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Lodi Outpatient Surgical Center/Endoscopy <br />Center of Lodi <br />Title: Hazardous Materials and Regulated <br />Medical Waste Management Plan <br />POLICY: HM 300 <br />Page 3 of 6 <br />State: <br />EFFECTIVE: <br />CMS: 416.42, 416.44 a 3 , 416.49(b)(2) 416.51 <br />REVISED: <br />TJC: EC.02.01.01.01 <br />AAAHC: 7-1,J 8-M <br />There are also mechanisms in place, which provide specific precautions, procedures, and protective <br />equipment used during hazardous materials and waste spills or exposures. <br />Data <br />Source <br />When and Where Reported <br />Material Safety Data Sheet Review <br />Internal <br />Annually (Quality Improvement <br />Committee) <br />Staff training records <br />Internal <br />Annually (Quality Improvement <br />Committee) <br />Review of HAZ-MAT or waste related incidents <br />Internal <br />Quarterly (Quality Improvement <br />Committee) <br />Safety Surveillance <br />Internal <br />Quarterly (Quality Improvement <br />Committee) <br />Preventive Maintenance records <br />Internal <br />BI -Monthly (Quality Improvement <br />Committee) <br />Hazardous Materials and Waste management program data is collected by the Administrator, and <br />reviewed by the Quality Improvement Committee on quarterly basis. Data is collected based on staff <br />input and observation of the physical environment, and internal and external monitoring. This review <br />will ensure that certain performance standards are met and maintained. <br />The following illustrates sources of data to be included in the analysis of the Hazardous Materials and <br />Waste management plan. <br />MEDICAL WASTE MANAGEMENT PLAN <br />For the purposes of this plan the terms "infectious waste", "bio -hazardous waste" and "medical waste" <br />are synonymous. <br />