Back to Standards/Criterion 2.2.1
Surveyor Consensus & Allocation Dispute
Team leader to resolve
Lead SurveyorDr Mohd Anis HaronAssigned Service Standard Lead
Rating SurveyorFully met
Pn Zaiton AbdullahRecorded finding during tracer inspection

Awaiting Dr Mohd Anis Haron (Lead Surveyor) resolution. Dual surveyor observations are recorded with full provenance and decided strictly by clinical leadership authority.

2.2.1Core StandardSafety Standard
Facilities and equipment

Fire Safety Management and Evacuation Preparedness

The hospital maintains fire safety systems, emergency lighting, clear evacuation routes and conducts mandatory fire drills with the Fire and Rescue Department (Bomba).

Compliance Criteria

  • 1Fire alarm, sprinkler and hose reel systems certified annually by Bomba
  • 2Unobstructed fire escape staircases and emergency directional signage
  • 3Hospital fire emergency response plan and departmental fire warden roster
  • 4Bi-annual hospital-wide fire evacuation drill report and critique records

Hospital Self-Rating

Rated by En. Mohd Zaki Ariffin on 19 Jan 2026

Evidence frozen on 30 March 2026 (14 days before survey)

"Bomba annual inspection was completed with fire certificates renewed. Hospital fire drills are conducted bi-annually in collaboration with the local fire station."

AccrediSense Intelligence
thin

Evidence documents establish procedural intent but lack documented verification records for the current audit period.

Unverified criteria:
  • Hospital fire emergency response plan and departmental fire warden roster
  • Bi-annual hospital-wide fire evacuation drill report and critique records
Derived from AccrediSense Evidence Engine · 1 document(s) attached with 2 unverified criteriaGovernance disclosure (1.4.1.4)

Evidence Documents (1)

PolicyStaleScore: 58/100

Hospital Fire Emergency Plan & Fire Warden Roster (2023/2024 Edition)

Fire evacuation plan has not been revised following ward relocations in 2025.

24 pages · EN, MSValid: 2023-01-01 to 2024-10-31

Linked Performance Indicators (1)

PI-02-001Facility & Environmental Safety

Hospital Fire Evacuation Drill Execution and Response Compliance

18 readings recorded (Target: >= 90%)
ZA
Person-in-ChargeSafety, Health and Environment Officer
Head of DepartmentHead of Facilities & Biomedical Engineering
HO
Surveyor Authority PaneAssigned: Pn. Zaiton Abdullah (Nursing & Quality Surveyor)

Surveyor Rating

Committed 14 Apr 2026

Fire detection, alarm and suppression systems are certified by Bomba. Fire evacuation routes are unobstructed with well-documented bi-annual drill critique records.

Ensure all ward fire wardens participate in hands-on extinguisher refresher drills.

Maintain high fire safety standards.