Safety Fact Sheet
Safety Compliance Requirements
- Facility safety can be confirmed through a certificate of occupancy and/or facility license that indicates Fire Marshal inspection.
- OSHA and state regulations should minimally include access to safety data sheets for hazardous materials, availability of personal protective equipment (e.g. googles, gloves) and eyewash stations when required. (Reference Standard K-2)
- The facility must have a policy that addresses hazardous materials used in the facility. This policy is to include proper disposal for all hazardous materials according to the manufacturer and applicable lab regulations. (e.g. sharps containers, waste bins.)
Safety Analysis Requirements
- Annually a safety analysis must be performed. This risk analysis includes a walkthrough of the facility documenting facility safety risks that may be hazardous to the patient. (Reference Standard K-4 for examples.) Additionally, the policy needs to reflect efforts to mitigate any risks identified during the safety risk analysis facility walkthrough. This is to be reviewed by the Facility Director.
- The facilities “Significant Adverse Events” policy needs to indicate how to perform investigation of all significant events. Reference Standard K-5 for, minimally, all significant events that must be included in the “Significant Adverse Events” policy.
- The facility must have a policy & procedure that addresses the investigation, discovery and mitigation for adverse events. This needs to include a root cause analysis which is to be reviewed by the Facility Director.
- It is acceptable to submit a policy addressing the events or the tool used to track and record the investigation process.
- The facility needs to have a policy that minimizes the risk for assault or allegations of inappropriate behavior during the testing timeframe. The policy should consider continuous video monitoring throughout the patient encounter when working alone or the use of a chaperone when two technologists are working at the same time.
Applicable Accreditation Standards
The facility must demonstrate compliance with all applicable OSHA requirements as well as appropriate state authorities. This includes but is not limited to: Access to safety data sheets for hazardous materials; Availability of personal protective equipment; and Eyewash stations when required.
Key Things to Keep In Mind
- Comprehensive hospital wide safety, risk management and OSHA policies must include the specifics as they relate to the sleep facility.
- Hospital wide risk analysis policies must include an indication that the inspection is sleep facility specific.
- A hospital wide Risk Management Policy must include the events specific to a sleep facility.
- There is no need for the hospital to revise their comprehensive policy; an addendum from the facility will show compliance.
- The facility must identify high-risk areas that would require methods to minimize potential risks. Include in the policy if the facility has identified high risk areas that would require methods to minimize potential risks. For example: Video monitoring in the hallways and waiting room. For facilities with multiple beds, there could be 2 technologist present during patient interactions.
- Falls risk assessment on each patient does not meet compliance to Standard K-4. A facility walk through of hazardous risk analysis is required.
- Policies are to reflect maintenance and access of safety data sheets for the sleep facility staff.