Checking And Corrective Action

• Monitoring and Measurement
• Evaluation of Compliance
• Nonconformity, Corrective Action and Preventive Action
• Control of Records
• Internal Audit

Monitoring And Measurement—Procedure SOM-P-MM-10

1. The SOM has established and maintains documented procedures to regularly monitor the key characteristics of its operations and activities that can have a significant impact on the environment to ensure they are addressed and handled in the most effective manner.
2. Roles and responsibilities have been assigned to SOM personnel and established procedures or mechanisms to track GEMS progress in meeting objectives and targets. Performance metrics have been established to measure progress in accomplishing objectives and targets. All calibration of equipment, including monitoring equipment, is carried out according to each SOM unit calibration schedule.  

Evaluation of Compliance - Procedure SOM-P-EC-11

1. The SOM has established and implemented a comprehensive compliance evaluation program to meet the GEMS program requirements in accordance with the EH&S Department at the University of South Carolina (USC)  The USC EH&S Department provides the SOM with periodic compliance evaluation, to ensure compliance with relevant local, state, and federal authorities. 
2. The SOM evaluates other requirements to which it subscribes/
3. Records of periodic evaluation and other requirements are maintained at the EH&S Office, which is in accordance with the Control of Records Procedure

Nonconformity, Corrective Action and Preventive Action—Procedure SOM-P-CAR-12

1. Designated SOM personnel to work with the USC EH&S Department and the Dorn Hospital's GEMS committee for handling and investigating GEMS nonconformance and noncompliance, taking action to mitigate and impacts caused, and for initiating and completing corrective and preventive action.  The SOM has implemented and recorded any changes in the documented procedures resulting from corrective and preventive action.  
2. The SOM documents its nonconformance and noncompliance deficiencies, recommended corrective actions, problem solving efforts, and plan actions and milestones for recommended corrective actions.  In areas of regulatory non-compliance the USC EH&S Department would keep all documentation of non-compliance.
3. Environmental management corrective and preventive actions will also address SOM services as related to educational and medical standards  in order to maintain or enhance hospital services.  All non-conformances that occur are identified through GEMS reviews or GEMS management review and are corrected through SOM corrective action forms.  SOM provides an action report to USC and to the GEMS committee on according to they type of action taking place.  Actions that contains a summary of corrective and preventive actions, a program area status summary, and an updated internal assessment plan.

Control of Records—Procedure SOM-P-REC-13  

1. SOM has established and maintains documented procedures for identification, maintenance and disposition of environmental records.  Records are handled in accordance with USC EH&S and SOM policy. Records retention period is determined through legal and other requirements of SOM in accordance with regulatory and departmental procedures.
2. SOM ensures through its procedures that all records are legible, identifiable and traceable to the practice involved.
3. Records are stored and maintained in a manner that they are readily retrievable and protected against damage, deterioration, or loss.

Internal Audit —Procedure SOM-P-SA-14

The SOM has established and maintains documented procedures for periodic EMS reviews to be carried out in order to:

1. Determine whether or not the EMS conforms to the VHA GEMS Program, the ISO 14001:2004 EMS and the USC EMS policy, and has been properly implemented and maintained.
2. Provides information on the results of reviews to management, and retains associated records.