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It lists example likely gaps, assigns related item numbers and gap types (e.g., policy, practice, monitoring), and maps requirements to document review targets, procedures to observe, and involved stakeholders. 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Documents may include policies and procedures, bylaws, quality program plans, surveys, board minutes, etc  \n| JCI FMS Chapter Team |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| ITEM | LIKELY GAP\u003Cbr>(where your current state doesn’t match the desired state) | RELATED \\# | GAP TYPE\u003Cbr>POL = Policy PRA = Practice MON = Monitoring | TYPE OF REQUIREMENT\u003Cbr>Policies and Procedures Documentation Communication Education Competency Responsibility\u003Cbr>Monitoring/Checking for Changes Data Collection and Analysis\u003Cbr>Time Limits Scope/Range | DOCUMENTS TO REVIEW | PROCEDURES TO OBSERVE | STAKEHOLDERS\u003Cbr>(of the various documents and processes the requirements address.*) | QUESTIONS TO ASK STAKEHOLDERS |\n| 1 | Hazardous materials inventory and documentation of types, locations, and quantities | FMS.5, ME1 and ME5 | PRA | Policies and Procedures, Documentation, Responsibility | Hazardous\u003Cbr>Materials\u003Cbr>and Waste Program, Hazardous\u003Cbr>Materials\u003Cbr>and Waste\u003Cbr>Inventory | Process of updating the inventory of hazardous materials and waste | Facility management staff | Who updates the hazardous materials and waste inventory? How often is it done?\u003Cbr>Can you show me where on the inventory it shows the location and quantity of each type of hazardous material and waste? Can you take me to one of the locations listed? |\n| 2 | Labeling hazardous\u003Cbr>materials\u003Cbr>and waste | FMS.5, ME4 | PRA | Policies and Procedures, Education | Hazardous\u003Cbr>Materials\u003Cbr>and Waste Program | Labeling of hazardous materials and waste | Nursing and medical staff; facility management staff | Can you please show me how you label hazardous materials and waste in this department/unit?\u003Cbr>When was your last training on this process?\u003Cbr>May I please see the policy that covers this process? |\n\nPATHWAY TO ACCREDITATION","cbCaiq7HMBWkMuLb","https://ap.wps.com/l/cbCaiq7HMBWkMuLb","pdf",128033,"English","# Gap Analysis Plan Form\n## Stakeholders and documents to review\n## Likely gaps and validation questions","[{\"question\":\"What questions does the form ask for hazardous materials inventory and labeling?\",\"answer\":\"It asks who updates the hazardous materials and waste inventory and how often, whether the inventory shows locations and quantities, and whether labeling methods and supporting policies are available, including the date of the last training.\"}]","Gap Analysis Plan Form - Hazardous Materials and Waste Program | PDF",1789152090]