The most challenging standards related to the environment of care include:
1. Security and safety risks are managed:
• Identify risks
• Take action to minimize risk
• Control access to security sensitive areas
2. Manage hazardous materials and waste
• List of hazardous materials/waste
• Hazardous chemicals
• Hazardous energy
• Label hazardous materials/waste
3. Maintain fire safety equipment/building
• Document monthly fire extinguisher checks
4. Medical equipment is maintained, tested and inspected
• Test and maintain all high-risk equipment
• Test and maintain medical equipment on inventory
• Document testing and maintenance of sterilizers
5. Collect information to monitor conditions in the environment
• Evaluate each environment of care plan annually
The human resources challenging standards include:
6. Clinical privileges are granted to licensed independent practitioners
• Primary source verify training
• Review PI activities
• Ensure privileges are site-specific
• Leaders grant privileges
The infection control challenging standards include:
7. Identify risks for acquiring and transmitting infection
• Identify risks based on geographic/pops served
• Prioritize document identified risks
8. Reduce the risk of infections associated with medical equipment devices, supplies
• Cleaning and performing low-level disinfection of medical equipment, device and supplies
• Perform intermediate and high-level disinfection and sterilization
• Storage
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