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Physical Environment



In order to ensure the safety of clients, personnel and the public, the administrator or designee will periodically examine the physical status of the clinic and ascertain whether or not it continues to comply with state and local building, fire and safety codes. The clinic is such that it is held "open to the public" and client treatment areas and other locations associated with clinic function (e.g. storage and toilet rooms) are to be physically separated from non-clinic areas. 



Major sources of information for compliance with this regulation are as follows: 

  • ​applicable federal, state and local laws

  • inspection reports of state and local building and fire authorities 

  • organization policies regarding maintenance of equipment, building and grounds

See sample checklists for clinic safety inspection in the attachments for Sub-Section K. ​



STANDARD SUBSECTION (A): Safety of Clients


The clinic satisfies the following requirements: 

  • The clinic complies with all applicable state and local building, fire and safety codes. 

  • The clinic has permanently attached automatic fire-extinguishing systems of adequate capacity that are installed in all areas of the premises considered to have special fire hazards. Fire extinguishers are conveniently located throughout the clinic. Fire regulations are prominently posted. 

  • Doorways, passageways and stairwells negotiated by clients are: 

  1. of adequate width to allow for easy movement of all clients (including those on stretchers or in wheelchairs).

  2. free from obstruction at all times

  • Lights are placed at all exits and in corridors used by clients and are supported by an emergency power source. 

  • A fire alarm system with local alarm capability.

  • At least two persons are on duty on the premises of the clinic whenever a client is being treated. 

  • No occupancies or activities undesirable or injurious to the health and safety of clients are located in the building. 

STANDARD SUBSECTION (B): Maintenance of Equipment, Building, and Grounds


The clinic has established a written preventive-maintenance program to ensure that: 

  1. The equipment is operative and properly calibrated and 

  2. interior and exterior of the building are clean and orderly and maintained free of any defects that are a potential hazard to clients, personnel and the public. 

For all electrically powered client care equipment, appropriate manufacturer's operating and maintenance information should be on file. 

All equipment will be inspected by the clinic at least yearly or in accordance with the manufacturer's guidelines. Any information including specific recommendations, by the manufacturer for equipment calibration checks, periodic maintenance procedures, etc. will be implemented. Copies of service repair statements or other documentation will be maintained in the maintenance binder. 

A Maintenance Binder will contain: 

  • List of equipment

  • Condition of equipment

  • Frequency of use

An equipment inspection log which details the following will be maintained:

  • Equipment to be inspected 

  • A monthly inspection of all equipment will be conducted and reported to the clinical administrator.

  • The equipment log will contain each area inspected on each of the equipment items. 

All client treatment items shall be disinfected after each client contact and no less than weekly. See lists for specific client treatment items as identified in the maintenance binder or posted in cleaning logs. 



STANDARD SUBSECTION (C): Other Environmental Considerations


The clinic monitors the control mechanisms, that ensure temperatures are at a comfortable and constant level. The mechanical means of ventilation such as air conditioner are utilized; placement of the unit(s) and vents should be such that the air is dispersed uniformly throughout the clinic. Where necessary, ramps are available to provide for easy access to the clinic and equipment. Examination and treatment areas are large enough to enable effective application of the plan of care. Client privacy may be assured through utilization of individual treatment booths, folding screens, draw curtains, etc. Where underwater exercise is utilized, a safe effective client lift device is available. 


The clinic provides a functional, sanitary and comfortable environment for clients, personnel and the public. 

  1. Provisions are made for adequate and comfortable lighting levels in all areas; limitation of sounds at comfortable levels; a comfortable room temperature; and adequate ventilation through windows, mechanical means, or a combination of both. None of the windows can be opened. 

  2. Toilet rooms, toilet stalls and lavatories are accessible and constructed so as to allow use by non-ambulatory and semi-ambulatory individuals. 

  3. There is an adequate amount of space for the services provided and disabilities treated, including reception area, staff space, examining room, treatment areas and storage. 



STANDARD SUBSECTION (D): Bio-hazard Waste Management


To provide guidelines for management of bio-hazardous wastes to control exposure of staff, clients and the public to disease-causing agents. 



Bio-hazardous waste will be packaged, labeled and stored to meet federal and state requirements. The clinic will obtain a contract with a transport service (registered pursuant to federal and state regulations) to remove bio-hazardous waste from the clinic. 

Bio-hazardous waste will be identified and segregated from other solid waste at the point of origin within the generating clinic. Any biohazardous waste mixed with hazardous waste will be managed as hazardous waste in accordance with federal and state requirements. 

All records, documentation and contracts will be maintained in accordance with state and federal laws and regulations and will be available to federal and state agencies upon request. 


  1. Identify bio-hazardous waste for separation from non bio-hazardous waste in the area where the objects became contaminated with blood or body fluids. 

  2. Contain bio-hazardous waste so that no discharge or release of any waste occurs. Use packaging appropriate for the type of waste generated and the type of treatment anticipated. (2.1) Single-use containers must be rigid, puncture-resistant, burst resistant, tear-resistant, and leak-resistant under normal conditions of handling and use. Single-use containers used for storage of bio-hazardous waste will be destroyed during the disposal process. (2.2) Multi-use storage containers will be constructed of smooth, easily cleanable, impermeable materials and be resistant to corrosion by disinfectant chemicals. 

  3. Package bio-hazardous waste, except sharps, in impermeable, red polyethylene or polypropylene plastic bags; seal all filled bags. ​

  4. Segregate discarded sharps from all other waste by placing them directly into rigid, leak-resistant, puncture resistant containers designed primarily for the containment of sharps. 

  5. Enclose bagged bio-hazardous waste in a rigid type container and seal container prior to transport by disposal service for off-site double-walled, corrugated and labeled with a stamp or symbol certifying that the box meets all construction requirements of applicable freight classification for a minimum busting strength of 200 pounds per square inch. 

  6. Packages of bio-hazardous waste must be handled in a manner to maintain their integrity, and must wear gloves when closing the box. 

  7. The designated Risk Manager will verify that adequate and appropriate space and equipment for safe handling and storage of bio-hazardous waste is provided. (7.1) All on-site storage of bio-hazardous waste will be in a designated area away from the general traffic flow patterns and accessible only to authorized personnel. Bio-hazardous waste may not be stored longer than 30 days. 

  8. All bio-hazardous waste generated at the clinic will be transferred off-site for treatment and disposal by a company registered pursuant to state regulations. (8.1) If the company contracted to pick-up and dispose of the bio-hazardous waste fails to perform their services as agreed upon, another company registered pursuant to state regulations will be contracted with for immediate service. The storage of bio-hazardous waste will remain unchanged. 

  9. Other methods of disinfection include: (9.1) Hot water at a temperature of at least 164 degrees Fahrenheit (73 degrees Celsius) for a minimum of 30 seconds. (9.2) Chemical germicides registered by the Environmental Protection Agency as hospital disinfectants and are tuberculocidal when used at recommended dilutions. 

STANDARD SUBSECTION (E): OSHA Record Keeping Requirements


To provide guidelines for compliance with the Occupational Safety and Health Act of 1970, current and accurate logs regarding recordable occupational injuries and illnesses will be maintained and posted in accordance with OSHA requirements. 

Any occupational injury or illness resulting in one or more fatalities or the hospitalization of five or more employees will be reported to OSHA within 48 hours. 


1. Log and Summary of Occupational Injuries and Illnesses (OSHA Form 300)

1.1  Record and classify recordable occupational injuries and illnesses by indicating the following:

1.1.1  When injury or illness occurred

1.1.2  Name of Employee

1.2.3  Job title of employee at time of injury or illness exposure

1.1.4  Department where employee is regularly employed

1.1.5  Description of injury or illness indicating part of body affected

1.1.6  How much time was lost

1.1.7  Whether case resulted in fatality

1.2  At the end of the year, total all injuries and illnesses and sign and date certification portion of form at bottom of page. 

1.3  This form must be kept and posted in the clinic for five years. 

1.4  This form will be updated to include newly discovered cases and to reflect changes that occur in recorded cases after the end of the calendar year. 

1.4.1  New entries will be made for previously unrecorded cases that are discovered or for cases that initially were not recorded, but were found to be recordable after the end of the year in which the case occurred. 

1.4.2  Line out recorded cases that are later found to be non-recordable. 

1.4.3  If the extent or outcome of a recorded injury or illness changes, line out the original entry and insert correct entry on that log. 

1.4.4  Modify log totals to reflect changes. 

2. Reporting Occupational Injuries and Illnesses

2.1  For every injury or illness entered on the log, worker's compensation, insurance or other reports will be filed and maintained in accordance with state worker's compensations laws. 

3. Recordable Injuries

3.1  Finger sticks

3.2  Medical treatment other than first aid required

3.3  Loss of consciousness

3.4  Caused restriction of work or motion

3.5  Caused transfer to anther job

4. Annual Surveys by OSHA

4.1  Firms selected to participate in surveys are mailed a reference year by the Bureau of Labor and Statistics or a participating state agency. 

4.2  If normally exempt small employers are selected to participate in the survey, they are notified in December, prior to the year to be documented. Employers are exempt if they have ten or less employees. Employer is not exempt if they have more than one establishment with a combined employment of eleven or more employees. 

CREATED:  04-01-2012


Form CMS-1893 (12/08):  42 CFR §485.723;

AAAASF Medicare RA/OPT (V. 3.0) Section 15; Sub-Section K

Believe Therapies

521 I-45 Suite 4,

Huntsville, TX 77340

phone: 936.293.8800


fax: 936.715.3721


Monday - Friday

8:00AM - 7:00PM

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Believe Therapies

2305 Longmire Dr Suite 300

College Station, TX 77845

phone: 936.293.8800


fax: 936.715.3721


Monday - Friday

8:00AM - 7:00PM

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