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Accreditation Compliance Services Available

Conducting a Continuous Readiness Survey for the Environment of Care/Physical Environment
Teri Alameda has participated in numerous successful accreditation surveys and brings her expertise to you.  Comprehensive inspections and audits for regulatory agencies (e.g. OSHA) are also available.  A continuous readiness survey will simulate a real agency survey and will include the document review, a building tour, and an EC functional interview with key staff.

The document review will focus on:
  • Management plans and associated annual evaluations
  • Quality improvement/performance monitoring data
  • Preventive maintenance records
  • Risk Assessments
  • Policy and Procedures
  • Committee Meeting Minutes

The unit visits can include the tracer methodology to evaluate staff knowledge and activities of various components of the organization’s environment of care/physical environment programs.  The functional interview will evaluate issues and processes and allow yourstaff to practice discussing their programs in an effective manner.

Reviewing and Developing Your Plans to Meet the Environment of Care/Physical Environment
Each applicable standard is reviewed and compared with your existing documentation and/or operations. A gap analysis is performed to identify out of compliance or nonexistent processes. Strategic planning and recommendations to identify priorities for an effective action plan are provided. Suggestions and draft documents for improvement can be customized for your facility's needs. 

Developing or Revising Your Policy and Procedure Manuals: Our consultants can provide a comprehensive review of your existing procedure manual and enhance what you have to meet regulatory requirements and/ or develop new programs.

Management Plan and Annual Evaluations: Our customized plans include scope, objective, performance and clarify in advance what is considered an effective program so the annual evaluation is comprehensive.

Proactive Risk Assessment: Teri Alameda Health and Safety Consultation, Inc. has extensive practical experience that can assist your organization to develop or enhance proactive risk assessments to improve safety, security, quality and identify and mitigate threats. Although the risk assessments are mandated by regulatory agencies, these tools are very useful in helping your team assess, measure and prioritize.

Supporting Your Environment of Care/Safety Committees: The Committee is evaluated to ensure that your program is focused on continuous improvement of operational systems that impact quality and safety. Our review will ensure that you have “closed the loop” by:
  • Implementing recommended interventions
  • Measuring effectiveness of programs
  • Documenting appropriate actions in the minutes and quarterly reports
  • Making recommendations and share appropriate information with the Leadership Team
  • Incorporating Training Tools and Workshops

Safety Officer Mentorship: 
On site Safety Officer Mentorship is available.

Security Program:
We can examine your security procedures and systems for vulnerabilities and provide quality solutions. Available services include:
  • Security risk assessment
  • Evaluation of the personnel identification systems and access control 
  • Roles and participation in emergency preparedness drills
  • Security incident investigations 
  • Policies and procedures and orientation and education programs

Fire Program and Interim Life Safety Measures: A comprehensive review of your existing fire safety and evacuation plans is available. The review will also evaluate fire equipment maintenance schedules, measure quality improvement and enhance your present procedures. ILSM program development is available.

Hazardous Material/Waste: Our customized compliance plans can include procedures, training tools and recommendations for effective hazardous materials and waste program.  We can evaluate if your organization is ready to deal with an internal hazardous material release; how to handle an external incident in which you are responsible for the victims of contamination and/or how to comply with a regulatory audit of your hazardous material/waste program

Medical Equipment and Utility Programs:
The following services are available:
  • Medical equipment program audits
  • Development or revision of medical equipment policy/procedure manual 
  • Utility management surveys
  • Development of utility failure plans in the Hospital Incident Command System format
Environmental Services: Audits are available for Environmental Services on staff knowledge, isolation precautions, cleaning practices and medical waste management
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