2021 EC Manual Table of Contents

Please Note: The CD-R or Thumb drive, which accompanies this manual, contains the following
documents as listed below. Documents are electronically saved as MS Word (.doc) or MS Excel (.xls)
files, unless identified otherwise
EC.01.01.01: The hospital plans activities to minimize risks in the environment of care.

Note 1: One or more persons can be assigned to manage risks associated with the
management plans described in this
standard.

Note 2: For hospitals that use Joint Commission accreditation for deemed status purposes:
The hospital complies with the 2012 edition of NFPA 99: Health Care Facilities Code.
Chapters 7, 8, 12, and 13 of the Health Care Facilities Code do not apply.

Note 3: For further information on waiver and equivalency requests, see

https://www.jointcommission.org/life_safety_code_information_resources/ and NFPA 99-
2012: 1.4.

MR-EC.01.01.01EP1 Appointment for Safety Officer

MR-EC.01.01.01EP3 Policy on the Library of EOC Information

MR-EC.01.01.01EP4 Safety Management Plan 2021

MR-EC.01.01.01EP5 Security Management Plan 2021

MR-EC.01.01.01EP6 Hazmat Management Plan 2021

MR-EC.01.01.01EP7 Fire Safety Management Plan 2021

MR-EC.01.01.01EP8 Medical Equipment Management Plan 2021

MR-EC.01.01.01EP9 Utility Systems Management Plan 2021

EC.02.01.01: The hospital manages safety and security risks.

SS-EC.02.01.01EP1 a Policy on Risk Assessment for Safety & Security

SS-EC.02.01.01EP1 b Form- Attachment I- Risk Assessment Form (2 tabs: 1-Safety &
Security and 2- Falls)
SS-EC.02.01.01EP1 c Form- Attachment II- Completed Risk Assessments

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SS-EC.02.01.01EP3 a Policy on Action to Safety & Security Risks

SS-EC.02.01.01EP3 b Form- Attachment I – Actions to Reduce Safety & Security Risk
(.xls)

SS-EC.02.01.01EP5 a Policy on Maintaining Grounds & Equipment

SS-EC.02.01.01EP5 b Form- Attachment I – Daily Grounds Inspection Form (.xls)
SS-EC.02.01.01EP5 c Form- Attachment II – Grounds & Equipment Inspection Form
(.xls)

SS-EC.02.01.01EP7 Identification of Individuals Policy

SS-EC.02.01.01EP8 a Policy on Access to Security Sensitive Areas

SS-EC.02.01.01EP8 b Attachment I – Security Sensitive Area Assessment Form
SS-EC.02.01.01EP8 c Attachment II – Protective Measures for Security Sensitive Areas
Form

SS-EC.02.01.01EP9 a Security Manual Table of Contents (.xls)

SS-EC.02.01.01EP9 b Policy on Infant/Pediatric Abduction Prevention
SS-EC.02.01.01EP9 c Missing Person Abduction Plan
SS-EC.02.01.01EP9 d Security Alert- Combative Patient
SS-EC.02.01.01EP9 e EOP ERP- Active Shooter EP-EM.02.01.01EP2

SS-EC.02.01.01EP10 Sample Incident Report

SS-EC.02.01.01EP11 a Policy on Product Recalls

SS-EC.02.01.01EP11 b Attachment I – Product Recall Tracking Report (.xls)
SS-EC.02.01.01EP11 c Attachment II – Letter of Notice for Product Recall

SS-EC.02.01.01EP14 a Policy on MRI Risk Assessment

SS-EC.02.01.01EP14 b Form- Attach I MRI Risk Assessment

SS-EC.02.01.01EP16 a Policy on MRI Safety

SS-EC.02.01.01EP16 b Form- Attach I- MRI Patient Screening

EC.02.01.03: The hospital prohibits smoking except in specific circumstances.

SS-EC.02.01.03EP1-6-Smoking Policy

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EC.02.02.01: The hospital manages risks related to hazardous materials and waste.

HM-EC.02.02.01EP1a Policy for Hazardous Materials & Waste Inventory

HM-EC.02.02.01EP1 b Attachment I – Form- Departmental Hazardous Materials &
Waste Inventory Form (.xls) (4 tabs: Tab 1- Chemical inventory, Tab2- Infectious
Inventory, Tab 3- Medication Inventory, Tab 4- Radioactive)
HM-EC.02.02.01EP1 c Attachment II – Form- Master Hazardous Materials & Waste
Inventory Form (.xls)

HM-EC.02.02.01EP3-4 a Policy on Hazardous Spill & Exposure

HM-EC.02.02.01EP3 a Policy on Eyewash/Shower Station
HM-EC.02.02.01EP3 b Form- Attach I-Eyewash Station Risk Assessment (.xls)
HM-EC.02.02.01EP3 c Form- Attach II-Weekly Eyewash / Shower Activation Record
(.xls)

HM-EC.02.02.01EP5 a Policy on Hazardous Chemicals

HM-EC.02.02.01EP5b Form-Attachment I Risk Assessment for Hazardous Materials &
Waste
HM-EC.02.02.01EP5 c Form-Attachment II – Contractor Acknowledgment Form (.xls)

HM-EC.02.02.01EP6 a Policy for Managing Radioactive Materials

HM-EC.02.02.01EP7 a Policy for Managing Hazardous Energy Sources

HM-EC.02.02.01EP08 a Policy for Disposal of Hazardous Medications

HM-EC.02.02.01EP08 b Attach I-Weekly Inspection of Storage Areas (.xls) (2 tabs:
Tab1- Accumulation, Tab 2- Main Storage)
HM-EC.02.02.01EP08 c Attach II-Hazardous Drugs for Pharmacy Personnel
HM-EC.02.02.01EP08 d Attach III-Listed Hazardous Medications and other RCRA
hazardous waste (.xls) (2 tabs: Tab 1- Listed Waste, Tab 2- Waste Segregation and
Disposal)
HM-EC.02.02.01EP08 e Attach IV-Generator Calculations

HM-EC.02.02.01EP9 a Policy for Managing Hazardous Gases & Vapors

HM-EC.02.02.01EP9 b Policy on Formaldehyde
HM-EC.02.02.01EP9 c Policy on Glutaraldehyde

HM-EC.02.02.01EP10 a Policy on Monitoring Hazardous Gases & Vapors

HM-EC.02.02.01EP11 a Policy on Permits, Licenses, Manifests & SDS

HM-EC.02.02.01EP11 b Attachment I – Permit & License List (.xls)

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HM-EC.02.02.01EP11 c Attachment II – Pictogram Symbols (.xls)

HM-EC.02.02.01EP12 a Policy on Labeling Hazardous Material & Waste

HM-EC.02.02.01EP17-18 a Policy on Staff Monitoring for Radiation Exposure

HM-EC.02.02.01EP17-18 b Attach I- ALARA Exposure levels
HM-EC.02.02.01EP17-18 c Attach II-Investigation Levels

HM-EC.02.02.01EP19 a Policy for Disposal of Trash

EC.02.03.01: The hospital manages fire risks.

FS-EC.02.03.01EP1 a Policy on Fire Safety

FS-EC.02.03.01EP4 Policy on Exits in Business Occupancy

FS-EC.02.03.01EP9 Fire Response Plan

FS-EC.02.03.01EP11-12 Policy on Fire Hazards during Surgical Procedures

FS-EC.02.03.01EP13 Compliance with NFPA 99-2012 Chapter 15

EC.02.03.03: The hospital conducts fire drills.

FS-EC.02.03.03EP1-5 a Policy on Fire Drills

FS-EC.02.03.03EP1-5 b Form- Attachment I Fire Drill Critique for Hospital (.xls)
FS-EC.02.03.03EP1-5 c Form- Attachment II Fire Drill Critique for Business Occupancy
(.xls)
FS-EC.02.03.03EP1-5 d Form- Attachment III Fire Drill Critique for OR-Surgery (.xls)
FS-EC.02.03.03EP1-5 e Form- Attachment IV Fire Drills Matrix (.xls)

EC.02.03.05: The hospital maintains fire safety equipment and fire safety building features.

Note: This standard does not require hospitals to have the types of fire safety equipment
and building features described below. However, if these types of equipment or features
exist within the building, then the following maintenance, testing, and
inspection requirements apply.

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FS-EC.02.03.05EP1-28 a Policy Fire Safety Equipment Inspections

FS-EC.02.03.05EP1-27 b Attachment I – Fire Safety Equipment Inventory & Testing
(.xls)
FS-EC.02.03.05EP1-Supervisory Signal Devices

FS-EC.02.03.05EP2-Form Tamper Switches & Water Flows (.xls)

FS-EC.02.03.05EP3-a Form Duct Heat Smoke Detectors and Manual Fire Alarm Boxes
(.xls)
FS-EC.02.03.05EP3-b Form Systems Testing Matrix (.xls)

FS-EC.02.03.05EP4-Form Visual Audible Speakers and Door Releasing Devices (.xls)

FS-EC.02.03.05EP5-Form Emergency Services Notification Test Devices (.xls)

FS-EC.02.03.05EP6-Form Fire Pump Test (.xls)

FS-EC.02.03.05EP7-Form Water Tank Level Alarm (.xls)

FS-EC.02.03.05EP8-Form Water Tank Temperature Alarm (.xls)

FS-EC.02.03.05EP9-Form Main Drain Test (.xls)

FS-EC.02.03.05EP10-Form Fire Department Connections (.xls)

FS-EC.02.03.05EP11-Form Fire Pump Flow Test (.xls)

FS-EC.02.03.05EP12-Form Standpipe Systems (.xls)

FS-EC.02.03.05EP13-Form Kitchen Hood Systems (.xls)

FS-EC.02.03.05EP14-Form CO2 and Other Gaseous Fire Extinguishing Systems (.xls)

FS-EC.02.03.05EP15-Form Fire Extinguisher Inspection (.xls)

FS-EC.02.03.05EP16-Form Fire Extinguisher Maintenance (.xls)

FS-EC.02.03.05EP17-Form Fire Hose Test (.xls)

FS-EC.02.03.05EP18-Form Fire Damper Inspection (.xls)

FS-EC.02.03.05EP19-Form Air Handler Shutdown (.xls)

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FS-EC.02.03.05EP20-Form Steel Rolling Fire Doors (.xls)

FS-EC.02.03.05EP25-Form Door Assemblies (.xls)

FS-EC.02.03.05EP27-Form Firefighters Emer Operations (.xls)

EC.02.04.01: The hospital manages medical equipment risks.

MEDICAL EQUIPMENT RISKS – EC.02.04.01

ME-EC.02.04.01EP2-3, 7 a Policy on Medical Equipment Inventory

ME-EC.02.04.01EP4 a Policy on Maintaining, Inspection, & Testing Activities

ME-EC.02.04.01EP4 b Form- Attach I-Medical Equipment Assessment (.xls)

ME-EC.02.04.01EP5 a Policy on Testing New Medical Equipment

ME-EC.02.04.01EP6 a Policy on Criteria for Alternate Operations of Medical Equipment

ME-EC.02.04.01EP9 a Policy on Medical Equipment Failure & Emergency Response

ME-EC.02.04.01EP9 b Attachment I- Emergency Response-Clinical Interventions

ME-EC.02.04.01EP10 a Policy on Diagnostic Images

EC.02.04.03: The hospital inspects, tests, and maintains medical equipment.

ME-EC.02.04.03EP1 a Policy on Initial Testing & Installation

ME-EC.02.04.03EP2-5 a Policy on Testing Medical Equipment, Sterilizers, and Dialysis

ME-EC.02.04.03EP2 b Form- Attachment I- High-Risk Form (.xls)

ME-EC.02.04.03EP3 b Form- Attachment II- Non- High-Risk Form (.xls)

ME-EC.02.04.03EP4 b Form- Attachment III- Sterilization Report (.xls)

ME-EC.02.04.03EP5 b Form- Attachment IV- Dialysis Bacteria Testing Form (.xls)

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ME-EC.02.04.03EP8 a Policy on Equipment Listed for use in Oxygen-Enriched

Atmospheres

ME-EC.02.04.03EP10 a Policy on Hyperbaric Facilities

ME-EC.02.04.03EP16 – Policy for Testing & Calibration of Nuclear Med Equipment

ME-EC.02.04.03EP18 a Policy on Diagnostic Images

ME-EC.02.04.03EP20-21 a Policy on CT Services Testing

ME-EC.02.04.03EP20-21 b Attachment I- CT Services Performance Evaluation (.xls)

ME-EC.02.04.03EP22 a Policy on MRI Services Testing

ME-EC.02.04.03EP22 b Form- Attach I- MRI Services Performance Evaluation

ME-EC.02.04.03EP23 a Policy on NM Services Testing

ME-EC.02.04.03EP23 b Form- Attach I NM Services Performance Evaluation (.xls)

ME-EC.02.04.03EP24 a Policy on PET Services Testing

ME-EC.02.04.03EP24 b Form- Attach I PET Services Performance Evaluation (.xls)

ME-EC.02.04.03EP25 a Policy on Display Monitors Testing

ME-EC.02.04.03EP25 b Form- Attach I Display Monitors Performance Evaluation (.xls)

ME-EC.02.04.03EP26 a Maintenance on Anesthesia Apparatus

ME-EC.02.04.03EP27 a Policy on Electrical Equipment

ME-EC.02.04.03EP34 a Policy on Fluoroscopic Services

ME-EC.02.04.03EP34 b Form- Attach I-Fluoroscopic Services Performance Evaluation
(.xls)

EC.02.05.01: The hospital manages risks associated with its utility systems.

UT-EC.02.05.01EP1 a Designing & Installing Utility Systems

UT-EC.02.05.01EP2 a Building Systems and Risk Assessment

UT-EC.02.05.01EP3-4 Policy on Utility Systems Inventory

UT-EC.02.05.01EP3-6, 8 Utility Systems Inventory Form (.xls)

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UT-EC.02.05.01EP5 a Policy on Inspecting, Testing & Maintenance

UT-EC.02.05.01EP3-6, 8 Utility Systems Inventory Form (.xls)

UT-EC.02.05.01EP5 b Attach I-Utility System Assessment Form (.xls)

UT-EC.02.05.01EP3-6, 8 Utility Systems Inventory Form (.xls)

UT-EC.02.05.01EP6 a Policy on Inspecting, Testing & Maintenance New Utility

Systems
UT-EC.02.05.01EP3-6, 8 Utility Systems Inventory Form (.xls)

UT-EC.02.05.01EP7 a Policy on Criteria for Alternate Operations of Utility Systems

UT-EC.02.05.01EP8 a Policy on Identifying Operating Components of Utility Systems in

an AEM program
UT-EC.02.05.01EP3-6, 8 Utility Systems Inventory Form (.xls)

UT-EC.02.05.01EP9 a Policy on Labeling for Emergency Shutdown

UT-EC.02.05.01EP10-11 a Policy on Utility Systems Failure & Emergency Response

UT-EC.02.05.01EP10 b EOP ERP - Electrical and Generator Failure UT-
EM.02.02.09EP2
UT-EC.02.05.01EP10 c EOP ERP – Elevator Failure
UT-EC.02.05.01EP10 d EOP ERP – HVAC Failure UT-EM.02.02.09EP7
UT-EC.02.05.01EP10 e EOP ERP – Medical Gas Failure UT-EM.02.02.09EP6
UT-EC.02.05.01EP10 f EOP ERP – Natural Gas Failure UT-EM.02.02.09EP5
UT-EC.02.05.01EP10 g EOP ERP – Pneumatic Tube System Failure
UT-EC.02.05.01EP10 h EOP ERP – Sewer and Water Failure UT-EM.02.02.09EP3-4

UT-EC.02.05.01EP12 a Policy on Emergency Clinical Interventions

UT-EC.02.05.01EP12 b Initial Staff Response Grid Response (.xls)

UT-EC.02.05.01EP13 a Policy on Response to Utility System Disruptions

UT-EC.02.05.01EP14 a Policy on Managing Biological Agents

UT-EC.02.05.01EP14 b Attachment I – Risk Assessment for Monitoring Waterborne
Organisms Procedure

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UT-EC.02.05.01EP15 a Policy on Instl & Mgt App Press Relations in Critical Areas
UT-EC.02.05.01EP15 b Form- Air Pressure Relations, Temperature & Humidity in
Critical Areas

UT-EC.02.05.01EP16 a Policy on Instl & Mgt App Press Relations in Non-critical Areas
UT-EC.02.05.01EP16 b Form- Air Pressure Relations, Temperature & Humidity in Non-
critical Areas (.xls)

UT-EC.02.05.01EP17 a Policy for Mapping the Distribution of Utilities

UT-EC.02.05.01EP17 b Attachment I – Distribution Map Locations (.xls)

UT-EC.02.05.01EP18 a Medical Gas Storage Rooms

UT-EC.02.05.01EP19 a Emergency Power Systems UT-EC.02.05.03EP1-7, 11-16

UT-EC.02.05.01EP20 a Policy on Operating Rooms

UT-EC.02.05.01EP21 a Policy on Electrical Distribution

UT-EC.02.05.01EP22 a Policy on Hospital-Grade Receptacles

UT-EC.02.05.01EP23 a Policy on Relocatable Power Taps (RPTs)

UT-EC.02.05.01EP24 a Policy on Extension Cords

UT-EC.02.05.01EP25-27 a Areas Designated for Admin of General Anesthesia

EC.02.05.03: The hospital has a reliable emergency electrical power source.

UT-EC.02.05.03EP1-17, 11-16 a Policy on Emergency Power Systems UT-

EC.02.05.01EP19

EC.02.05.05: The hospital inspects, tests, and maintains utility systems.

Note: At times, maintenance is performed by an external service. In these cases, hospitals

are not required to possess maintenance documentation but must have access to such
documentation during survey and as needed.

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UT-EC.02.05.05 EP1 a Policy on Repair & Maint Risk Management

UT-EC.02.05.05 EP1 b Comprehensive RMRA Tool (.xls)
UT-EC.02.05.05 EP1 c Air Quality Assessment Tool (.xls)
UT-EC.02.05.05 EP1 d Noise Vibration Assessment Tool (.xls)
UT-EC.02.05.05 EP1 e Utility Systems Assessment Tool (.xls)
UT-EC.02.05.05 EP1 f Other Hazard Assessment Tool (.xls)
UT-EC.02.05.05 EP1 g Odor Risk Assessment Tool (.xls)

UT-EC.02.05.05EP2 Policy on Initial Testing of Utility Systems

UT-EC.02.05.05EP4-6 a Policy on Testing Utility Systems

UT-EC.02.05.05EP4 b Testing High-risk Utility System (.xls)
UT-EC.02.05.05EP5 c Testing Infection Control Operational Components (.xls)
UT-EC.02.05.05EP6 d Testing Non-High-risk Utility Systems (.xls)

UT-EC.02.05.05EP7 Policy on Line Isolation Monitoring Testing

UT-EC.02.05.05EP8 Meeting the Requirements of NFPA 99-2012 Chapters 6 & 9

EC.02.05.07: The hospital inspects, tests, and maintains emergency power systems.

Note: This standard does not require hospitals to have the types of emergency power
equipment discussed below. However, if these types of equipment exist within the building,
then the following maintenance, testing and inspection requirements apply.

EMERGENCY POWER SYSTEMS- EC.02.05.07

UT-EC.02.05.07EP1-2 a Policy for Testing Battery Powered Lights

UT-EC.02.05.07EP1-2 b Attachment I- Battery-powered Lights Log (.xls)
UT-EC.02.05.07EP1-2 c Attachment II- Exit sign inspection log (.xls)

UT-EC.02.05.07EP3 a Policy on SEPSS System

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UT-EC.02.05.07EP4-6 a Policy on Emergency Generators Testing

UT-EC.02.05.07EP4-6 b Form-Attachment I – Emergency Generator Test Log (.xls)
UT-EC.02.05.07EP4-6 c Form-Attachment II- Individual Generator Test Form (.xls)
UT-EC.02.05.07EP4-6 d Form-Attachment III-Individual Weekly Generator
Maintenance Log (.xls)

UT-EC.02.05.07EP7 a Policy on Automatic and Manual Transfer Switch Testing

UT-EC.02.05.07EP7 b Form-Attachment I- Automatic and Manual Transfer Switch Log
(.xls)

UT-EC.02.05.07EP8 Testing Diesel Fuel

UT-EC.02.05.07EP9-10 a Policy on Four-Hour Generator Testing

EC.02.05.09: The hospital inspects, tests, and maintains medical gas and vacuum systems.

Note: This standard does not require hospitals to have the medical gas and vacuum systems
discussed below. However, if a hospital has these types of systems, then the following
inspection, testing, and maintenance requirements apply.

UT-EC.02.05.09EP1-6 a Management of Gas Storage Locations

UT-EC.02.05.09EP7 a Policy on Maint & Testing of Piped Medical Gas and Vacuum

UT-EC.02.05.09EP8-9 a Policy on Bulk Oxygen

UT-EC.02.05.09EP10 a Testing Purity, Pressure, Etc. of Piped Medical Gas

UT-EC.02.05.09EP11 a Access & Labeling of Medical Gas Systems

UT-EC.02.05.09EP12 a Compressed Gas Cylinders

UT-EC.02.05.09EP13 a Policy on Transfilling

UT-EC.02.05.09EP14 a Meeting the Requirements of NFPA 99-2012 Chapters 5 & 11

EC.02.06.01: The hospital establishes and maintains a safe, functional environment.

Note: The environment is constructed, arranged, and maintained to foster patient safety,
provide facilities for diagnosis and treatment, and provide for special services appropriate
to the needs of the community.

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AE-EC.02.06.01EP1-26 a Policy Providing a Safe Environment

AE-EC.02.06.01EP1-26 b Appropriate Environment Checklist (.xls)

EC.02.06.05: The hospital manages its environment during demolition, renovation, or new
construction to reduce risk to those in the organization.

MC-EC.02.06.05EP 1 a Policy on Planning Construction Activities

MC-EC.02.06.05EP2 a Policy on Preconstruction Risk Assessment (PRA)

MC-EC.02.06.05EP2 a2 Policy on Hot Work

MC-EC.02.06.05EP2 b PRA Team

MC-EC.02.06.05EP2 c Project List (.xls)
MC-EC.02.06.05EP2 d Comprehensive PRA Tool (.xls)
MC-EC.02.06.05EP2 e Air Quality Assessment (.xls)
MC-EC.02.06.05EP2 f Noise & Vibration Assessment (.xls)
MC-EC.02.06.05EP2 g Utility Systems Disruption Assessment (.xls)
MC-EC.02.06.05EP2 h Other Hazards Assessment (.xls)
MC-EC.02.06.05EP2 i Form-Attach I- Hot Work Inspections, Instructions and Fire
Watch Log (.xls)

MC-EC.02.06.05EP2 a2 Policy on Infection Control Risk Assessment for Construction

MC-EC.02.06.05EP2 b2 Infection Control Risk Assessment (.xls)
MC-EC.02.06.05EP2 c2 Infection Control Risk Monitoring Form (.xls)

MC-EC.02.06.05EP3 a Policy on Construction Monitoring

MC-EC.02.06.05EP3 b Air Quality Monitoring Form (.xls)
MC-EC.02.06.05EP3 c Noise & Vibration Monitoring Form (.xls)
MC-EC.02.06.05EP3 d Utility Systems Monitoring Form (.xls)
MC-EC.02.06.05EP3 e Other Hazards Monitoring Form (.xls)

MC-EC.02.06.05EP4-6 a Policy on New Imaging Construction

EC.03.01.01: Staff and licensed independent practitioners are familiar with their roles and
responsibilities relative to the environment of care.

RR-EC.03.01.01EP1-2 a Policy on Orientation & Education

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EC.04.01.01: The hospital collects information to monitor conditions in the environment.

CM-EC.04.01.01EP1 a Policy on Process for Monitoring

CM-EC.04.01.01EP3 a Policy on Occurrence Reporting

CM-EC.04.01.01EP4 a Policy on Occupational Illness & Injury

CM-EC.04.01.01EP5 a Policy on Reporting Property Damage

CM-EC.04.01.01EP6 a Policy on Reporting Security Incident

CM-EC.04.01.01EP8 a Policy on Reporting Hazmat Incident

CM-EC.04.01.01EP9 a Policy on Reporting Fire Safety Incident

CM-EC.04.01.01EP10 a Policy on Reporting Medical Equipment Incident

CM-EC.04.01.01EP11 a Policy on Reporting Utility System Incident

CM-EC.04.01.01EP15 a Policy on Annual Evaluations

CM-EC.04.01.01EP15 b Attachment I- Safety Annual Evaluation 2019
CM-EC.04.01.01EP15 c Attachment II- Security Annual Evaluation 2019
CM-EC.04.01.01EP15 d Attachment III- HAZMAT Annual Evaluation 2019
CM-EC.04.01.01EP15 e Attachment IV- Fire Safety Annual Evaluation 2019
CM-EC.04.01.01EP15 f Attachment V- Medical Equipment Annual Evaluation 2019
CM-EC.04.01.01EP15 g Attachment VI- Utility Systems Annual Evaluation 2019

EC.04.01.03: The hospital analyzes identified environment of care issues.

AN-EC.04.01.03EP2 a Policy of the EOC Committee

EC.04.01.05: The hospital improves its environment of care.

IM-EC.04.01.05EP1 a Policy on Performance Monitoring

IM-EC.04.01.05EP1 b Attach I- Identified Physical Environment Issues Log

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