Complying With HIPAA and JCAHO Requirements Specific security concerns are controlled access to specialized areas, supply rooms and medical carts, especially to control the access to medications, drugs, syringes, and needles. By Rod Oden While adhering to the usual group of local, state...
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An exception in LSC 184.108.40.206.4 permits the locking of doors where there is a clinical need. “Door locking arrangements shall be permitted in health care occupancies or portions of health care occupancies where the clinical needs of the patients, require special security measures for their safety, provided staff can readily unlock doors at all times.”
In LSC 220.127.116.11.4, certain circumstances will allow a delayed-egress out of a security-sensitive area. “Delayed egress locks complying with 18.104.22.168.1 shall be permitted, provided not more than one such device is located in any egress path.” Note: Building must be protected throughout with a fire detection system or be fully-sprinklered. Such doors must unlock upon activation of one of the following: “the sprinkler system, any heat detector, not more than two smoke detectors, loss of power controlling the locks, or an irreversible process within 15 seconds (30 sec. w/ AHJ approval) of pushing the release device.”
It is possible to set up a door (in this area) that can be opened by remote-control (key fob), providing the area is staffed all the time. This is stated in LSC 22.214.171.124.5. “Doors located in the means of egress that are permitted to be locked under the provisions of this chapter shall have adequate provisions made for the rapid removal of occupants by such a reliable means as the remote control of locks, by keying all locks to keys carried by staff at all times or by other reliable means available to staff at all times. Only one such locking device shall be permitted on each door.”
Additionally, security-sensitive areas can be “compartmentalized” to take advantage of another powerful exception contained in LSC 126.96.36.199.3. “For purposes of Section 7-2, a building shall be considered occupied at any time it is open for general occupancy, open to the public, or at any other time it is occupied by more than 10 persons.”
If the “compartmentalized” area has been scaled down so that the occupancy load is less than 10 persons, the door can feature a deadbolt or other auxiliary lock.
The point is that all areas should be carefully evaluated when they have been declared a “security-sensitive” area.
The best policy is to review all locations within the facility and limit (whenever possible) the number of “security-sensitive” areas. In this manner controversy between JCAHO and LSC can be reduced.
Remember that healthcare facilities and hospitals have ongoing matters regarding these requirements, life safety codes and fire codes. They will continually be working with the local AHJ (Authority Having Jurisdiction). When in doubt, talk to their AHJ about any concerns or applications regarding controlled areas.
Installing locks in HIPAA and JCAHO areas
A HIPAA concern is that medical records rooms are always secured, accessible only by persons needing access. Door locks that protect these areas must always be lockable from the exterior side. The door will be specified with a storeroom function. Door closers are appropriate to guarantee the door is self-latching.
JCAHO requires most locking hardware to be self-latching. In Figure 1, cabinet doors in a nurse's station are going to be fitted with self-latching locks, as each cabinet has the potential of storing drugs and medicines. The active leaf of each cabinet is fitted with an Olympus mortise cabinet lock. The inactive leaf will be secured from the inside with a latch mechanism.
Note that the cabinet locks can accommodate an interchangeable core for quick rekey. In JCAHO environments, locks must be routinely rekeyed as access to the areas change.
Self-latching is important as JCAHO requires ongoing inspections of the areas relating to the status of security. When the performance of locking hardware is routinely checked, visual inspections (closed cabinet doors) can indicate that areas are secured.
The access to refrigerators that store drugs, syringes, and needles must be limited.
Comp-X builds an electronic lock for this purpose. Figure 2 shows the electronic lock on the refrigerator door and Figure 3 shows how it secures the door to the frame. The Comp-X lock can be ordered to work with a combination and/or a proximity card.
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