Person/Committee/
Department
|
Responsibilities
|
Director, Facilities Management
|
 | Maintain/enforce the Life Safety Management Plan
|
| Ensure that each building used for patient treatment or overnight housing has one of the following:
|
 | Compliance
with the appropriate provisions of the 2000 edition of the Life Safety
Code of the National Fire Protection Association (NFPA)
|
| Equivalent protection and documentation
|
| Submit a comprehensive state of Construction and Fire Protection to The Joint Commission
Describing: The structural features of the facility
Frequency: Every three years
|
| Develop a comprehensive plan of correction
When: UTHCPC does not meet Life Safety Code standard requirements
|
| Develop, implement, and document interim life safety plans
When: Construction affects fire protection or environment and grounds safety requirements |
|
Facilities Management
|
| Provide an ongoing plan to ensure:
|
| Buildings and grounds are suitable for the nature of services provided
|
| Ages and other characteristics of the patient population
|
| Ensure that new construction provides for the safe and convenient use of building and grounds by physically disabled individuals
|
| Develop specific procedures for the maintenance, supervision, and safe use by patients of all grounds, equipment, and special activity areas
|
| Document Life Safety Management plan compliance |
|
Safety Committee and other appropriate staff
|
| Analyze documentation of the Life Safety Management plan
|
| Review summaries of the Life Safety Management plan
|
| Review, analyze, and take appropriate action on information referred from the Life Safety Management plan as part of the hospital-wide information collection and evaluation system |
|
Safety Compliance Coordinator
|
| Takes action to resolve problems identified in the Life Safety Management plan
|
| Documents actions taken
|
| Evaluates effectiveness of actions taken
|
| Evaluates the need for continued monitoring when an action has proven effective
|
 | Refers appropriate information from the Life Safety Management plan to the Safety Committee as part of the hospital-wide information collection and evaluation system |
|
