FMS.1 - Hospital Leaders establish and support a facility management and safety program.

 
  ( Partially Met )

FMS.1.1 - The facility management and safety program includes the following written and approved plans:

FMS.1.1.1 Safety of the Building.

FMS.1.1.2 Security.
FMS.1.1.3 Hazardous materials and waste disposal.
FMS.1.1.4 External emergency.
FMS.1.1.5 Internal emergency.
FMS.1.1.6 Fire Safety.
FMS.1.1.7 Medical equipment.
FMS.1.1.8 Utility System.
Partially Met
Activity Comment

Document Review FMS program was lacking measurable objectives.

1126132

FMS.1.2 - Hospital leaders support the facility management and safety program to acquire the necessary equipment.
Fully Met
FMS.1.3 - The program includes regular inspection, testing, and maintenance of all the operating components of the program.
Partially Met
Activity Comment

Document Review Inspection, testing, and maintenance was not listed for all components of fire safety systems.
1125895

FMS.1.4 - The program has a budget for the necessary upgrading or replacement as identified by monitoring data or to meet applicable laws and regulations.
Fully Met
FMS.1.5 - There is an orientation program conducted for new hires on the facility management and safety plans.
Fully Met
FMS.2 - There is a qualified individual(s) responsible for directing and coordinating the facility management and safety program. 
  ( Fully Met )

FMS.2.1 - The hospital has a facility management and safety program director who directs and coordinates all aspects of the facility management and safety program.

Fully Met

FMS.2.2 - The program director is qualified by education (e.g., bachelor’s degree in engineering science), training, and experience in healthcare facility management and safety.

Fully Met

FMS.2.3 - The program director is assisted by qualified staff (e.g., safety officer) as required, according to the size and complexity of the hospital services.

Not Met
Activity Comment
 Document Review The FMS program director was not assisted by qualified safety officer as required, according to the size and
complexity of the hospital services.
1125896

Personnel File Review The FMS program director was not assisted by qualified safety officer as required, according to the size and
complexity of the hospital services.
1126092

Environmental Safety The FMS program director was not assisted by qualified safety officer as required, according to the size and
Committee complexity of the hospital services.
1125898

FMS.2.4 - The program director provides ongoing consultation to all departments.

Fully Met

FMS.2.5 - Each department has an assigned "liaison safety officer" to liaise all safety issues within the department.

Fully Met

FMS.3 - There is a multidisciplinary safety committee that provides oversight of the facility management and safety program. 
  ( Fully Met )

FMS.3.1 - The committee's membership consists of representatives from relevant departments such as safety, security, housekeeping, infection control, risk management, biomedic
engineering, laboratory, medical staff (E.R), nursing, radiation safety, maintenance, and quality management.

Fully Met
FMS.3.2 - The safety committee provides oversight of the facility management and safety program.

Fully Met

FMS.3.3 - Safety committee meets at least ten times per year on a monthly schedule. Minutes are documented to be approved by the hospital leadership.

Fully Met

FMS.3.4 - The safety committee, through a multidisciplinary team, conducts quarterly and as needed facility safety tours to identify risks and hazards related to the facility and
physical plants as well as evaluation of staff knowledge.

Fully Met

FMS.3.5 - The committee uses the resulting information for corrective and preventive actions, planning, and budgeting of long-term upgrading and replacement.

Not Met
Activity Comment

Environmental Safety The committee did not use the resulting information for corrective and preventive actions, planning, and
Committee budgeting of long-term upgrading and replacement.
1126106

FMS.4 - The hospital is in compliance with applicable laws and regulations. 

  ( Partially Met )
FMS.4.1 - The hospital has a valid Saudi Civil Defense license.

Not Met
Activity Comment

Document Review The hospital did not have a valid Saudi Civil Defense license.
1125919

FMS.4.2 - The hospital has a valid Saudi Civil Defense report and action plan as applicable.

Fully Met

FMS.4.3 - Hospital leaders ensure compliance with applicable building and environmental protection standards, laws, and regulations (e.g., MOMRA's hospital building
requirements, Saudi building code, discharges to drainage systems, safe disposal of waste).

Fully Met

FMS.5 - The hospital ensures safety and security of staff and patients during construction, renovation, or demolition projects. 
  ( Not Met )

FMS.5.1 - The hospital implements a policy for safety and security of patients, staff and visitors during construction, renovation, or demolition that includes:

FMS.5.1.1 Safety and security instructions.

FMS.5.1.2 Education of contractors.
FMS.5.1.3 Proper isolation of construction and renovation sites.
FMS.5.1.4 How to eliminate the risks of fire and spread of dust.
 FMS.5.1.5 Penalties incurred on contractors for violating the policy.
FMS.5.1.6 Safety rounds on construction/renovation sites by facility management and safety and infection control staff.
Fully Met
FMS.5.2 - A work permit is signed by the construction team and posted in the construction, renovation, or demolition sites.
Not Met
Activity Comment

Observation There was no work permit available at renovation areas.

1126065

FMS.6 - Warning and directive signs are posted inside the hospital as appropriate. 
  ( Fully Met )

FMS.6.1 - There are warning signs posted as appropriate in the hospital and include:

FMS.6.1.1 Signs for the radioactive materials including warning signs for pregnant women.
FMS.6.1.2 Signs for wet floors during cleaning.
FMS.6.1.3 No smoking signs.
FMS.6.1.4 Signs and warning lights for x-ray room(s).
FMS.6.1.5 Signs to restrict cellular phones in sensitive areas as appropriate, e.g. MRI or critical care units.
Fully Met
FMS.6.2 - There are directive signs posted as appropriate in the hospital and include:
FMS.6.2.1 Signs indicating the hospital name and main entrances/exits.
FMS.6.2.2 Directional signs.
FMS.6.2.3 Signs to direct staff and patients to the different services in the hospital.
FMS.6.2.4 Fire exit signs.
FMS.6.2.5 Signs to identify floor level at staircases and in front of elevators.
FMS.6.2.6 Signs to instruct staff, patients, and visitors in restricted areas.
FMS.6.2.7 MRI patient safety measures and steel restriction signs.
FMS.6.2.8 Signs for populations with special needs.
Fully Met
FMS.7 - The hospital is equipped for vulnerable individuals and others with special needs. 
  ( Fully Met )

FMS.7.1 - The hospital is equipped with special parking spots.

Fully Met

FMS.7.2 - The hospital is equipped with wheel chairs and relevant ramps are in all elevated areas.

Fully Met

FMS.7.3 - The hospital is equipped with handrails in the corridors and stairs.

Partially Met
Activity Comment

Observation The hospital was not equipped with handrails in some corridors. Other corridors with handrails were obstructed by seating chairs.
1126150

FMS.7.4 - The hospital is child safe in the public areas (tamper free outlets, no sharp ends).

Fully Met

FMS.8 - Safety measures and equipment are applied where needed in the hospital to ensure safety of patients and staff. 
  ( Partially Met )

FMS.8.1 - The patients bathrooms and showers are provided with the following safety measures:

FMS.8.1.1 Non-slipping floors’ surfaces.

FMS.8.1.2 Bars to support patients.
FMS.8.1.3 Bell or a system to call for help.
FMS.8.1.4 Lock system that allows opening from outside.
Not Met
Activity Comment

Observation The patients bathrooms floors were slippery and had no safety bars or patient alarms, and the locks were not opening from out
side in case patient locked himself inside. patients room were not equipped with calling bell.
1123326

Observation The patients bathrooms and showers were not provided with the following safety measures: - Bars at shower area (male
inpatient ward) - Nurse call (male patient ward)
1126060

Staff The patients bathrooms and showers were not provided with the following safety measures: - Bars at shower area (male
Interview inpatient ward) - Nurse call (male patient ward)
1126068

FMS.8.2 - The kitchen has safety equipment that include:

FMS.8.2.1 Eye wash stations.
FMS.8.2.2 Fire blankets.
FMS.8.2.3 First aid kit.
FMS.8.2.4 Fire Extinguishers.
FMS.8.2.5 Emergency shut off valve for liquid propane gas.
FMS.8.2.6 Emergency shower.
Fully Met
FMS.8.3 - The laundry has safety equipment that include:
FMS.8.3.1 Eye wash stations.
FMS.8.3.2 Fire blankets.
FMS.8.3.3 First aid kit.
FMS.8.3.4 Fire Extinguishers.
FMS.8.3.5 Emergency shower.
N/A
FMS.8.4 - The Laboratory has safety equipment that include:
FMS.8.4.1 Eye wash stations.
FMS.8.4.2 Fire blankets.
FMS.8.4.3 First aid kit.
FMS.8.4.4 Fire extinguishers.
FMS.8.4.5 Emergency shower.
FMS.8.4.6 Fire resistant safety cabinets for laboratory chemicals.
Fully Met
FMS.9 - The hospital ensures that all its occupants are safe from radiation hazards. 
  ( Fully Met )

FMS.9.1 - The hospital has a radiation safety policy and procedure and it is implemented.

Partially Met
Activity Comment

Document Review The policy was lacking proper references and definitions. There was no list of exposure limits as per ICRP.
1125893

FMS.9.2 - All radio-active materials are clearly labeled and safely and securely stored.
 N/A

FMS.9.3 - The hospital has the relevant valid license(s) from King Abdulaziz City for Science and Technology.

N/A

FMS.9.4 - Staff handling nuclear materials are qualified and certified by King Abdul-Aziz City for Science and Technology.

N/A

FMS.9.5 - There is a valid shielding certificate of the x-ray room(s) including regular test to ensure permissible radiation levels.

Fully Met

FMS.9.6 - Lead aprons and gonad/thyroid shields are available to cover patients and staff needs and are annually tested according to a hospital-wide inventory.

Fully Met

FMS.9.7 - Personal radiation dosimeters (TLD cards) are available, tested every 3 months, and actions taken when test results exceed permissible levels.

Fully Met

FMS.10 - Patients and staff are protected from unnecessary exposure to laser beams in areas where it is used. 
  ( N/A )
FMS.10.1 - There are laser warning signs at all areas where the laser is used.

N/A

FMS.10.2 - Laser is performed in rooms that do not have refractive surfaces such as glass and mirrors.

N/A

FMS.10.3 - Staff working or assisting in laser procedures are provided with protective eye goggles appropriate to the wavelength used.

N/A

FMS.10.4 - Laser safety manuals are available for the concerned staff.

N/A

FMS.11 - The hospital environment is secure for patients, visitors, and staff. 
  ( Fully Met )

FMS.11.1 - There are identification badges for the following staff categories:

FMS.11.1.1 Hospital staff.
FMS.11.1.2 Temporary employees.
FMS.11.1.3 Contractor staff.
Fully Met
FMS.11.2 - Security personnel or alternative security systems are utilized to restrict access to sensitive areas that include, but are not limited to, the following:
FMS.11.2.1 Delivery room.
FMS.11.2.2 Neonatal intensive care unit.
FMS.11.2.3 Nursery.
FMS.11.2.4 Female wards.
FMS.11.2.5 Operating room.
FMS.11.2.6 Central sterilization service department.
FMS.11.2.7 Morgue.
FMS.11.2.8 Medical records.
FMS.11.2.9 Hospital roof.
FMS.11.2.10 Medical equipment and goods stores including pharmacy narcotic vault.
Fully Met
FMS.11.3 - There are policies and procedures for the following:
FMS.11.3.1 Preventing children and neonates abduction.
FMS.11.3.2 Lost and found items.
FMS.11.3.3 Safe keeping of patient belongings.
FMS.11.3.4 Involvement of police in cases of trauma, motor vehicle accidents, and medico-legal incidents.
FMS.11.3.5 Incidents of violence (violence code).
FMS.11.3.6 Women and child abuse.
Fully Met
FMS.11.4 - Staff are trained on response to all security alerts.
Fully Met
FMS.12 - The hospital has a mechanism to deal with a bomb threat. 
  ( Fully Met )

FMS.12.1 - There is a written policy on how to deal with a bomb threat in the hospital which includes:

FMS.12.1.1 Defining the code or alert.

FMS.12.1.2 Defining the role of the person receiving threat alerts.
 FMS.12.1.3 Defining the response team including the individual responsible for announcing the emergency status and contacting the local authorities.
FMS.12.1.4 Defining the duties and the responsibilities of all staff involved and their action cards.
FMS.12.1.5 The command center location.
FMS.12.1.6 Defining the steps to be taken during the bomb threat.
Fully Met
FMS.12.2 - Staff are trained on response to bomb threat alerts.
Fully Met
FMS.13 - The hospital has qualified individuals assigned to maintain security. 
  ( Partially Met )

FMS.13.1 - The number of security personnel is proportional to the size of the hospital, number of entrances, and the availability of supporting security systems.

Fully Met

FMS.13.2 - The security personnel have written job descriptions.

Not Met
Activity Comment

Personnel File Review The security personnel did not have written job descriptions.
1126093

FMS.13.3 - The security personnel receive orientation about:

FMS.13.3.1 Scope of work and job description.

FMS.13.3.2 Emergency codes.
FMS.13.3.3 Fire safety.
Not Met
Activity Comment

Staff Interview The security personnel did not receive hospital orientation.
1126074

Personnel File Review The security personnel did not receive hospital orientation.
1126094

FMS.13.4 - The security personnel roles are clearly defined for the following:
FMS.13.4.1 External disaster plan.
FMS.13.4.2 Internal disaster plan.
FMS.13.4.3 No smoking policy.
Fully Met
FMS.13.5 - The security personnel have a dress code.
Fully Met
FMS.13.6 - The security personnel conduct hospital wide security rounds and significant findings are documented.
Fully Met
FMS.14 - The hospital ensures safe management of hazardous materials. 
  ( Partially Met )

FMS.14.1 - There is a written hazardous materials plan that includes the following:

FMS.14.1.1 Appropriate handling, storing, transporting, and disposing of hazardous materials.

FMS.14.1.2 Education and training on signs and symptoms of exposure to hazardous materials and the appropriate treatment according to Material Safety Data Sheets
(MSDS).
Fully Met
FMS.14.2 - Each department has a current list of hazardous materials used in the department. The list covers:
FMS.14.2.1 Purpose of use.
FMS.14.2.2 The responsible person.
FMS.14.2.3 Permitted quantity.
Partially Met
Activity Comment

Document Evidence There were no hazardous materials list in place.

1126868

FMS.14.3 - Each department dealing with hazardous materials has Material Safety Data Sheets (MSDS) relevant to its current list of hazardous materials.
Fully Met
FMS.14.4 - Each department using hazardous materials has proper personal protective equipment (PPE) and spill kits to handle any spill or exposure.
Fully Met
FMS.14.5 - All hazardous materials are labeled clearly and this includes:
FMS.14.5.1 Anti-neoplastic drugs.
FMS.14.5.2 Radioactive materials.
FMS.14.5.3 Corrosives, acids, and toxic materials.
FMS.14.5.4 Hazardous gases and vapors.
FMS.14.5.5 Anesthetic gases.
FMS.14.5.6 Flammable liquids.
Partially Met
Activity Comment

Observation The majority of hazardous materials were lacking proper labeling as per hospital hazmat management plan.
1126157

FMS.14.6 - Any leak, spill, or exposure to any hazardous material is reported.

Partially Met
Activity Comment
 Document Review There was no chemical spills to be documented.
1122694

Document Review No records of hazmat leak, spill, drill or exposure incident was presented..
1125930

FMS.15 - The hospital implements a waste management plan. 

  ( Fully Met )

FMS.15.1 - The hospital has a waste management plan that includes handling, storing, transporting, and disposing all kinds of waste (e.g., clinical waste, radioactive waste, and
hazardous gases).

Fully Met

FMS.15.2 - The plan is implemented.

Fully Met

FMS.15.3 - Staff (including contractors’ staff) are trained on dealing with hazardous waste.

Partially Met
Activity Comment

Personnel File Only 60% of reviewed personnel files for staff and contractors had evidence on were trained on dealing with hazardous
Review waste.
1121126
 Personnel File There were no specific checklists to ensure addressing all required elements in safety and infection control. However, there
Review was only infection control certificate.
1126954

FMS.16 - The hospital ensures preparedness for external disasters. 

  ( Fully Met )

FMS.16.1 - The hospital has a plan to deal with potential external disasters. The plan includes:

FMS.16.1.1 Identification of all potential external emergencies and disasters.

FMS.16.1.2 Names and titles of all staff to be called including their contact numbers and action cards.
FMS.16.1.3 Duties and responsibilities of hospital leaders.
FMS.16.1.4 The triage areas, their locations, and triage action cards.
FMS.16.1.5 The individual responsible for announcing the emergency state and contacting the local authority.
FMS.16.1.6 The control room location and the person in charge.
FMS.16.1.7 The total number of beds that can be evacuated.
FMS.16.1.8 The role of the security personnel.
FMS.16.1.9 The role of each department in the hospital.
Fully Met
FMS.16.2 - The hospital conducts an external disaster drill at least annually.
Fully Met
FMS.16.3 - The hospital ensures the availability of ambulances and medical supplies and equipment required in case of external disasters (e.g., medical bags, drugs and mobile
monitors).
Fully Met
FMS.16.4 - There is an orientation on the external disaster plan for new hires with an annual update for all staff.
Fully Met
FMS.17 - The hospital ensures preparedness for internal disasters. 
  ( Not Met )

FMS.17.1 - The hospital has a plan to deal with potential internal disasters. The plan includes:

FMS.17.1.1 Names and titles of all staff to be called in case of internal disaster, their contact numbers, and action cards.
FMS.17.1.2 The control room location and the position of the individual in charge.
FMS.17.1.3 The duties and responsibilities of hospital leaders.
FMS.17.1.4 The procedure for relocation of patients.
FMS.17.1.5 The individual responsible for announcing the emergency state and contacting local authority.
FMS.17.1.6 Individual(s) authorized to deal with the electricity supply and medical gas system and to shut them off as needed in case of fire or explosions in the hospital.
FMS.17.1.7 The meeting point for the staff in case of horizontal evacuations (assembly points) inside the building.
FMS.17.1.8 The meeting point for the full evacuation (holding area) outside the building.
FMS.17.1.9 The evacuation procedure for patients, visitors, and employees.
Fully Met
FMS.17.2 - Every department has a specific internal disaster plan that addresses departmental actions in case internal disasters.
Not Met
Activity Comment

Document Review There was no specific internal disaster plan for Laboratory and Kitchen.
1125933

Document Review There was no departmental actions in case of internal disaster.

1126909

Staff Interview There was no specific internal disaster plan for ICU, Kitchen, and laboratory.
1126111

Staff Interview All staff were not able to describe departmental actions in case of internal disaster.
 1126908

Document Evidence There was no departmental actions in case of internal disaster.

1127204

FMS.17.3 - There are evacuation maps posted hospital wide indicating locations of:
FMS.17.3.1 You are here.
FMS.17.3.2 Fire extinguishers.
FMS.17.3.3 Fire hose reel/cabinets.
FMS.17.3.4 Fire blankets.
FMS.17.3.5 Escape routes.
FMS.17.3.6 Assembly points.
FMS.17.3.7 Fire exits.
FMS.17.3.8 Call points break glass/pull station.
FMS.17.3.9 Medical gas isolation valves.
Not Met
Activity Comment

Observation The evacuation maps posted hospital wide were not matching the existing floor layout.
1126163

FMS.18 - The hospital has a system for scheduling and conducting fire drills regularly. 
  ( Partially Met )

FMS.18.1 - Fire drills are scheduled and conducted regularly in all departments.

Fully Met
FMS.18.2 - Fire drills are conducted during different shifts to test:

FMS.18.2.1 Using Rescue, Alarm, Confine, Extinguish/Evacuate (RACE) procedure.

FMS.18.2.2 Using Pull, Aim, Squeeze, Sweep (PASS) procedure.
FMS.18.2.3 The ability to contain the fire when it starts.
FMS.18.2.4 Staff performance in the event of fire.
FMS.18.2.5 Evacuation procedures.
FMS.18.2.6 Whether the oxygen and electricity supplies were shut off at the right time.
Partially Met
Activity Comment

Document Evidence There was no evidence for conducting drills for each shift.
1125934

FMS.18.3 - All staff participate in the fire drills.

Partially Met
Activity Comment

Document Evidence Staff participation in the fire drills was not properly documented to show the involvement of all staff in each unit per drill.
1125935

FMS.18.4 - All fire drills’ results and corrective actions are documented and integrated into the quality improvement program.
Partially Met
Activity Comment

Document Review Fire drills results were not utilized for corrective actions.
1125936

FMS.18.5 - A full fire drill is conducted for the internal disaster plan once a year and this drill is evaluated.
Fully Met
FMS.19 - The hospital supports fire prevention. 
  ( Not Met )

FMS.19.1 - The hospital ensures procuring materials like curtains and drapes that are fire retardant.

Not Met
Activity Comment

Document Review There was no document for procuring materials like curtains and drapes that are fire retardant.
1125900

FMS.19.2 - The hospital ensures separating all dangerous materials or flammables from heat generating areas.

Fully Met

FMS.19.3 - The hospital ensures installing fire rated walls as appropriate, especially in high risk areas like the laboratory, electrical rooms, and kitchen.

Not Met
Activity Comment

Document The fire zones were not designated or properly identified in the hospital, therefore, fire rated walls could not be properly
Review evaluated.
1125901

Observation The fire zones were not designated or properly identified in the hospital, therefore, fire rated walls could not be properly
evaluated.
1126165
FMS.19.4 - The hospital ensures installing fire stop materials to seal penetrations as appropriate (especially in technical rooms, electrical rooms, and escape routes).

Not Met
Activity Comment

Observatio The hospital did not install fire stop materials to seal penetrations as appropriate (especially in technical rooms, electrical rooms,
n and escape routes).
1126166

FMS.19.5 - The hospital ensures developing and scheduling staff training programs on the use of fire extinguishers.

Fully Met

FMS.20 - Fire extinguishers are available in the hospital and are properly distributed. 
  ( Fully Met )

FMS.20.1 - The fire extinguishers are adequate in number as per civil defense guidelines.

Fully Met

FMS.20.2 - The fire extinguishers are appropriately distributed throughout the hospital.

Fully Met

FMS.20.3 - The fire extinguishers are appropriately positioned as per civil defense guidelines.
Fully Met

FMS.20.4 - The fire extinguishers are inspected monthly to assess functionality.

Fully Met

FMS.21 - The hospital has an effective fire alarm system. 

  ( Not Met )

FMS.21.1 - There is a fire alarm system that is functioning and regularly inspected as per civil defense guidelines.

Not Met
Activity Comment

Observation There was a fire alarm system under installation during CBAHI survey.
1125904

Document Evidence There was a fire alarm system under installation during CBAHI survey.
1125905

FMS.21.2 - The fire alarm system testing results are documented.

Not Met
Activity Comment

Document Evidence There was a fire alarm system under installation during CBAHI survey.
1125908

FMS.21.3 - The fire alarm system has preventive maintenance.

Not Met
Activity Comment

Document Evidence There was a fire alarm system under installation during CBAHI survey.
1125909

FMS.21.4 - The elevators are connected to the fire alarm system.

Not Met
Activity Comment

Document Review The elevators were not connected to the fire alarm system.
1125914

Observation The elevators were not connected to the fire alarm system.
1125915

FMS.22 - The hospital has a fire suppression system available in the required area(s). 
  ( Partially Met )

FMS.22.1 - The hospital has a functional sprinkler system.

Not Met
Activity Comment

Observation The sprinkler system was under commissioning. The fire pump was not connected to emergency generator.
1126003

Document Evidence The sprinkler system was under commissioning. The fire pump was not connected to emergency generator.
1125910

FMS.22.2 - The hospital has clean agent suppression system.

Partially Met
Activity Comment

Observation The hospital did not have clean agent suppression system at Medical Record.
1125912

Document Evidence The hospital did not have clean agent suppression system at Medical Record.
1125911
FMS.22.3 - The hospital has wet chemical system.

Fully Met

FMS.22.4 - The hospital has stand pipes and hose system.

Partially Met
Activity Comment

Observation The hose system was functional thought the fire pump was not connected to emergency generator.
1126005

Document Evidence The hose system was lacking checking tag.

1125916

FMS.23 - There are fire exits that are properly located in the hospital. 
  ( Not Met )

FMS.23.1 - Fire exits are available and are properly located in the hospital.

Partially Met
Activity Comment

Observation Fire exits were not properly located in the hospital due to lack of designated fire zones.
 1126006

FMS.23.2 - Fire exits are not locked.

Partially Met
Activity Comment

Observation Fire exits were found locked at OPD.

1126007

FMS.23.3 - Fire exits are not obstructed.

Partially Met
Activity Comment

Observation Fire exits were found obstructed at ICU.

1126009

FMS.23.4 - Fire exits have panic hard ware.

Partially Met
Activity Comment

Observation Fire exits did not have panic hard ware at ICU.
1126008
FMS.23.5 - Fire exits are fire resistant.

N/A

FMS.23.6 - Fire exits are clearly marked with illuminated exit sign.

Not Met
Activity Comment

Observation Fire exits were not clearly marked with illuminated exit sign.
1126010

FMS.24 - The hospital and its occupants are safe from fire and smoke. 
  ( Partially Met )

FMS.24.1 - The hospital implements a strict “No Smoking” policy.

Fully Met

FMS.24.2 - There are no obstructions to exits, fire extinguishers, fire alarm boxes, emergency blankets, safety showers, and eye wash stations.

Fully Met

FMS.24.3 - Emergency lighting is adequate for safe evacuation of the hospital.

Fully Met

FMS.24.4 - Storage areas are properly and safely organized:

FMS.24.4.1 Shelves and racks are sturdy and in good condition.

FMS.24.4.2 No items stored directly on the floor (a minimum of ten centimeters is left to manage spills).
FMS.24.4.3 Items should be stacked on a flat base.
FMS.24.4.4 Heavier objects are close to the floor and lighter/smaller objects are higher.
FMS.24.4.5 Items are not stacked so high to block sprinklers or come in contact with overhead lights or pipes (a minimum distance of fifty centimeters from ceiling level)
Partially Met
Activity Comment

Observatio Storage areas were not properly and safely organized at laboratory, pharmacy store, and technical workshops (biomedical &
n utility).
1126013

FMS.24.5 - Fire rated doors are available according to the hospital zones with no separation between walls and ceiling to prevent smoke spread between rooms and areas.
Not Met
Activity Comment

Observation Fire rated doors were not properly located due to lack of designated fire zones.
1126014

FMS.25 - The hospital has a biomedical equipment plan to ensure that the medical equipment are regularly monitored, maintained, and ready for use. 
  ( Not Met )

FMS.25.1 - The hospital has adequate number of qualified biomedical staff.

Partially Met
Activity Comment

Staff Interview The department was in lack of administrative staff.

1126113

Document Evidence Due to the load of medical gas system, the hospital was lacking at least 2 certified medical gas technicians.
1125938

FMS.25.2 - There is a written biomedical equipment plan that covers the following:

FMS.25.2.1 A comprehensive inventory of medical equipment with their corresponding locations.

FMS.25.2.2 Preventive maintenance program that conforms with the manufacturer’s instructions.
FMS.25.2.3 The program specifies, for each equipment, the frequency of checks, methods of checks, acceptance criteria, and actions to be taken in the event of
unsatisfactory results.
FMS.25.2.4 The program includes the process for investigation and follow-up of equipment failure that addresses reporting of failure, immediate remedial actions,
assessment of the failure effect on reported results and services (needs alignment), and requalification of the equipment.
FMS.25.2.5 Electrical safety testing for patient related equipment.
FMS.25.2.6 History record for the maintenance schedule, failure incidence, and repairs done.
Partially Met
Activity Comment

Document The plan was lacking specific measurable objectives.

Review
1125961

Observation The equipment file was not properly documented to reserve the maintenance history. Some test equipment were lacking
valid calibration.
1126170
 Staff Interview The plan was in lack of specific measurable objectives.
1126114

FMS.25.3 - Technical service manuals for all equipment are available at the biomedical workshops.
Fully Met
FMS.25.4 - Operator manuals are available at all departments using the equipment.
Fully Met
FMS.25.5 - The hospital ensures that all maintenance works are conducted by qualified and trained staff.
Partially Met
Activity Comment

Personnel File Although biomedical engineers were found qualified and competent, they did not have License from Saudi Council for
Review Engineers.
1126099

FMS.25.6 - Equipment maintenance and repairs are documented to help in the decision making for replacement.
Not Met
Activity Comment

Document Evidence Equipment maintenance and repairs were not documented to help in the decision making for replacement.
1125962

FMS.25.7 - Investigation procedures conform to manufacturer’s instructions.

Partially Met
Activity Comment

Document Evidence There was no annual certification test for Biological Safety Cabinets.
1125939
FMS.25.8 - There is an equipment recall system that is implemented.
Not Met
Activity Comment

Observation There was no equipment recall system.

1126116

Staff Interview There was no equipment recall system.

1126115

Personnel File Review There was no equipment recall system.

1126098

FMS.25.9 - Each department has a back-up or alternative for each critical equipment to cover for prolonged downtime.
Not Met
Activity Comment

Document Review The hospital was in lack of back-up or alternative for defibrillators, ventilators, and anesthesia machines.
1125963

Observation The hospital was in lack of back-up or alternative for defibrillators, ventilators, and anesthesia machines.
1126173

Observation There were no back-up equipment specially for high risk equipment such as chemistry and hematology.
1126907

FMS.25.10 - Preventative Maintenance data are used for upgrading/replacing of equipment.

Not Met
Activity Comment
 Document Review Maintenance data were not used for upgrading/replacing of equipment.
1125940

FMS.26 - The hospital has policies and procedures that support the medical equipment management program. 
  ( Fully Met )

FMS.26.1 - There is a policy to perform inspection on all new equipment for conformity before commissioning including those brought for "demos".

Fully Met

FMS.26.2 - There is a written policy for tagging medical equipment as follows:

FMS.26.2.1 Preventive maintenance with testing date and due date.

FMS.26.2.2 Inventory number.
FMS.26.2.3 Removal from service.
FMS.26.2.4 Electrical safety check.
Fully Met
FMS.26.3 - There is a policy for removal of equipment from service.
Partially Met
Activity Comment

Document Review There is a policy for removal of equipment from service that was lacking detailed procedure.
1125943

FMS.26.4 - There is a policy to address agent or contractor repairs.

Fully Met
FMS.26.5 - There is a policy to eliminate the use of extension cords.
Fully Met
FMS.26.6 - There is a policy to restrict the use of cellular phones in the intensive care units, operating room, and cardiology units, as needed.
Fully Met
FMS.27 - Hospital staff are trained on safe operation of medical equipment. 
  ( Partially Met )

FMS.27.1 - Hospital staff are trained to operate safely all medical equipment.

Partially Met
Activity Comment

Staff Interview Out of 8 medical staff interviewed, none received training to operate safely medical equipment. The interviewed 12 nursing
staff, however, said that they received the necessary training.
1125687

Staff Interview There was no training for physicians to operate safely medical equipment.
1126117

Document There was no training for physicians to operate safely medical equipment.
Evidence
1126178

Document No document provided for training and competency assessment records on newly acquired equipment or method.
Evidence
1126933
 Document There was a documented attendance of training for nurses, but none for physicians
Evidence
1125513

FMS.27.2 - The training includes physicians, nurses, and paramedics.

Partially Met
Activity Comment

Staff Interview The training included nurses only.

1125688

Staff Interview The training did not include physicians.

1126118

FMS.27.3 - The training considers the following:

FMS.27.3.1 New equipment.
FMS.27.3.2 Staff transferred from a department to another.
FMS.27.3.3 New staff hired.
FMS.27.3.4 Recurrent misuse of equipment.
Fully Met
FMS.28 - The hospital has a utility system management plan. 
  ( Not Met )
FMS.28.1 - The hospital has adequate number of qualified staff to manage the utility system.

Partially Met
Activity Comment

Staff Interview The hospital did not have adequate number of qualified staff to manage the utility system. The hospital was in need to at
least 3 technicians.
1126119

Personnel File The hospital did not have adequate number of qualified staff to manage the utility system. The hospital was in need to at
Review least 3 technicians.
1126100

FMS.28.2 - There is a utility system management plan that includes management of failure or interruption of the following utilities:

FMS.28.2.1 Normal power.
FMS.28.2.2 Emergency power, cases of no power at sockets at critical areas, and lamp failure at critical areas.
FMS.28.2.3 Elevators.
FMS.28.2.4 Water supply.
FMS.28.2.5 Reverse osmosis plant.
FMS.28.2.6 Air-conditioning fan coil unit (FCU) at patient rooms.
FMS.28.2.7 Air-conditioning air handling unit (AHU) at operating rooms.
FMS.28.2.8 Medical gas system.
FMS.28.2.9 Sewer lines.
FMS.28.2.10 Boiler.
FMS.28.2.11 Telephone service (Public Address Exchange - PABX).
FMS.28.2.12 Intercom, nurse call, and overhead paging.
FMS.28.2.13 Fire alarm.
Not Met
Activity Comment
 Document The mitigation actions were described as of normal corrective maintenance. There was no risk assessment process for each
Review system in order to evaluate the appropriate response per failure impact.
1126184

FMS.28.3 - The utility system management plan includes description of necessary hospital programs to:
FMS.28.3.1 Acquire necessary equipment.
FMS.28.3.2 Upgrade equipment.
FMS.28.3.3 Upgrade physical condition of the building.
Not Met
Activity Comment

Document The utility system management plan did not include description of necessary hospital programs.
Review
1125949

Observation Fire pump was not connected to emergency generator. Emergency generators were too aged. AC split units were the majority
that lack humidity control and improperly maintained.
1126139

FMS.28.4 - Emergency plans are tested in simulation at least once a year and the test results are evaluated.
Not Met
Activity Comment

Staff Interview Utility systems emergency plans were not tested in simulation at least once a year.
1126120

Document Evidence Utility systems emergency plans were not tested in simulation at least once a year.
1125948

FMS.28.5 - The utility system plan ensures the availability of the following:
 FMS.28.5.1 Technical utility drawings that show the distribution lines for all utilities and how to control them centrally and peripherally so that lines can be controlled as
required in case of emergency.
FMS.28.5.2 Statistical data produced by the maintenance management system as an indicator to evaluate performance of the systems, suggest improvements and upgrade
required.
Not Met
Activity Comment

Document Review There was no technical utility drawing, in addition to the lack of statistical data.
1125951

Observation There was no technical utility drawing.

1126180

FMS.29 - The hospital implements a preventive maintenance plan. 

  ( Partially Met )

FMS.29.1 - There is a preventive maintenance plan that covers at least the following:

FMS.29.1.1 Electrical system.
FMS.29.1.2 Elevators.
FMS.29.1.3 Refrigerators/Freezers.
FMS.29.1.4 Air conditioning system.
FMS.29.1.5 Medical gas system.
FMS.29.1.6 Medical suction.
FMS.29.1.7 Domestic water system, including water pumps and fire hydrants.
FMS.29.1.8 Fire water system, including fire pumps.
FMS.29.1.9 Boilers.
FMS.29.1.10 Plumbing.
FMS.29.1.11 Low current and communication system.
FMS.29.1.12 Pavement and ground.
 FMS.29.1.13 Hospital building and ancillaries.
Fully Met
FMS.29.2 - The hospital ensures all maintenance works are conducted by qualified and trained staff.
Partially Met
Activity Comment

Staff Interview HVAC technicians did not demonstrate adequate knowledge.

1126122

Personnel File Review HVAC technicians did not have adequate knowledge.
1126121

FMS.30 - The hospital ensures electrical safety. 

  ( Not Met )

FMS.30.1 - The electrical outlets are identified for:

FMS.30.1.1 Voltage (110/220).
FMS.30.1.2 Source (essential/prime).
Partially Met
Activity Comment

Observation The electrical outlets were not identified for source (essential/primary).
1126179

FMS.30.2 - Thermal inspection of circuit breakers is annually conducted for:

FMS.30.2.1 Operating Room.
FMS.30.2.2 Laboratory.
 FMS.30.2.3 Critical care units.
FMS.30.2.4 Alarm system.
FMS.30.2.5 Blood storage.
FMS.30.2.6 Medical gas system.
Not Met
Activity Comment

Observation There was no evidence of conducting thermal inspection of circuit breakers.

1126181

Document Evidence There was no evidence of conducting thermal inspection of circuit breakers.
1125953

FMS.30.3 - There is an earthing system in the roof top and sockets used for medical equipment.
Not Met
Activity Comment

Observation There was no earthing system in the roof top.

1126182

FMS.31 - The hospital ensures that emergency power covers the critical areas in case of failure. 
  ( Not Met )

FMS.31.1 - The hospital has an emergency power that covers at least the following critical areas:

FMS.31.1.1 Operating room.
FMS.31.1.2 Labor and delivery.
FMS.31.1.3 Critical care units.
FMS.31.1.4 Alarm system.
 FMS.31.1.5 Fire pumps
FMS.31.1.6 Blood storage.
FMS.31.1.7 Medical gas system.
FMS.31.1.8 Refrigerators in the pharmacy, laboratory, medical store, and kitchen.
FMS.31.1.9 Elevators.
FMS.31.1.10 Escape routes/corridors.
FMS.31.1.11 Morgue.
FMS.31.1.12 Medications stores.
FMS.31.1.13 Emergency room.
Not Met
Activity Comment

Document Review There was no single line diagram that shows the emergency power distribution to the required areas.
1125954

Environmental Safety The committee members have demonstrated well awareness of the emergency power requirement, however there
Committee was no evidence of emergency power coverage to all required critical areas.
1125982

FMS.31.2 - The hospital ensures the readiness of its emergency power generator(s).
FMS.31.2.1 The hospital maintains its generator(s) on a periodic basis. The maintenance results are documented.
FMS.31.2.2 The hospital performs weekly test without load for ten minutes.
FMS.31.2.3 The hospital performs monthly on load test for thirty minutes.
FMS.31.2.4 The hospital performs full load test every three years on external load.
FMS.31.2.5 The hospital generator starts normally without load for ten minutes.
Partially Met
Activity Comment

Observation Generator rooms were not clean. There was no Protective Equipment.
1126140

Document Evidence Inspection reports were lacking measurable data. In addition, there was no evidence of conducting the external load test.
 1125950

FMS.32 - The hospital ensures proper maintenance of the medical gas system. 
  ( Partially Met )

FMS.32.1 - The medical gas system is regularly tested for:

FMS.32.1.1 Pressure.
FMS.32.1.2 Leaks.
FMS.32.1.3 Functionality of valves, alarms, pressure gauge, and switches.
Not Met
Activity Comment

Document Evidence The medical gas system was not regularly tested for pressure and leaks.
1126015

FMS.32.2 - There is a policy and procedure that ensures effective use of medical gas system. Areas covered include, but are not limited to, the following:
FMS.32.2.1 The procedures to follow for taking any part of the system offline.
FMS.32.2.2 Commissioning and testing new branching or modifications.
FMS.32.2.3 The procedure for ordering and filling liquid oxygen.
FMS.32.2.4 Documenting all repairs/alterations/tests/filling logs/consumption.
Fully Met
FMS.32.3 - Compressed medical air is regularly tested for humidity and purity.
Not Met
Activity Comment

Document Evidence Compressed medical air was not regularly tested for humidity and purity.
 1126016

FMS.32.4 - The central medical gas station is in a safe and secure place.
Not Met
Activity Comment

Observatio The central medical gas station was lacking proper maintenance as the manifold control monitor was defective. The manifold was
n the primary supply of medical gas. There was no temperature monitoring of manifold or reserve room. There was No hazmat
labeling.
1125969

FMS.32.5 - The outlets of medical gases in patient care areas are clearly marked with the type of gas and have different connections according to the gas type.
Fully Met
FMS.32.6 - All medical gas pipes are clearly marked and labeled for the contents and direction of gas flow.
Partially Met
Activity Comment

Observation All medical gas pipes were not clearly marked and labeled for the contents and direction of gas flow at manifold room.
1125970

FMS.32.7 - In case of gas pipe repairs or new extensions, outlets are tested for the type of gas to ensure the correct type is delivered through the new pipe. Results of testing are
recorded and maintained with engineering and the unit manager.
N/A
FMS.32.8 - The hospital keeps standby oxygen and medical air cylinders enough for forty eight hours of average consumption.
Not Met
Activity Comment

Observation The daily consumption data were not monitored or recorded. There was no proper estimation of standby oxygen and medical
air.
1125971
 Staff There was no certified/qualified medical gas technician in the hospital. There was lacking of proper estimation for standby
Interview oxygen and medical air.
1125972

FMS.32.9 - The gas cylinders are regularly tested for gas type, amount, and any leaks.
Fully Met
FMS.32.10 - Emergency shut off valves are available in all units and are clearly marked with areas/rooms affected.
Fully Met
FMS.32.11 - The hospital dedicates the responsibility of the closure of shut off valves to well-trained individual(s) available in the unit concerned.
Fully Met
FMS.32.12 - The hospital has adequate medical gases outlets in the patient care areas as appropriate and these outlets are to be error proof medical gas outlets- preferred to be in
accordance with DIN standards related to gases piping, outlets and valves.
Partially Met
Activity Comment

Observation The hospital did not have adequate medical gases outlets in the ICU.
1125975

FMS.33 - The hospital has a documented system for handling the various types of compressed gasses. 
  ( Not Met )

FMS.33.1 - There is a policy on how to handle various types of compressed gasses, which includes:

FMS.33.1.1 Storing them in a well-ventilated area.

FMS.33.1.2 Positioning them upright the wall and secured by a chain.
FMS.33.1.3 Separating any flammables from oxidizing gases.
Partially Met
Activity Comment

Observation There was group of large size cylinders chained together.

1126183

FMS.33.2 - Exhausts of the following gases are extended to the roof and identified:
FMS.33.2.1 Laboratory safety cabinet gases of a certain classes.
FMS.33.2.2 Central vacuum gases.
FMS.33.2.3 Scavenger gases of certain types.
FMS.33.2.4 Bone marrow transplantation (BMT) laboratory gases.
Not Met
Activity Comment

Observation All exhausts on the roof were not properly identified.

1126185

FMS.34 - There is a periodic preventive maintenance plan for heating, ventilating, and air- conditioning. 
  ( Partially Met )

FMS.34.1 - There is a periodic preventive maintenance (PPM) plan for heating, ventilating, and air-conditioning (HVAC) that is supported by trained and specialized
staff/contractor.

Partially Met
Activity Comment

Document Review HVAC maintenance staff were lacking essential competencies and technical knowledge. Specialized trainings is highly
advised.
1126103
 Personnel File HVAC maintenance staff were lacking essential competencies and technical knowledge. Specialized trainings is highly
Review advised.
1126101

FMS.34.2 - The HVAC maintenance records are maintained.

Fully Met

FMS.34.3 - The HVAC is maintained to control the air quality by:

FMS.34.3.1 Cleaning /replacement of filters.

FMS.34.3.2 Cleaning of diffuser.
FMS.34.3.3 Cleaning of ducts.
Partially Met
Activity Comment

Observation AC split units were lacking proper maintenance on the roof.

1126186

FMS.34.4 - HEPA filters are monitored on a monthly basis and the results are documented.
Fully Met
FMS.34.5 - Air change per hour is maintained as per national and international guidelines (e.g., American Society of Heating, Refrigerating & Air-Conditioning Engineers,
ASHRAE).
Partially Met
Activity Comment

Staff Air change per hour was not maintained as per national and international guidelines for most areas in the hospital such as
Interview Laboratory, labor and delivery, and CSSD.
 1126124

FMS.35 - The hospital ensures proper air flows (positive, negative, balanced) in the required locations. 
  ( Not Met )

FMS.35.1 - Appropriate air flows (positive, negative, balanced) are established and monitored in operating room(s).

Fully Met

FMS.35.2 - Appropriate air flows (positive, negative, balanced) are established and monitored in labor and delivery.

Not Met
Activity Comment

Observation Appropriate air flows (positive, negative, balanced) were not established and monitored in labor and delivery.
1126189

Staff Interview Utility manager/Engineer was not aware of above areas air flow requirements (ASHRAE).
1126191

Document Evidence Appropriate air flows (positive, negative, balanced) were not established and monitored in labor and delivery.
1126190

FMS.35.3 - Appropriate air flows (positive, negative, balanced) are established and monitored in isolation room(s).
Fully Met

FMS.35.4 - Appropriate air flows (positive, negative, balanced) are established and monitored in critical care unit(s).

Fully Met

FMS.35.5 - Appropriate air flows (positive, negative, balanced) are established and monitored in clean and dirty utility.

Not Met
Activity Comment

Observation Appropriate air flows (positive, negative, balanced) were not established and monitored in clean and dirty utility.
1126128

Staff Interview Appropriate air flows (positive, negative, balanced) were not established and monitored in clean and dirty utility.
1126127

Document Evidence Appropriate air flows (positive, negative, balanced) were not established and monitored in clean and dirty utility.
1126129

FMS.35.6 - Appropriate air flows (positive, negative, balanced) are established and monitored in janitorial closet.

Not Met
Activity Comment

Observation Appropriate air flows (positive, negative, balanced) were not established and monitored in janitorial closet.
 1126192

Staff Interview Utility manager/Engineer was not aware of above areas air flow requirements (ASHRAE).
1126194

Document Evidence Appropriate air flows (positive, negative, balanced) were not established and monitored in janitorial closet.
1126193

FMS.35.7 - Appropriate air flows (positive, negative, balanced) are established and monitored in the laboratory.

Not Met
Activity Comment

Observation Appropriate air flows (positive, negative, balanced) were not established and monitored in the laboratory.
1126197

Staff Interview Utility manager/Engineer was not aware of above areas air flow requirements (ASHRAE).
1126195

Document Evidence Appropriate air flows (positive, negative, balanced) were not established and monitored in the laboratory.
1126196

FMS.35.8 - Appropriate air flows (positive, negative, balanced) are established and monitored in triage and trauma management areas.

Not Met
Activity Comment
 Observation Appropriate air flows (positive, negative, balanced) were not established and monitored in triage and trauma management
areas.
1126199

Staff Interview Utility manager/Engineer was not aware of above areas air flow requirements (ASHRAE).
1126200

Document Appropriate air flows (positive, negative, balanced) were not established and monitored in triage and trauma management
Evidence areas.
1126198

FMS.35.9 - Appropriate air flows (positive, negative, balanced) are established and monitored in the central sterilization and supply department.

Not Met
Activity Comment

Observation Appropriate air flows (positive, negative, balanced) were not established and monitored in the central sterilization and
supply department.
1126049

Staff Interview Appropriate air flows (positive, negative, balanced) were not established and monitored in the central sterilization and
supply department.
1126048

Document Appropriate air flows (positive, negative, balanced) were not established and monitored in the central sterilization and
Evidence supply department.
1125966
FMS.36 - The hospital provides appropriate control of temperature and humidity in the required locations. 
  ( Partially Met )

FMS.36.1 - Temperature and humidity are controlled and regularly monitored in operating and recovery room(s).

Fully Met

FMS.36.2 - Temperature and humidity are controlled and regularly monitored in nursery.

Partially Met
Activity Comment

Observation Humidity were not controlled in nursery.

1126201

FMS.36.3 - Temperature and humidity are controlled and regularly monitored in critical care unit(s).

Partially Met
Activity Comment

Observation Temperature and humidity were monitored but not controlled in critical care unit(s).
1126032

FMS.36.4 - Temperature and humidity are controlled and regularly monitored in sterile storage supply.
Not Met
Activity Comment

Observation Temperature and humidity were not controlled and regularly monitored in sterile storage supply.
1126050

Staff Interview Temperature and humidity were not controlled and regularly monitored in sterile storage supply.
1126051

FMS.36.5 - Temperature and humidity are controlled and regularly monitored inpatient rooms.

Not Met
Activity Comment

Observation Temperature and humidity were monitored but not controlled at inpatient rooms.
1126061

Staff Interview Utility engineer was not aware of above areas Temperature and humidity requirements (ASHRAE).
1126062

FMS.37 - The hospital has a periodic preventive maintenance plan for the water system. 
  ( Fully Met )
FMS.37.1 - There is a periodic preventive maintenance plan (PPM) for the water system that is supported by trained and specialized staff/contractor.

Fully Met

FMS.37.2 - The PPM records are maintained for the following:

FMS.37.2.1 Water is available twenty four hours a day, seven days a week.

FMS.37.2.2 The incoming water supply is checked regularly for at least: chemicals (once every six months) and bacteria (monthly), and results are monitored.
Fully Met
FMS.38 - The hospital ensures safe sewage handling and disposal. 
  ( Fully Met )

FMS.38.1 - Sewage handling and disposal is safely conducted in an efficient and sanitary manner according to professional codes of practice.

Fully Met

FMS.39 - The hospital maintains the kitchen and laundry equipment in good working condition. 
  ( Fully Met )

FMS.39.1 - Laundry equipment are regularly inspected and tested.

N/A
FMS.39.2 - Results of inspection and testing of kitchen equipment are documented as follows:

FMS.39.2.1 Hoods’ fans are in good operating condition and free from grease.
FMS.39.2.2 Hood filters are cleaned weekly and no cooking is done with missing filters.
FMS.39.2.3 Cold room temperature is monitored.
FMS.39.2.4 Kitchen and pantry microwaves, stoves, and ovens are at least annually tested and maintained.
Fully Met