Joint Commission Environment of Care Compliance

Teri Alameda has over 15 years experience in the fields of Environmental, Health and Safety. She has participated in numerous successful Joint Commission surveys.

Teri provides healthcare regulatory management services to many facilities in the United States. She routinely provides compliance audits, risk assessments, policy and program development, monitoring, development of tailored training curriculum, as well as a focus on vulnerability reduction.

Conducting A Mock Survey With A Tracer

Teri Alameda has participated in numerous successful Joint Commission surveys and brings her expertise to you.

A mock survey will simulate a real agency survey and will include the document review, a building tour, a tracer and an EC functional interview with key staff.

The document review will focus on:

  • Management plans
  • Emergency Operation Plan
  • Drills, exercises
  • Statement of condition
  • Hazard Vulnerability Analysis and other risk assessments
  • Quality improvement/performance monitoring data
  • Preventive maintenance records
  • Annual evaluations
  • Risk Assessments

The Building Tour will focus on the life safety components of the program. This will include fire and smoke barriers;,exits and hazardous areas.

The unit visits with the tracer methodology will evaluate staff knowledge and activities of various components of the organization’s environment of care programs.

The EC Functional Interview will evaluate issues and processes related to the seven EC management areas and ILSM program and allow your staff to practice discussing their programs in an effective manner.

Reviewing And Developing Your Risk and Safety Plans

REVIEWING AND DEVELOPING YOUR COMPREHENSIVE ENVIRONMENT OF CARE (EOC) PROGRAM: A comprehensive review and assessment of your Environment of Care program is a specialty of Teri Alameda. 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 PROACTIVE RISK ASSESSMENT: Teri Alameda's extensive practical experience will help you develop or enhance your proactive risk assessments to improve safety, security, quality and identify and mitigate threats. Although the risk assessments are mandated by regulatory agencies, her tools are useful in helping your team assess, measure and prioritize. The risk assessment is an important step in protecting your patients, staff and facility.

DEVELOPING OR REVISING YOUR POLICY AND PROCEDURE MANUALS: Teri Alameda can provide a comprehensive review of your existing Environment of Care manual and enhance what you have to meet regulatory requirements.

She can customize new Environmental Health and Safety Procedures, which are proven to provide thorough and effective information in an easy-to-use format.

FIRE AND INTERIM LIFE SAFETY MEASURES (ILSM): She can provide a comprehensive review of your existing Fire safety and evacuation plans. The recommendations to enhance your current fire/evacuation plans will meet regulatory requirements, include tools to document drills and critiques and incorporate department specific templates The plan will also provide fire equipment maintenance schedules, measure quality improvement and enhance your present procedures. ILSM program development available.

REVIEW YOUR HAZARDOUS MATERIAL SYSTEMS: With the increasing demands of governmental requirements to prepare for Mass Casualty Incidents, your program will be evaluated to determine:

  • If you are 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
  • How to comply with a regulatory audit of your hazardous material/waste program

Teri Alameda's compliance plans include procedures, training tools and recommendations for effective equipment.


EquipmentThe following services are available:

  • Medical equipment program audits
  • Development or revision of medical equipment manual
  • Utility management surveys
  • Utility failure plans in Hospital Incident Command System format

Teri Alameda can provide:

  • The management plans
  • Equipment failure exercises and incident critiques
  • Review of the Statement of conditions
  • Risk assessments
  • Policies and procedures
  • Quality improvement/performance monitoring data
  • Preventive maintenance record review
  • Annual evaluation
  • Audit of staff knowledge in the procedures in the event of a failure of the medical equipment and/or utility system
  • Organization of programs in a manner to expedite retrieval of the documents
  • Review of recalls and safety alert program

REVIEW YOUR SECURITY PROGRAM: The company will 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

Supporting Your EOC/Safety Committees and Evaluating Performance (ICES)

Teri Alameda can evaluate your organization’s Environment of Care/Safety Committee 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 related to the EC Program and share appropriate information with the Governing Body


  • Provide training to meet requirements for the California Medical Facility Infection Control and Prevention Act or Nile’s Law
  • Audits available for Environmental Services on staff knowledge, isolation precautions, cleaning practices and medical waste management

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