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ENDOSCOPY CENTER OF LODI <br /> Title: Hazardous Materials and Regulated POLICY: EOC 300 <br /> Medical Waste Management Plan Page 3 of 6 <br /> State: EFFECTIVE: 4/19/2012 <br /> CMS: 416.42, 416.44 a 3 , 416.49(b)(2) 416.51 REVISED: <br /> TJC: EC.02.01.01.01 <br /> AAAHC: 7-I,J 8-M <br /> Performance standards exist in the form of policies and procedures and standard work <br /> practices. <br /> These things include staff knowledge and skill necessary for managing hazardous <br /> materials and wastes, staff participation in hazard materials and waste activities, <br /> monitoring, inspection and corrective action, routine procedures for incident reporting, <br /> and the inspection, preventive maintenance, and testing of applicable equipment. <br /> There are also mechanisms in place, which provide specific precautions, procedures, <br /> and protective equipment used during hazardous materials and waste spills or <br /> exposures. <br /> Hazardous Materials and Waste management program data is collected by the <br /> Administrator, and reviewed by the Quality Improvement Committee on a quarterly <br /> basis. <br /> Data is collected based on staff input and observation of the physical environment, and <br /> internal and external monitoring. <br /> This review will ensure that certain performance standards are met and maintained. <br /> The following table illustrates sources of data to be included in the analysis of the <br /> Hazardous Materials and Waste management plan. <br /> ata. SQ�i^ HOU <br /> - nnld Where Rep ed <br /> Safety Data Sheet Review Internal Annually (Quality Improvement <br /> Committee) <br /> Staff training records Internal Annually (Quality Improvement <br /> Committee) <br /> Review of HAZ-MAT or waste related Internal Quarterly (Quality Improvement <br /> incidents Committee) <br /> Safety Surveillance Internal Quarterly (Quality Improvement <br /> Committee) <br /> Preventive Maintenance records Internal Quarterly (Quality Improvement <br /> Committee) <br /> Regent Surgical Health-1/1/12 <br />