Maintenance of Structures

The facility is clean and well maintained; the design 
provides opportunity for efficiency in carrying out the 
mission of the organization as well as in maintenance of the 
physical structure.  The facilities and their premises shall 
be kept clean, neat and free of uncontained litter or rubbish.
All buildings, fixtures, equipment, spaces, and sanitation 
systems shall be maintained in operable condition.  
Maintenance issues and problems shall be included on the 
monthly safety inspection for review and correction by the 
appropriate supervisor.
Any chemical or agents with the capability of compromising 
patient safety will be properly labeled and will not be 
stored with patient care items.
Policies and procedures relating to maintenance and 
sanitation issues will be reviewed and updated as needed, at 
least annually.  Structural and major equipment changes will 
be updated onto the architectural plans and specifications 
for use by appropriate personnel.
Maintenance work will be done on a proactive basis, to 
preclude the development of problems which may compromise 
patient safety.  All work outsourced to an outside vendor 
will be certified by the vendor, consistent with acceptable 
Pest control will be conducted to assure freedom from rodents 

and other vermin.  Pest control measures will be conducted by 
those trained in the use of chemicals and traps with concern 
demonstrated at all times for proper use of such modalities.  
Doors, vents, and windows will be equipped with appropriate 
barriers (screening, foyers, etc.) and/or constantly 
monitored to prevent the entry of undesirable insects or 
The biomedical equipment review, discussed elsewhere in these 
policy and procedures, will include provision of 
instructional information and specifications for reference by 
appropriate individuals; power specifications, including any 
alternate power source backup, will be specified as a part of 
such biomedical review.  Staff will not use any equipment on 
which training has not been received.
Appropriate preventive maintenance, including painting and 
repair of weather related structural or finish damage, will 
be reviewed on a regular basis.
1.  Cracks in plaster, peeling wall paper or paint, tears or 
    splits in floor coverings, and missing tiles shall be
    repaired promptly.
2.  Electrical systems including appliances, cords, 
    equipment, call systems, switches, and grounding 
    systems shall be maintained to assure safe functioning.
3.  Heating and cooling systems shall be inspected and 
    documented annually to assure safe operation.  Written
    records of maintenance on high intensity filters and
    humidifier shall be kept.  Generally, it is anticipated 
    that the heating equipment will have the capacity to 
  maintain 80 degrees F; cooling equipment, 64 degrees F.
4.  Electrical circuits are tested annually as a part of the
    biomedical inspection.
5.  At any time that inhalational anesthetic agents are used,
    grounding systems in the operating rooms will be
    inspected monthly.
6.  All new equipment shall receive biomedical inspection 
    before use in the facility.
Records shall be maintained of all inspections and testing; 
maintenance work performed will be similarly documented.
Information regarding the mechanisms for safe disconnect of 
all utilities will be readily available to all staff.
Approved By Governing Board    
Control #279.0