Guide to JCAHO Environment
of Care Standard 1.20.1-5
© 2005
Joint Commission on Accreditation of Healthcare Organizations. Any
use of any or all of the Joint Commission standards and elements of
performance beyond this particular tool is strictly forbidden without
the written permission of the Joint Commission.
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Introduction Table
of Contents Checklist
for 1.20.1-5
Environment
of Care Standard 1.20: The organization maintains a safe
environment.
Element
of Performance 2: Environmental Tours.
1.
The organization conducts environmental tours to identify environmental
deficiencies, hazards and unsafe practices.
4.
The hospital conducts environmental tours at least annually in
all areas where individuals are not served.
5.
The organization conducts environmental tours at least annually
in areas where individuals are not served. |
- Environmental
Tours
- Written Documentation
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Compliance
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Environmental Improvement
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Tools and Resources
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Environmental Tours
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Tours include inspection
of areas where hazardous materials are used and stored, hazardous waste
are stored including satellite accumulation, and solid and infectious
wastes are managed
Add bullet with
guidance on what to look for when inspecting these areas and if appropriate
how to conduct the tour. Is the guidance based on regulatory
requirements?
Special attention
is paid to areas where corrective action was previously taken due
to deficiencies identified
Add a bullet specifying
who should be involved in conducting the tour
Add a bullet about
how often the tours should be conducted
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Written Documentation
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Tours are documented
as written audits
Written audit reports
are complete and corrections are made.
Inspection reports
from local, state, or federal regulatory agencies are maintained
and corrective actions are identified and implemented
Inspection reports
from third party insurance agents or other consultants are used to
identify environmental compliance action items.
Completed environmental
audits have been filed with EPA
Employee incident
reports are reviewed and actions are taken to correct and mitigate
future problems.
Spill incidences
are documented and actions are taken to reduce future incidences
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Evidence of Environmental
Improvement
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Appropriate response
to deficiencies identified (EC 9.10-.30)
Action taken to
prevent deficiencies, e.g. problematic chemicals eliminated.
Purchasing policy
and criteria to reduce waste, conserve energy and eliminate hazardous
chemicals to prevent deficiencies, hazards and unsafe practices
Inspection reports
from third party insurance agents or other consultants are used to
identify environmental quality improvement action items
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Regulations
Do any regulations specifically
require tours? RCRA specifically requires review of HW storage areas
and satellite accumulation kept under reviewof operator. Others?
OSHA Hazardous Materials
29 CFR 1910
EPA Community Right-to Know 40 CFR 370
Hazardous Waste 40 CFR
260
DOT Hazardous Materials 49 CFR 171-180
Executive Order 13148
EMS required for all Federal
Facilities & Agencies by 12/31/05.
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