Environment of Care (EC) (Critical Access Hospitals / Critical Access Hospitals)
Q. Health care organizations are responsible for adhering to local, state and federal regulations for proper handling and disposal of hazardous materials and wastes. How is it possible for the Joint Commission surveyors to determine whether an organization is complying with all of these codes, standards and regulations when they often differ from one location or state to another?
Updated | November 24, 2008
A. The process of conducting surveys at a wide range of geographic locations presents unique challenges to each surveyor. The federal EPA regulations apply to most organizations, and it is with these regulations that surveyors are most familiar. State and local regulations are generally even more restrictive. Thus, the surveyor must usually determine what additional requirements the state or local regulations have imposed.
The organization's hazardous material and waste management program is required to be designed and operated in accordance with all applicable laws and regulations. This written program contains the policies and procedures that are necessary for the organization to be in compliance with all applicable laws. Through a thorough review of the hazardous materials and waste program, surveyors are able to determine the extent to which the state and local regulations have been included within the scope of the program. Each organization is encouraged to maintain a reference library of all applicable federal, state and local laws and regulations. Maintenance of this library helps demonstrate that all of the various regulatory requirements have been taken into consideration during program design. If the organization is unable to refer to the actual regulations, it is difficult to see what requirements the program is based on and how the organization keeps abreast of change to these regulations.