Regulated Medical Waste Waste Reduction Facilities Management Regulations & Standards

Guide to JCAHO Environment of Care Standard 1.20.1,4,5

Please note: this page is under development. Contact (603) 795-9966,
if you have questions or suggestions.

Introduction        Table of Contents       Checklist for 1.20.1,4,5

Environment of Care Standard 1.20:  The organization maintains a safe environment.

Elements of Performance:  Environmental Tours

  • Element of Performance 1:  The organization conducts environmental tours to identify environmental deficiencies, hazards and unsafe practices.
  • Element of Performance 4:  The hospital conducts environmental tours at least annually in all areas where individuals are not served.
  • Element of Performance 5:  The organization conducts environmental tours at least annually in areas where individuals are not served.
    © 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.  

This page provides a set of criteria for evaluating the facility's commitment to evaluating its physical environment and its practices periodically by direct observation.

 
= Compliance
= Environmental Improvement
= Tools and Resources
  Environmental Tours
Tours include inspection of areas where:
  • hazardous materials are used and stored
  • hazardous waste are stored including satellite accumulation
  • solid wastes are managed
  • infectious wastes are managed

   

Space EC3.10.4

Separation EC3.10.10

  
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
Tours are conducted at least every six months.
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
  Written Documentation
Tours are documented as written audits.

   

Documentation: EC3.10.7  
Written audit reports are complete and corrections are made.

   

Documentation: EC3.10.7  
Inspection reports from local, state, or federal regulatory agencies are maintained and corrective actions are identified and implemented.

   

Documentation: EC3.10.7  
Inspection reports from third party insurance agents or other consultants are used to identify environmental compliance action items.

   

Documentation: EC3.10.7  
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.

   

Emergency: EC3.10.6  
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