Your complete workflow guide inside Kipu Compliance — from daily facility safety checks to quarterly fire drills and annual Environment of Care evaluations.
What Kipu Compliance gives you
| 📋 Operations Forms | 📊 Live LCR Score | 🔗 Regulation → Form Mapping | 📈 View Charts |
|---|---|---|---|
| Pre-built fire safety, life safety, EC, and generator forms — all regulation-mapped | Filter to Operations | Physical Plant — your real-time facility compliance posture | Every EC and life safety form mapped to the TJC or NFPA standard it satisfies | Trend data on any form — show leadership year-over-year EC compliance without exporting |
Key numbers
| Fire & Life Safety Forms | Urgent Same-Day Threshold | Facility Walkthrough | LCR Filter |
|---|---|---|---|
| 20+ Fire drills, extinguishers, sprinklers, alarms, generators | 0 Open facility safety incidents or unresolved safety issues | Weekly One per level of care — if previously noted, surveyor will ask for resolution | Ops | Physical Plant Your daily command center inside the LCR |
Log in immediately when:
- Facility safety incident reported
- Fire system impaired or offline
- Generator failure or alarm
- State or TJC survey notice received
- Maintenance issue affecting client safety
- New facility or level of care added
- LCR score drops unexpectedly
The LCR Filtered to Operations | Physical Plant — Your Daily Command Center
Open on every login. If an issue was previously noted, a surveyor will ask whether it was resolved.
| 📊 Location Compliance Report — Operations View Left Nav → LCR → Filter: Operations | 🏗️ The Operations Director's Role in the LCR |
|---|---|
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Operations Forms — Organized by Category
All pre-built and regulation-mapped · Use Ctrl+F / Cmd+F in the system to search by name
| 🔥 Fire Safety & Life Safety | 💧 Sprinkler, Water & Generator | 🏢 Facility Inspections & EC | 🧪 Infection Control & Safety |
|---|---|---|---|
Fire Drills form uses conditional formatting — answer facility type questions at top first. |
Generator: weekly visual + monthly load test + quarterly Level 2 functional test (diesel). |
Facility Walkthrough: if issue was previously noted, surveyor will ask for documented resolution. |
Daily Temp Log: food refrigerators daily, medication refrigerators twice per day — most commonly cited item. |
Daily — Safety-first morning checks
Urgent items must be resolved same day. Every day / every other day at minimum.
Review Dashboard for facility safety incident reports (Urgent — Same Day)
Check the Required Approval box for any open incident reports. Operations-related incidents — facility safety issues, equipment failures, workplace violence near-misses — must be escalated to the Compliance Manager and Executive team same day. TJC surveyors will trace the time between incident report and your documented response. A fast, documented response chain is evidence of a functioning safety culture.
Navigate to: Dashboard → Required Approval
Confirm no urgent maintenance issues are unresolved
Review open maintenance requests. Any issue affecting patient safety or life safety systems requires same-day action and documented resolution. If an issue was previously noted in your Facility Walkthrough, a surveyor will ask specifically whether it was resolved. Use Actions → Assign Task from the LCR to create the documented resolution trail.
Navigate to: Forms → Operations / LCR
Review LCR — Operations | Physical Plant filter for Past Due items
Filter the LCR to Operations | Physical Plant and scan for Past Due or Not Compliant items. Also check any Elsewhere entries — vendor or city inspection records documented externally should have a Document Date that satisfies the time requirement, or they'll still show as Not Compliant. Assign tasks for anything approaching the flip from Upcoming to Due.
Navigate to: LCR → Filter: Operations
Verify daily facility checklists are being completed by staff
Confirm responsible staff have completed the Daily Temperature Log — food refrigerators every day, medication refrigerators twice daily. These are required on every operating day and are among the most commonly cited items in state and TJC inspections. Missing a single day creates a gap that's visible in the LCR and during a survey.
Navigate to: Forms → Operations → Daily Temp Log
Weekly — Life safety inspections, generator checks & facility walkthroughs
Confirm Facility Walkthroughs are completed — one per level of care
Verify scheduled walkthroughs were completed this week. If your facility has multiple levels of care, one form per level. Only 3–4 checklist selections plus state-specific requirements should be selected per walkthrough — don't try to cover everything at once. Use View Charts on this form to surface trend data for leadership over time. The Facility Walkthrough is your documented evidence that you're actively monitoring the EC.
Navigate to: Forms → Operations → Facility Walkthrough
Weekly Generator visual inspection (If diesel generator on site)
Complete the Weekly Generator Inspection — a visual check of the emergency power supply system (EPSS) including fuel level, coolant, battery condition, and all associated components. Required by NFPA 110 and TJC EC.02.05.07 for diesel-driven generators. This takes minutes and prevents the scenario where a generator fails during an actual power outage and you have no documented inspection history.
Navigate to: Forms → Operations → Generator
Review Weekly Facility Checklist completion
Confirm the Weekly Facility Checklist was completed covering common areas, client rooms, medication storage, outdoor spaces, and equipment condition. This is distinct from the Facility Walkthrough — the weekly checklist covers general operational safety while the walkthrough captures EC-specific compliance items. Both need to run on schedule.
Navigate to: Forms → Operations → Weekly Facility Checklist
Monthly — Fire safety & life safety systems
Fire extinguisher monthly inspection
Complete the Monthly Fire Extinguisher Inspection & Maintenance Log. TJC EC.02.03.05 and NFPA 10 require at least monthly inspection of all portable extinguishers. Annual certified maintenance by a licensed individual is a separate Q4 requirement — document both, they satisfy different standards.
Navigate to: Forms → Operations
Emergency lighting & exit sign functional test
Complete the Monthly Inspection of Emergency Lighting / Exit Signs — 30-second minimum functional test per NFPA 101 and TJC EC.02.05.07 EP1. The annual test (1.5 hours) is a separate requirement completed in Q3. Both must be documented separately — they satisfy different standards.
Navigate to: Forms → Operations
Generator monthly load test (If generator on site)
Complete the Generator Testing / Load Test — cold start under load for at least 30 continuous minutes per NFPA 110 and TJC EC.02.05.07 EP5. Log all automatic and manual transfer switch tests. The weekly visual inspection and monthly load test are separate — both are required.
Navigate to: Forms → Operations → Generator
First aid & emergency medications inventory
Complete the Monthly First Aid & Emergency Medications Checklist. Ensure supplies are fully stocked and medications are not expired. Coordinate with clinical/nursing staff for the medication storage area. This checklist is among the easiest things to pass in a survey — and among the most avoidable reasons to fail one.
Navigate to: Forms → Nursing/Medical
Monthly Safety Drill & H&S Inspection (CARF)
Required for CARF providers in addition to quarterly emergency drills. Document results in Committee/Leadership Meeting Minutes when applicable. CARF also requires a semi-annual external H&S inspection — coordinate with a fire department rep, OSHA specialist, or licensed safety engineer for that separate requirement.
Navigate to: Forms → Operations
Monthly — Infection control, LCR review & EC monitoring
Monthly Infection Control Tracking log
Complete Monthly Infection Control Tracking — log communicable diseases for both staff and clients present in the facility. Trend data over time identifies mitigation opportunities and feeds the Annual ICP Evaluation. Operations and clinical staff share ownership of infection control; this is Operations' documented contribution.
Navigate to: Forms → Nursing/Medical
Review LCR filtered to Operations for items moving Upcoming → Due
Scan the LCR for any items transitioning from Upcoming to Due next month. Use Duplicate Latest Entry for recurring forms where available — it saves time and maintains a consistent completion record. Assign tasks now to the responsible person before items flip.
Navigate to: LCR → Filter: Operations
Infection Control Rounds Checklist
Complete the Infection Control Rounds Checklist — a structured walkthrough assessing hand hygiene compliance, PPE availability, cleaning and disinfection protocols, and sharps disposal across facility areas. This feeds the overall IC program and produces the documented round history surveyors review when evaluating IC program rigor.
Navigate to: Forms → Nursing/Medical
Monthly Safety Review Log
Complete the Monthly Safety Review Log covering environment of care conditions, equipment status, safety hazard identification, and staff safety protocol compliance. Results are reviewed by the Safety Committee — this is one of the key inputs to the monthly QA/QI Committee meeting and to the Annual EC Evaluation.
Navigate to: Forms → Operations
Food Services Inspection
Complete the Food Services Inspection covering food storage, preparation, sanitation, temperature compliance, pest control, and licensure. Ensures the facility stays inspection-ready year-round and provides a self-audit record for state licensing and accreditation reviews. Coordinate with kitchen staff or dietary service for completion.
Navigate to: Forms → Operations
Quarterly — Fire drills, sprinkler tests & generator functional tests
Every quarter — stagger shift coverage.
Fire Drills — Inpatient: one per shift per quarter (TJC EC.02.03.01)
Complete the Fire Drills form for each shift this quarter. The form is conditionally formatted for inpatient vs. outpatient and sprinklered vs. non-sprinklered — answer all top-of-form questions first to receive the correct prompts. One annual drill must activate the fire alarm to notify the central station; this can be combined with a quarterly drill. Outpatient settings have different frequency requirements — confirm your facility type drives the form correctly.
Navigate to: Forms → Operations → Fire Drills
Water flow device test, FDC inspection & supervisory signal devices (If sprinklered)
Complete the Water Flow Device Test, Quarterly Fire Department Connection Inspection, and Quarterly Supervisory Signal Device Inspection. These three forms run together — all are required under NFPA 25 and TJC EC.02.05.07 for facilities with automatic fire sprinkler systems. Schedule with your fire protection contractor to complete all three in one visit.
Navigate to: Forms → Operations → Fire Sprinkler
Quarterly Level 2 Generator Functional Test (If diesel generator)
Complete the Quarterly Level 2 EPSS Functional Test — at least 30% of nameplate rating or manufacturer-recommended exhaust gas temperature per NFPA 110 and TJC EC.02.05.07 EP5. This is distinct from the monthly load test and weekly visual inspection — all three are required on their own schedule.
Navigate to: Forms → Operations → Generator
Quarterly Security Log review
Complete the Quarterly Security Log — assess access controls, door and window security, monitoring systems, lighting, and staff adherence to security protocols. Identify any vulnerabilities and document corrective steps. Facility security is part of the EC program and is reviewed by TJC surveyors as part of the safety and security standard.
Navigate to: Forms → Operations → Security Log
Contribute EC data to Quarterly QA/QI Committee
Pull trend data from facility walkthroughs, monthly safety reviews, infection control tracking, and incident reports. Use View Charts on key forms to show trend lines without exporting. Operations data is often under-represented in QA/QI committees — your trend data tells the facility safety story that clinical data can't.
Navigate to: LCR / Forms → View Charts
Annual — Evaluations staggered through the year. Leadership is always last.
Do not batch — space across Q1 through Q4.
Q1 — Annual Evaluation of the Infection Prevention & Control Plan
Review and document your ICP program annually. Contains a built-in workflow linking to companion forms that must be completed alongside it — including the Monthly Infection Control Tracking data you've been collecting all year. Complete alongside infection control data from the prior 12 months to identify trends requiring mitigation.
Navigate to: Forms → Compliance → ICP Evaluation
Q1 — Worksite Analysis
Evaluate the effectiveness of your Workplace Violence Prevention Program and implement environmental modifications based on findings. This is a required annual form — assess risk factors in the physical environment, identify control measures, and document what modifications were made or planned. OSHA 1910 and TJC standards both inform this requirement.
Navigate to: Forms → Operations → Worksite Analysis
Q2 — Annual Evaluation of the Emergency Management Plan & HVA
Complete the Annual Evaluation of the Emergency Management Plan alongside the Hazard Vulnerability Assessment (HVA) Mitigation & Action Plan. Your HVA drives your drill priorities for the year — the two forms are designed to be completed together. HVA now includes a facility type field and TJC Telehealth accreditation guidance.
Navigate to: Forms → Compliance → EM Evaluation
Q2 — Annual Ligature Risk Assessment
Assess all ligature risk points and document required safeguards — required for both inpatient and outpatient behavioral health facilities. The form has companion forms for Bedrooms, Bathrooms, Common Areas, and Offices/Group Rooms. Complete all applicable sub-forms. Walk the entire facility with clinical leadership — this is a joint EC and clinical responsibility.
Navigate to: Forms → Compliance → Ligature Risk
Q3 — Annual Evaluation of the Environment of Care Plan
The most important annual form for Operations. Step-by-step review of the entire EC program covering safety and security, hazardous materials, fire and life safety, medical equipment, utility systems, and environmental risk prioritization (TJC EC.04.01.01). Update EC policies while completing this form. Use View Charts after completion to show year-over-year data to leadership — this is one of the most compelling trend visualizations in the system.
Navigate to: Forms → Compliance → EC Evaluation
Q3 — Annual Fire Door Assembly Inspection
Complete the Annual Fire Door Assembly Inspection for all fire-rated door assemblies — test that they close fully, latch properly, and maintain fire-rated barrier integrity (NFPA 80). Must be completed by individuals who can demonstrate knowledge of fire door operating components. Document any gaps, latching failures, or hardware issues and create Maintenance Work Orders for corrective action before year-end.
Navigate to: Forms → Operations
Q3 — Physical Plant Requirements Audit
Comprehensive infrastructure audit covering building safety, ADA accessibility, space requirements, environmental controls, infection control systems, special systems (seclusion rooms, security, medication storage), and general safety (CO detectors, emergency power, safe furniture). Use for pre-licensure inspection prep, remodeling compliance, and ongoing EC monitoring.
Navigate to: Forms → Operations → Physical Plant
Q4 — Annual Evaluation of Leadership ⭐ (Always Last)
Complete last — it is the full year in review. Operations data on EC compliance trends, safety incidents, facility performance, and your year's audit rehearsal findings all feed this evaluation. TJC requires Health Care Equity tracking (LD.04.03.08). New Emergency Management communication requirement added (LD.02.03.01).
Navigate to: Forms → Compliance → Leadership Evaluation
Operations Director Workflow Guide · Updated March 2026
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