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Title: Section 405.24 - Environmental health

Effective Date


405.24 Environmental health. The hospital shall be operated and maintained to ensure the safety of patients.

(a) Building and grounds. Facility grounds and physical plant shall be maintained in a manner to assure a safe and suitable environment for patients.

(1) Grounds and buildings shall be maintained in functional condition and to meet design intent, free of safety hazards, excessive noise, odors and environmental pollutants as may adversely affect the health or welfare of patients.

(2) There shall be facilities for emergency provision of adequate fuel and water supplies during any period in which the supply of fuel and/or water from usual sources temporarily becomes disrupted.

(b) Life safety from fire. (1) Buildings and equipment shall be so maintained as to prevent fire.

(2) The hospital shall have a written master fire plan that contain provisions for prompt reporting of fires; extinguishing fires; protection of patients, personnel and visitors; evacuation; and cooperation with firefighting authorities.

(3) Personnel shall be trained in procedures to be followed in emergencies, including but not limited to the use of firefighting equipment, evacuation of patients and personnel and all other duties in the master fire plan.

(4) Fire drills shall be conducted at irregular intervals at least 12 times per year covering all shifts.

(5) The hospital shall ensure the thorough investigation of all fires. A written report of the investigation shall be produced and shall remain on file for not less than six years.

(c) Engineering and maintenance. (1) Water supplies of medical facilities. All water used in operation shall be provided in conformance with Part 5 of the State Sanitary Code and section 702.1(a) of this Title.

(2) Preventive maintenance. A written preventive maintenance program shall be established and implemented to insure that all equipment and buildings are operative, safe, sanitary and maintained in good repair.

(i) Hospitals shall develop and adhere to schedules for testing, maintenance and calibration of all patient care and life safety equipment. Such maintenance schedules shall, at a minimum, be conducted in accordance with manufacturer's specifications.

(ii) Written reports documenting such tests, maintenance and calibration shall be retained on file for not less than three years after the date of such tests, maintenance or calibration.

(d) Waste. Hospitals shall develop and implement infectious waste management programs as required by the provisions of title XIII of article 13 of the Public Health Law.

(e) Housekeeping. (1) The entire facility, including but not limited to the floors, walls, windows, doors, ceilings, fixtures, equipment and furnishings, shall be kept clean and maintained in good repair.

(2) The facility shall be kept free of insects and rodents.

(3) All cleaning shall be done in a manner which will not spread dust or other particulate matter.

(4) Supplies and equipment for housekeeping functions shall be provided with cleaning compounds and hazardous substances properly labeled and stored.

(f) Linen and laundry. (1) Clean linen shall be provided to meet the requirements of patients.

(2) All linen shall be handled, stored, laundered and processed, and transported in a manner that will prevent infection and assure the maintenance of linen that is clean and in good repair. The hospital shall ensure that any use of inks or dyes contained aniline oil (aminobenzene) or oil of mirbane (nitrobenzene) or other benzene derivatives by such hospital, laundry or diaper service conforms to the requirements in section 12.10 of the State Sanitary Code.

(3) All linen, including blankets, shall be laundered between patient use.

(4) To prevent the spread of infection, all soiled linen shall be enclosed in containers within the patient care unit for transportation to the laundry.

(5) All linen from isolation rooms, infectious patients and the pathology service shall be enclosed in identifiable containers distinguishable from other laundry.

(g) Emergency and disaster preparedness. The hospital shall have a written plan, rehearsed and updated at least twice a year, with procedures to be followed for the proper care of patients and personnel, including but not limited to the reception and treatment of mass casualty victims, in the event of an internal or external emergency or disaster arising from the interruption of normal services resulting from earthquake, flood, bomb threat, chemical spills, strike, interruption of utility services, nuclear accidents and similar occurrences. Personnel responsible for the hospital's accommodation to extraordinary events shall be trained in all aspects of preparedness for any interruption of services and for any disaster. This shall be in addition to the Surge and Flex Plan that is required pursuant to Part 360 of the Title.

(h) Animals. Animals, exclusive of those required for laboratory purposes shall only be allowed in a hospital in the following instances:

(1) service dogs or other service animals which have been individually trained to do work or perform tasks for the benefit of an individual with a disability when the presence of such animal will not pose a significant risk to the health or safety of others that cannot be eliminated by reasonable accommodation and is not medically contraindicated. However, if the safe operation of the hospital would be jeopardized, a service animal need not be allowed to enter. A finding by appropriate medical personnel at the hospital that the presence or use of a service animal would pose a significant health risk in certain designated areas of a hospital may serve as a basis for excluding service animals in those areas;

(2) when a hospital chooses to initiate and operate an organized animal visitation or animal-assisted therapy program that is jointly developed, approved and monitored by the hospital's quality assurance, risk management and infection control committees or designees. In each such approved program, the hospital must at a minimum ensure that:

(i) participating animals meet the qualifications set by the hospital including:

(a) certification of current vaccinations and being free of communicable diseases or infections;

(b) documentation of having training and temperament acceptable to the hospital;

(ii) each participating patient signs a patient consent form that includes an assessment of the risks and benefits of program participation;

(iii) hospital personnel and non-participating patients in proximity to the program are not negatively impacted by the presence of such animals;

(iv) the well-being of the participating animals is considered and maintained;

(v) patient and staff satisfaction is assessed, ensuring that participating patients and staff as well as a representative sample of non-participating patients and staff are routinely sampled for feedback; and

(vi) infection control protocols established for the program include a comparative assessment of infections for participating and non-participating patients.

(i) Central supply services. The hospital shall ensure the provision of central supply services for the preparation, storage, handling and distribution of sterile supplies and other patient care items. The hospital shall conform to current, acceptable standards of practice for central services.

(1) Central services shall be under the direction of an individual qualified by education, training and experience to supervise the personnel and functions of central services, and who shall be responsible to the chief executive officer either directly, or through a designated department head.

(2) Central services shall be evaluated as part of the hospital's ongoing quality assurance program.

(3) The functional design and workflow patterns in central services shall provide for the separation of soiled and contaminated supplies from those that are clean and sterile.

(4) There shall be written policies and procedures for the decontamination and sterilization activities performed in central services and elsewhere in the hospital, and for related requirements. These policies and procedures shall include, but not be limited to provisions for:

(i) the decontamination, cleaning, preparation and sterilization of patient care supplies and equipment;

(ii) the separation of soiled or contaminated supplies and equipment from clean and sterilized supplies and equipment;

(iii) the assembly, wrapping, storage, handling and distribution of sterile supplies and equipment in central services and all other areas of the hospital as applicable;

(iv) requirements for aeration of gas-sterilized items;

(v) maintaining and recording time and temperature for each sterilization cycle and aeration cycle, if any, with provisions for records to be kept at least one year;

(vi) the labeling of each sterilized item with the date sterilized, cycle and expiration date indicating the shelf life of the sterilized item if the hospital chooses to use time-related sterility criteria with established expiration dating of in-house reprocessed and sterilized supplies and equipment;

(vii) event-related sterility assurance if the hospital chooses to use such criteria for sterility assurance. Such sterility assurance shall:

(a) comply with generally accepted standards for sterility assurance such as those endorsed by the Association for the Advancement of Medical Instrumentation, the Joint Commission on the Accreditation of Healthcare Organizations or other such entities recognized as appropriate by the Commissioner;

(b) be based on the results of an evaluation of current hospital policies and procedures for handling sterile supplies;

(c) be reflected in the hospital's written policies which detail the process and responsibilities and which have been approved by the infection control officer and Infection Control Committee, if any;

(d) be addressed through inservice education of staff; and

(e) provide for quality assurance monitoring to evaluate effectiveness;

(viii) the use of chemical indicators with each cycle and weekly bacteriological spore monitoring for all sterilizers;

(ix) the rotation and reprocessing of sterile equipment and supplies; and

(x) the routine checking and removal of outdated or damaged sterile supplies and equipment or supplies or equipment which no longer meet the sterility standards of the event-related sterility assurance criteria and the recall of such supplies and equipment from all areas of the hospital.

(j) Injury control. The hospital shall:

(1) have a safety education program which shall include both orientation of new employees and continuing inservice training programs;

(2) develop and implement programs designed to eliminate safety hazards; and

(3) maintain, during any construction, alterations or repairs, a safe environment and safe access.


VOLUME C (Title 10)