Central Fabrication Accreditation Guide

The Safety and Equipment Standards address facility safety, safety management and occupational exposure risks. The standards require you to administer a written safety management program that provides a physical environment free of hazards as well as procedures that reduce the risk of injury to employees.

You must also have a disaster preparedness plan designed to manage the consequences of natural disasters, long term power outages, fires and other emergencies. Staff must be trained to carry out duties and responsibilities specified in the contingency plans.

You are required to administer an equipment management program that is designed to assure safe equipment performance that is supported by preventive maintenance programs.

SE1

The business administers a written safety management program that is designed to provide a physical environment free of hazards and to manage staff activities to reduce the risk of injury.

Tip–Safety Management

You need to have written policies and procedures that reduce the risk of injury to employees. A copy of this plan needs to be in your policy manual and available to all staff. Examples may include, but are not limited to:

• Appropriate use and storage of hazardous materials
• Proper use and maintenance of equipment
• Training and orientation on facility safety

SE2

The business conducts and evaluates the results of safety inspections of the facility. These inspections must be performed and documented at least annually.

Tip–Safety Inspections

Document each of your facility safety inspections and include documentation of any deficiencies and corrective actions taken as a result of the inspection. Examples of documentation may include, but are not limited to:

• Staff meeting minutes
• Equipment logs
• Safety inspection checklists
• Safety consultant reports

SE3

The business conducts and documents safety management training for all staff, at least annually.

Tip–Safety Management Training

Your safety management training should include:

• General safety procedures
• Safety plans
• Emergency preparedness
• Emergency plans
• Special hazards related to assigned duties
• Safety practices
• Explanation of any changes since last training

Documentation of safety management training may include, but is not limited to:

• Staff meeting minutes
• Sign-in sheets

SE4

The business establishes and maintains procedures for cleaning the facility and equipment.

Tip–Facility and Equipment Cleaning

You need to have processes in place to ensure that your facility and equipment are adequately cleaned. Staff training should include procedures for the appropriate cleaning of the facility and equipment, even if you use an outside cleaning service.

SE5

The business has established written policies and procedures and complies with all appropriate hazardous waste disposal procedures.

Tip–Hazardous Waste Disposal

You need a process that ensures and documents that your staff is trained and consistently follows appropriate hazardous waste disposal procedures. This process should include federal, state and local disposal requirements.

SE6

The business has established an emergency evacuation plan that addresses appropriate staff response to fires or other emergencies and provides appropriate education and training to all staff. Based upon occupancy classification, the plan includes provisions for appropriate fire alarm and fire suppression systems.

Tip–Facility Emergency Evacuation Plan

Your plan needs to include evacuation routes, as well as the duties of specific staff, in the event of an emergency. These duties should include identifying who is responsible for calling fire and other emergency personnel and who is responsible for checking that all staff have safely evacuated the premises and assembled in a previously designated area. You also need to document that your staff has been trained on the emergency evacuation plan with sign-in sheets, program agendas or staff meeting minutes.

SE7

The business conducts an emergency evacuation drill in accordance with the evacuation plan, at least annually.

Tip–Emergency Evacuation Drill

Your emergency evacuation drill must include all staff members. If you have more than one shift, you must conduct a drill for each shift. Your drill also needs to include testing of the fire suppression and/or alarm systems, if applicable.

SE8

Written evaluations of the effectiveness of the emergency evacuation drill are prepared and results of the evaluation are documented.

Tip–Drill Evaluation

After you’ve conducted the drill, write an evaluation of its effectiveness. Your evaluation might include items such as timeliness of evacuation, confirmation that all staff exited the premises, all staff gathered at the pre-determined meeting location and the all clear procedures for returning to the facility were followed. The written evaluation should be kept in your emergency preparation files.

SE9

The business has created a disaster preparedness plan designed to manage the consequences of natural disasters or other events that affect its ability to service its customers.

Tip–Disaster Preparedness

Fires are not the only emergency for which you need to be prepared. Other events such as natural disasters (i.e., flood, tornado, hurricane or wind storm) or widespread and lengthy power outages could also disrupt your ability to serve your customers.

Provide documentation that you have a plan to manage the consequences of such a disaster or interruption. This might include a process for data backup and/or restoration in order to continue operations in the event of a disaster, or contracts and/or agreements with other businesses to help you maintain service to your customers.

SE10

When the business elects to maintain specialized emergency equipment, such as an Automatic External Defibrillator (AED), personnel are trained in the proper use of that equipment.

Tip–Specialized Emergency Equipment

If you have any specialized emergency equipment on your premises, you must provide documentation that your staff has been trained in its use. Documentation could be in the form of sign-in sheets, program agendas or course certificates.

SE11

The business has established written policies and procedures that prohibit smoking within its facility.

Tip–No Smoking Policy

Your facility must be a non-smoking environment. A copy of your no smoking policy needs to be in your policy manual, which is available to all staff as well as included in staff orientation. The policy also needs to be posted in a location visible to all staff.

SE12

The business has implemented an equipment management program for all serviceable equipment that promotes its safe use by staff.

Tip–Equipment Management Program

Your equipment management program must include, but is not limited to:

• An inventory of all equipment
• Staff training on the appropriate use of equipment
• A plan for the appropriate maintenance of equipment

SE13

The business has documented training for appropriate staff on the safe use of equipment.

Tip–Equipment Safety

You must have documentation that your equipment safety training program trains staff in the safe use of all equipment and items.

Documentation may include, but is not limited to:

• Staff meeting minutes
• Training log
• Agenda for staff safety training

SE14

The equipment management program includes documented maintenance of each piece of equipment.

Tip–Equipment Maintenance

Your equipment management program (referenced in SE12) must include an inventory of all equipment and a log to identify the maintenance of each item. Your staff needs to be trained on the program and the maintenance requirements.

SE15

The business has established and adheres to written policies and procedures that address occupational exposure.

Tip–Occupational Exposure

Occupational exposure is defined as the exposure to potentially harmful chemical, physical or biological agents that occurs as a result of one’s occupation. You must have documentation that these policies are consistently followed by staff.

Examples may include, but are not limited to, policies that address items such as:

• Contaminated patient cast impressions
• Injury in the workplace
• Blood borne pathogens
• Chemical handling
• Noise abatement

SE16

The business maintains a current file of Safety Data Sheets (SDS). All appropriate staff are trained on the potential risks and dangers of materials used in the facility.

Tip–Safety Data Sheet

You collect, maintain and update all pertinent Safety Data Sheets. All staff must have access to the SDS file and be knowledgeable of its contents.

SE17

The business has written policies and procedures that address cross-contamination risks.

Tip–Cross-Contamination

You need a policy that documents the proper handling of items that have come in contact with a patient such as cast impressions, positive models and/or devices returned for repair. Your procedures should include universal precautions and cross contamination policies. Staff must be trained on the policy. A copy needs to be in your policy manual and must be available to all staff.

SE18

The business adopts written policies and procedures that address the use of Personal Protective Equipment (PPE) for all appropriate staff.

Tip–Personal Protective Equipment

You must require the use of PPE items as per OSHA regulations or as you deem additionally necessary for the services you provide.

These policies may include items such as:

• Hearing protection
• Protective eyewear
• Dust masks
• Respirators
• Gloves and lab coats
• Other protective clothing