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0 0 <br /> mechanisms in place which provide specific precautions, procedures, and protective <br /> equipment used during hazardous materials and waste spills or exposures. <br /> Hazardous Materials and Waste management program data is collected by a designated <br /> staff member (Safety Officer) and reviewed by the Safety/Quality Committee on a quarterly <br /> basis. Data is collected based on staff input and observation of the physical environment, and <br /> internal and external monitoring. This review will ensure that certain performance standards <br /> are met and maintained. The following table illustrates sources of data to be included in the <br /> analysis of the Hazardous Materials and Waste management plan. <br /> Data, Source When and Where,Repoded, <br /> Safety Data Sheet Review Internal Annually (Safety/Quality <br /> Committee) <br /> Staff training records Internal Annually (Safety/Quality <br /> Committee, MEC, GB) <br /> Bio-Hazard waste removal work practices Internal Annually (Safety/Quality <br /> Committee, MEC, GB) <br /> Review of HAZ-MAT or waste related Internal Quarterly (Safety/Quality <br /> incidents Committee) <br /> Safety Surveillance Internal Quarterly (Safety/Quality <br /> Committee) <br /> Preventive Maintenance records Internal Quarterly (Safety/Quality <br /> Committee) <br /> Hazardous Material & Waste Management Internal Annually (Safety/Quality <br /> Plan Review Committee, MEC, GB) <br /> References® <br /> Standard Operations Manual Appendix L-Guidance for Surveyors: Ambulatory <br /> Surgery Center for Medicare and Medicaid Services (Rev. 137, 4-01-15). <br /> The Joint Commission. 2015. Accreditation Standards and Requirements for <br /> Ambulatory Surgery Centers <br /> The Accreditation Association for Ambulatory Care, 2015.Accreditation Handbook. <br /> 2 <br />