AHCA REQUIREMENTS

The following is a list of items from the AHCA inspectors checklist. These apply to most facilities that provide medical care in an Emergent, Ambulatory Surgery, Outpatient Eye Surgery, Clinic’s, Nursing Homes, and Medical offices. There may be other requirements that the inspector identifies for the facility being inspected.

FIRE EXTINGUISHERS: In most facilities, fire extinguishers are required. They must be inspected monthly (in-house inspection is OK) for a full condition by the gage and whether the trigger lock is unopened. Used extinguishers must be refilled or replaced. Documentation is required. Annually they are to be inspected and weighed by an outside authorized vendor. Documentation is required.

BATTERY EMERGENCY LIGHTS: In most facilities where battery powered emergency lighting is used, they must be tested monthly and annually. Monthly, they must be activated by pressing the button on the unit for that purpose to see that they activate for 30 seconds. Documentation is required. Annually, they are to be activated for 90 minutes by removing AC power from the unit. This may require an licensed electrician to accomplish. Documentation is required. Any failures require repair or replacement and of course, documentation of any action is required.

GENERATORS: If an Emergency power generator is required, weekly, monthly, and annual testing is required. A qualified person is required in most cases. Weekly, the generator is to be manually started and run for 30 minutes. Monthly, the generator is to be started and run powering the facility. The generator requires to be tested on at least 30% load on the nameplate for the generator. Annually, the generator is to be run under load for 2 hours documenting the start time, stop time and load conditions. Of course full documentation is required and any failures and corrective action is required. In general, facilities that do not keep patients over night do not require a generator.

RECEPTACLES: Power outlets in a patient area such as Surgery, Recovery, or patient holding or Pre-op should have the receptacles tested for for correct polarity and minimum tension. Tension testing requires a special device for accurate testing. Documentation is required for the testing and failures and corrections must be documented. A qualified person is required for the testing and an licensed electrician should be used for the repairs.

MAIN & FEEDER CIRCUIT BREAKERS: Annually the Main & Feeder circuit breakers should be exercised. This means turning them OFF and then back ON. Before doing this test, insure there are no patients are at risk for loss of power such as under anesthesia. This can be accomplished by any qualified person but a licensed electrician is preferred. Documentation is required of the test and failures are required and action taken.

MEDICAL EQUIPMENT: All medical equipment must be tested and inspected at a minimum annually. Some devices of critical nature (such as Defibrillators and some Anesthesia machines) should be done semi-annually. A current inventory of the equipment tested and test results should be available at time of inspection. A running history of up to 3 years may be requested by the inspector. During the testing of equipment, any equipment failing the test should be documented. Any actions taken to repair or replace the equipment should be documented.

PACE MEDICAL MAINTENANCE, INC. Tests, inspects and documents medical equipment as required. Pace  Medical uses a Computerized Medical Maintenance System (CMMS) to document the testing and keeps inventory records and history for greater than 3 years.

LIM test: Line Isolation Monitors (LIM) is tested monthly and annually. Not all facilities have these devices, usually in a surgical environment. But if you have them in use, you must test them to meet the requirements. Monthly, the test button feature should be pressed to check that the alarm sounds. Annually, they must be tested with a special device that activates the alarm from an outlet in the circuit protected by the LIM. This is a check calibration test. A qualified person or vendor should be used for this test. Documentation of the testing and/or failures is required and actions taken to correct.

MED GAS SYSTEMS: If Med gases such as Medical Air, Oxygen, and Vacuum are supplied by a piped system (in the wall), they are required to be tested annually. Med Gas alarm panels are checked for alarm operation and functioning gages. The Med Gas outlets are checked for leaks, operation, pressure and purity of gases supplied. If bottled sources are used, this is not required.

PM PLAN: A written plan is required. This can be a simple statement such as: “The medical equipment is tested and inspected on an annual basis. Documents are kept in the facility and at the vendors facility (such as Pace Medical) stored in the Director offices.” Substitute the specific testing and frequency as needed for each of the above.

FIRE DRILLS: Some facilities may require Fire Drills to be held depending on occupancy and facility status. Check with AHCA for requirements for your facility.