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Frequently Asked Questions

Environmental Monitoring Rounds | JCAHO Inspections Safety Training | Biosafety Cabinets and Clean Air Benches

Environmental Monitoring Rounds

Q. What can be stored under the sink?

A. According to JCAHO requirements, the area under a sink should be considered a soiled environment. Therefore, anything that a patient or staff member wears, ingests, or is treated with should not be stored under a sink. Anything durable that is contaminated anyway, like a toilet bowl brush, toilet bowl cleaner, or trash can liners, could be kept under a sink.  

Please be advised that the storage area under the sink needs to be cleaned on a regular schedule. If you are working in a pediatric or psych area please assess whether the storage area under the sink (because of contents) needs to be locked.

Q. Who should be contacted with questions about Environmental Monitoring Rounds?

A. Brian Schott at Questions that pertain to multiple areas of the hospital and/or OPDs will be posted on the web site with the answer.

Q. Why do I need an eyewash station?

A. Accidental exposure of the eyes to chemical substances in any form can result in irritation, temporary or permanent vision impairment, or blindness. Under the Workplace Safety and Health Act an employer is required to provide approved emergency eyewash equipment.

Q. Why do I have to run the eyewash for three minutes each week? Three minutes is an awful long time. (HSE037)

A. Because it is recommended by APIC (Associated Professionals in Infection Control and Epidemiology) and OSHA. View OSHA's response to the DOE Hazardous Information Bulletin:

Q. Why can't we run a central class to train employees on how to use the eyewash? I don't know how to train them.

A. Hopkins has more than twenty (20) different models of eyewashes. Employees have to know how to use the eyewash in the area where they work. This is best accomplished by teaching them to use the eyewash in their own area and then have them do a return demonstration so you, as the supervisor, know they actually understood what you taught.

Pathology has put together a teaching plan for their supervisors who have to teach the use of the eyewash. They are willing to share this with other departments. If you go to their web site: and look under "Forms and templates" you can use this as your teaching guide. The actual guide is called "Emergency Equipment Training Guide".

The form you use to document the training is found on this web site under "Forms". It is called "Eye Wash Training Log".

Q. Why do I have to send HSE a copy of my training log?

A. HSE maintains a data base of employee safety training. Often this training is mandated by OSHA and/or JCAHO. HR can call HSE to obtain these records when they need to present the records to inspectors, such as JCAHO and OSHA. It is much easier and quicker for HR to call one location (HSE) than it is to call each Nurse Manager or Administrator for each employee in order to obtain proof of mandatory training. Inspectors are not willing to wait for long periods of time while these records are located.

Q. There is 'wasted' space at the end of our floor in our building.  We often have visitors who are waiting to enter a patient room.  I would like to place a sofa in those areas (Green areas on diagram) to provide comfortable seating area for the visitors.  That way they can see when the doctor and/or nurse finish with the patient they are visiting.  Can I do this?

A.  No.  Even though you are not blocking an egress fire route with the sofa, you are providing fuel (combustible sofa) to the hallway.  Even plastic is a combustible.  So plastic chairs in the hallway are not acceptable either.

Q. What is wrong with these pictures?

Oxygen tankOxygen TankOxygen Tank

A. Unsecured compressed gas cylinders can fall over and start a fire. The strap that would secure the oxygen cylinder to the stretcher or wall is missing. This stretcher should not be used until this is replaced.

 CGC Poster 1    CGC Poster 2

Q. What are you talking about when you say "expiration date" for the Oxygen?

A. An expiration date was added a few years ago for all compressed gas cylinders. Compressed gas cylinders are only good for five years. So Oxygen compressed gas cylinders which were changed out in 2004 will expire in 2009.

Recently, we have found several expired compressed gas tanks, including an oxygen tank on an emergency cart that expired in 1998.

O2 Label

The expiration sticker looks like a white price sticker that you would see in a store. If you have oxygen tanks on your emergency cart, an "H" reserve tank or any compressed gas tanks, please check to see that they are in date.

As of today 9/23/04, Marty Palen is making rounds on all the JHH units. He is checking volume of compressed gases present in each unit, storage conditions of the compressed gas cylinders, expiration date and whether the compressed gas cylinder is full. He is currently finding a lot of empty tanks. His recommendations:

  • DO NOT open the tank to see if it still has gas. It is very difficult to shut off these valves so the tanks will continue to leak until they are empty. Don't turn on a tank unless it is being used on a patient.
  • As he makes round, he is checking the expiration dates on all of the compressed gas cylinders he finds and replacing those tanks which are expired. So the only thing you need to do now if you find a compressed gas cylinder that is expired is make sure no one uses it .
  • Exception: If the expired tank is your only tank of oxygen, do call him immediately
  • Starting 11/15/04 - if you find an expired tank or a missing expiration label, contact Marty Palen at (410) 955-6530 or

Q. Why can't I prop (wedge) open the door?

Door StopDoor StopDoor Stop

A. Door Stoppers endanger the lives of both patients and staff. They help smoke and fire to spread around the building trapping and possibly killing the occupants.

 DoorStop Poster

Q. What is wrong with storing things on the top shelf?


A. The distance from the bottom of the sprinkler to the top edge of the shelf is 18.5 inches. Nothing can be within 18 inches of the bottom of the sprinkler - so nothing can be stored on the top shelf. Things may only be stored on the top shelf if there is more than 18 inches of space between the bottom of the sprinkler and the top of what is stored on the shelf.

Q. What is wrong with this picture?

Linen Storage

A. If linen is stored in a closet with other items, it must be covered.

Q. What is wrong with this picture?

Dirty Bucket

A. Water (in yellow bucket) sitting in a closet.  Infection control problem.

Q. What is wrong with this picture?

Floor Storage

A. Clean paper towels sitting on a dirty closet floor - Infection Control problem.

Q. What is wrong with this picture?

Linen Chute

A. Linen Chute door is blocked. There is no yellow sign on the linen chute door explaining that this is a confined space and that you need a permit and confined space training in order to enter the linen chute.

Q. What is wrong with these pictures?

Mechanical SpaceMechanical SpaceMechanical Space

A. Nothing should be stored in these mechanical spaces. The temperature in mechanical spaces which house autoclaves is high enough that some of the chemicals might catch on fire. The combustible (mop head) - lying against the autoclave insulation would provide additional fuel for such a fire. The scrubs and the trash also could be fuel for a fire.

Q. What is wrong with this picture?

Eye Wash

A. There are two things:

  1. Unable to reach eyewash because of cart blocking it.
  2. Cart contains plastic container where dirty instruments are soaked waiting to be transported to sterile processing area but no Blood borne pathogen sign was on the container.
Can you imagine being half blind from a chemical in the eye, crashing into this cart and then having disinfectant with dirty instruments fall onto you before you could start the eye wash?

Q. What is wrong with this picture?

Blanket Storage

A. The fire marshal says that we need three (3) feet clearance on all sides of the blanket warmer. In fact any electrical equipment that heats - including such items as toaster ovens and microwaves - also need three feet clearance from combustibles. Examples of combustibles are linen, cardboard, etc. Make sure your compressed gases are not stored near a blanket warmer.

Q. What is wrong with this picture?

Chemical Container with no Label

A. All chemicals have to be labeled and the label has to be readable. If you look at the bottle to the right, you will notice that the label is no longer readable - so a new label needs to be applied if you want to keep using this chemical.

Q. What is wrong with this picture?

Ceiling Tile

A. The main reason why wet ceiling tiles are a problem is because they are breeding grounds for mold. If a stained ceiling tile is noticed please call Facilities immediately to place a work order.

Q. What is wrong with this picture?


A. Integrity of Patient items (ie. mattress, chair cover, stretch, wheel chair...): tears in the outer covering of patient care items prevent the adequate cleaning from occurring. The torn surface can harbor bacteria and other microorganisms, which the cleaning solution cannot get to.

Q. What is wrong with this picture?

Oxygen Tank

A. JCAHO is enforcing NFPA 99 (2002 edition) regarding compressed gas storage. This is found on page 128 of the Health Care Facilities Handbook 2002. This is a NFPA publication that explains how NFPA 99 pertains to healthcare facilities. A copy of this book is available for viewing at 2024 E. Monument ST, B-200 - Department of Health, Safety and Environment.

"Chapter Design and Construction. Locations for central supply systems and the storage of medical gases shall meet the following requirements:... (7)Be provided with racks, chains, or other fastenings to individually secure all cylinders, whether connected, unconnected, full, or empty, from falling."

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JCAHO Inspections


Q. What is JCAHO and why is it important?

A. JCAHO JCAHO stands for The Joint Commission on Accreditation of Healthcare Organizations. By asking for accreditation, an organization agrees to be measured against national standards set by health care professionals. An accredited organization substantially complies with Joint Commission standards and continuously makes efforts to improve the care and services it provides.

Health care organizations seek Joint Commission accreditation because it:

  • Enhances community confidence.
  • Provides a report card for the public.
  • Offers an objective evaluation of the organization's performance.
  • Stimulates the organization's quality improvement efforts.
  • Aids in professional staff recruitment.
  • Provides a staff education tool.
  • May be used to meet certain Medicare certification requirements.
  • Expedites third-party payment.
  • Often fulfills state licensure requirements.
  • May favorably influence liability insurance premiums.
  • Favorably influences managed care contract decisions.
For more information visit:

Q. How does JCAHO benefit Johns Hopkins?

A. JCAHO is the Joint Commission on Accreditation of Healthcare Organizations. The Centers for Medicare and Medicaid Services (CMS) is a Federal agency within the U.S. Department of Health and Human Services which pays many of the medical bills for Medicare and Medicaid; but, does not do their own inspections. Instead they delegate to JCAHO to inspect. If a healthcare institution does not pass the JCAHO inspection, they will not receive payment from CMS for the bills of Medicare and Medicaid patients who use that healthcare institution's services. The bottom line is that it is possible that the healthcare institution could be shut down if it does not pass the JCAHO inspection.

Q. How often are the JCAHO surveys?

A. JCAHO surveys occur approximately every three years. In an in-service Kathy Norins - a JCAHO surveyor - said a year ago that healthcare organizations that passed with low marks on their last JCAHO survey and when JCAHO's assessment of their eighteen month self-assessment/corrective action plan - the assessment raised concerns - might see JCAHO as soon as two years. Healthcare institutions that passed with a good score and whose self assessment is realistic might not see JCAHO until four years. If a patient incident makes the newspaper or an institution reports a sentinel event, JCAHO can come back in at any time

Q. When is the next survey for Johns Hopkins Hospital?

A. The next survey is scheduled for the 15th through 19th of November 2004 (the week before Thanksgiving). This is the last time we will know when JCAHO is coming before they arrive at the JHH door.

Q. Are surveys always announced?

A. Presently they are announced ahead of time. However, starting January 2005 surveys will not be announced.

Q. How long is the JCAHO survey?
A. It depends on the size of the institution. At JHH it is usually a week long.

Q. What happens during the survey?

A. JCAHO inspects everything from doors/floors/walls/ceilings to patient records. They will talk to staff and patients.

Q. What areas are surveyed?

A. Any patient care (clinical) area or clinical support area (such as linen distribution, facilities workshops, power plants, etc).

Q. Who makes up the group conducting the JCAHO survey?

A. The survey team can include one, two, three or more health care professionals, including a physician, nurse or hospital administrator who has senior management level experience. The surveyors are selected from the Joint Commission's cadre of more than 350 surveyors. JCAHO will be adding an engineer starting January 2005.

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Safety Training


Q. What training do I need to have? How often do I need to have them? Why do I have to have them?

A. HSE offers many different training classes. Depending on where you work and what your responsibilities are influences what trainings you are required to have.

  • All new Hopkins employees must attend new employee orientation. At this orientation you will receive fire safety, hazard communication, and bloodborne pathogen training.
  • Any employee who may have a potential to be exposed to blood or body fluids...i.e. they work with or around patient blood/body fluids and/or non-human primate blood/body fluids must attend annual bloodborne pathogens training. This is an OSHA regulation.
  • Any employee who has to wear a respirator of any type (N95, PAPR, etc) must have annual fit testing on the respirator. This is an OSHA regulation.
  • It is required that every employee receive fire safety and hazard communication training at least once every three years.
  • It is recommended that employees who work in a biosafety lab take the Biosafety Training Class at least once.
  • Before an employee operates a power industrial truck, the employee must be trained in the operation of that equipment and is then recertified every three years. This is an OSHA regulation.
  • Any employee who has the responsibility for repairing powered equipment that must be locked and/or tagged out prior to repairing must receive lockout/tagout training. This is an OSHA regulation.
  • DOT/IATA Dangerous Goods Shipping Certification course for individuals who ship hazardous materials (including biological samples)
  • All laboratory employees should take the Laboratory Safety course which reviews the items covered by the annual laboratory research safety inspections.
  • All employees who work with radioactive material must attend the Radiation Safety course. The Primary Investigator is responsible for assuring that individuals who handle radioactive materials under their authorization are trained in radiation safety. This training may be done in-house or through the Radiation Safety course.

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Biosafety Cabinets (BSCs) and Clean Air Benches (CABs)

Q. How often do HEPA-filter containing devices need to be certified?

A. At least annually. Biosafety cabinets used by the Pharmacy and certain non-exhausted units need to be certified every six (6) months.

Q. How do I initiate an annual certification service request?

A. Contact the Biosafety Office with the following information: serial number, contact information, and method of payment. JHU departments should identify an SAP budget account number that can be charged for the service. JHH departments should complete a check request for the full amount made payable to Johns Hopkins University. Be sure to include the serial number, room number, and contact person for the BSC or CAB to be certified.

Q. Why is annual certification required?

A. To ensure the BSC is operating according to Original Manufacturer's Specifications. Regulatory agencies such as the FDA, USDA, CDC, Public Health Service and funding agencies such as the NIH, NCI, and American Heart Association require compliance with this standard. Certification includes tests for proper air flow through the equipment as well as HEPA filter integrity. Your safety and the sterility of the work environment within the equipment are not assured if the unit has not been certified.

Q. How do I enroll my equipment in this program?

A. Provide Biosafety, HSE with the following information:

  • Owner name & office address
  • Cabinet location building and room number
  • Laboratory contact person name and phone number
  • Cabinet manufacturer, unit model and serial number

Q. How will I know when my equipment is due for certification?

A. It is the Principle Investigator's responsibility to maintain compliance with the annual certification. The Biosafety Office suggests the PI or Dept Administrator maintain a tickle file to remind themselves to schedule routine services on an annual basis. The Biosafety Office does send out reminders approximately 30 days prior to certification expiration, but this system is not 100% accurate due to changes in contact information (names, phone and addresses) that may have occurred since the previous certification, but have not been submitted to the Biosafety Office.

Q. Who pays for this service?

A. Payment is made by the PI or, in some instances, the department covers these costs.

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