meets compliance to the standards.
  • Facilities may submit individual policies for each standard or combine the elements of K-2-7 in other policies.
  • Comprehensive hospital wide policies may be acceptable provided the policies describe the roles and responsibilities of the sleep department (staff).
    • If the hospital wide policies do not describe the sleep department’s role and responsibilities, a customized sleep facility addendum describing the procedures may be requested to be submitted.
  • At a minimum all nine (9) elements listed in standard K-5 must be included in policy.
  • Falls risk assessment on each patient does not meet compliance to Standard K-4. A facility walk through of hazardous risk analysis is required.