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Environment of Care Management Plan - Annual Evaluation

What is the annual evaluation requirement for Environment of Care management plans?

Any examples are for illustrative purposes only. 

An annual evaluation of the management plans provides a systematic approach that the organization can use to ensure that the plans are still relevant, effective and useful. 
Organizations are required to have a written plan for managing the following: 
  • Environmental safety of patients and everyone else who enters the facility
  • Security of everyone who enters the facility
  • Hazardous materials and waste
  • Fire safety
  • Medical equipment
  • Utility systems
It is not necessary to have a separate plan for each of these environments of care risk categories, they may all be contained in a single document.  

Review of the plan since the last annual evaluation would include a determination of:
  • effectiveness of the plan 
  • whether the previous year’s objectives were achieved
  • new services, programs, or sites added
  • services, programs, or sites that have been eliminated
  • new hazards that have been introduced 
  • critique of fire drills
  • review of incident reports 
  • need for new objectives areas for improvement

Additional Resources:
EC.04.01.01 EP 15
Last updated on March 29, 2021
Manual: Critical Access Hospital
Chapter: Environment of Care EC

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