Regulated Medical Waste Solid Waste Facilities & Grounds Regulations & Standards

Guide to JCAHO Environment of Care Standard 3.10.3

Please note: this page is under development. Contact (603) 795-9966,
if you have questions or suggestions.

Introduction        Table of Contents       Checklist for 3.10.3

Environment of Care Standard 3.10: The organization manages hazardous materials and waste risks

Element of Performance 3. Implementation of Hazardous Material and Hazardous Waste Program

The organization establishes and implements processes for selecting, handling, storing, transporting, using and disposing of hazardous materials and wastes from receipt or generation through use and/or final disposal, including managing the following: chemicals, chemotherapeutic materials, pharmaceuticals, radioactive materials and infectious and regulated medical waste including sharps. 

This page provides a set of criteria for evaluating how well a facility has implemented its procedures for managing hazardous materials and waste.  The criteria have been grouped into categories covering:

  • general management topics (procuring, handling, and disposing of various classes of waste)
  • specific materials and wastes of concern
  • facilities and equipment

Categories:

= Compliance
= Environmental Improvement
= Tools and Resources

Hazardous Materials Management

  Purchasing
bullet Newly purchased hazardous materials are added to the inventory.

   

Inventory:  EC 3.10.2

 

bullet
Purchasing policy promotes selection of less hazardous, environmentally preferable products.

   

Plan: EC3.10.1

Inventory:  EC 3.10.2

Impl. (Univ. Waste): EC3.10.3

Roles (Risk Min.): HR2.20.2

 

bullet TRACER Staff can describe environmentally preferable products that are in use, e.g. non-toxic or less-toxic cleaners, mercury-free medical devices (thermometers, blood pressure cuffs), or other hazardous chemical alternatives. 
bullet Purchase non-PVC equipment to eliminate patient risks associated with DEHP and environmental risks associated with dioxin formation from the incineration of PVC.
bullet TRACER Staff are trained to use less hazardous chemicals to reduce exposures, and generate less waste.
  • Having fewer hazardous materials on-hand means having fewer to manage.  Purchase and track products that are are non-toxic or less toxic, use less energy, have less waste associated with them and are made with recycled content materials.
  • H2E:
 

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  Handling, labeling, and storage
bullet Facility maintains a hazardous materials inventory that lists all hazardous chemicals used, and their locations.

   

Plan: EC3.10.1

<Inventory:  EC 3.10.2

 

bullet Facility maintains an MSDS management program.

   

 

Hazard communication: 29 CFR 1910.1200

Material safety data sheets: 29 CFR 1910.1200 (g)

bullet Hazardous materials are labeled (with name, hazard warnings, hazard symbols, etc.), and are stored, handled, and used appropriately.

   

 

Hazard communication: 29 CFR 1910.1200

bullet Personal protective equipment is available, appropriate to hazards and maintained.

   

 

Personal Protective Equipment (general): 29 CFR 1910.132

Personal Protective Equipment (eye, face): 29 CFR 1910.133

Personal Protective Equipment (respiratory): 29 CFR 1910.134

Personal Protective Equipment (head): 29 CFR 1910.135

Personal Protective Equipment (foot): 29 CFR 1910.136

bullet TRACER Staff can describe appropriate handling procedures and personal protective equipment to be used with hazardous material in question
bullet Storage cabinets and/or storage rooms are available for the storage of flammable liquids and other hazardous chemicals as appropriate.

   

=Space: EC3.10.4

=Separation: EC3.10.10

Accidental ignition or reaction: 40 CFR 265.17

bullet Personal protective equipment is reused whenever possible (e.g. gowns).
 

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  Spills
bullet Spill clean up procedures are in place in all areas where hazardous materials are used and/or stored.

   

 

[need citation]

bullet Spill clean up residues are managed as hazardous waste.

   

=Emergency: EC3.10.6

Hazardous waste definition 40 CFR 261.3

bullet Spills are reported to local authorities and National Response Center, if necessary.

   

=Emergency: EC3.10.6

Emergency procedures (SQG): 40 CFR 262.34 (d)(5)

Contingency plan (emergency procedures): 40 CFR 265.56

bullet Spill control and decontamination equipment is readily available in areas where hazardous materials are used.

   

  Required equipment for HazWaste facilities: 40 CFR 265.32
bullet Spill control equipment is maintained in usable condition.

   

 

Maintaining equipment for HazWaste facilities: 40 CFR 265.33

bullet

Eyewashes and showers (ANSI approved) are available in all areas where hazardous materials are routinely used and/or stored, and are checked regularly.

   

 

Medical services, first aid: 29 CFR 1910.151 (c)

bullet All employees who may be involved in spills are appropriately trained.  Spill response team members are HAZWOPER trained.

   

Impl. (HazWaste): EC3.10.3

Emerg. (HazWaste): EC3.10.6

Emerg. (RMW): EC3.10.6

Roles (Incident): HR2.20.3

Hazardous waste operations (HAZWOPER) training: 29 CFR 1910.120 (e)

Emergency response plan (OSHA): 29 CFR 1910.120 (l)(1)

Emergency procedures (SQG): 40 CFR 262.34 (d)(5)

Contingency plan (emergency procedures): 40 CFR 265.56

bullet TRACER Staff respond appropriately to spills of hazardous material used in patient care (e.g. mercury, formalin, glutaraldehyde, etc.).

   

Competence: HR2.10.9

 

 (Staff competence: HR2.10.9, Safety roles: HR2.20.2).

  • Hazardous material elimination or minimization programs reduce the potential for spills. Where the risk of spills is high, consider an alternative less hazardous material, and ensure proper training and education in that area to reduce the overall risk of spills.

bullet Hazardous Material Spill Policy is established and implemented..
  • Sample Hazardous Material Spill Policy [link]

 

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  Training
bullet Staff are trained on hazards of materials used and appropriate handling and use of protective equipment.

   

Competence: HR2.10.9

Roles  (Risks): HR2.20.1

Hazardous waste operations (HAZWOPER) training: 29 CFR 1910.120 (e)

Personal Protective Equipment (general): 29 CFR 1910.132

Personal Protective Equipment (eye, face): 29 CFR 1910.133

Personal Protective Equipment (respiratory): 29 CFR 1910.134

Personal Protective Equipment (head): 29 CFR 1910.135

Personal Protective Equipment (foot): 29 CFR 1910.136

Hazard communication (OSHA): 29 CFR 1910.1200

bullet Staff are trained and competency tested in appropriate spill response for hazardous materials and waste.

   

Plan: EC3.10.1

Impl. (HazWaste): EC3.10.3

Emerg. (HazWaste): EC3.10.6

Emerg. (RMW): EC3.10.6

Roles (Incident): HR2.20.3

Emergency response training (OSHA): 29 CFR 1910.120 (e)(7)

Emergency response plan (OSHA): 29 CFR 1910.120 (l)(1)

Emergency procedures (SQG): 40 CFR 262.34 (d)(5)

Employees familiar with HazWaste handling: 40 CFR 262.34 (d)(5)(C)(iii)

Contingency plan (emergency procedures): 40 CFR 265.56

bullet Documentation for all training, including staff trained, content covered, competency levels attained, and dates of training, is kept for a minimum of 3 years.
bullet TRACER Staff respond appropriately regarding use of hazardous material used in patient care, e.g. solvents for specimen analysis, cleaning agents for rooms, sterilants for surgical procedures.
bullet TRACER Staff respond appropriately regarding clean up of a hazardous material spill used in patient care, e.g. formalin, disinfectant, glutaraldehyde.
bullet TRACER Staff respond appropriately regarding disposal of hazardous material used in patient care, e.g. solvents for specimen analysis, aerosols, cleaning agents for rooms, sterilants for surgical procedures, drug disposal.
bullet
TRACER Staff can describe elimination and/or substitution of less hazardous materials as part of the facility’s environmental improvement, e.g. use of biodiesel, rechargeable batteries, energy-efficient equipment and vehicles, mercury-free devices, ethylene oxide elimination.
bullet Mandatory Hazard Communication Training during new employee orientation sessions includes environmental improvement elements such as waste prevention, using less materials, commitment to environmental performance, etc.
bullet Waste prevention and proper waste handling requirements are included in all employee job descriptions, according to a progressive facility-wide policy. (This is important, particularly where safety issues are concerned.  It will also emphasize the importance of participation in pollution prevention commitments.)
 

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  More resources
  • Hazardous materials are most often found in Dialysis, Environmental Services/Housekeeping, Facilities Management, Laboratories, Nursing Care, Nutrition Services, Oncology, Pharmacy, Radiology, Surgery, Emergency Services and Vehicle Maintenance.
 
 
 

Hazardous Waste Management

  Recordkeeping and reporting
bullet The facility has obtained an EPA Identification Number.

   

 

HERC:  Managing Hazardous (RCRA) Wastes (EPA ID)

EPA ID number: 40 CFR 262.12

bullet Generator status is determined and reviewed monthly.

   

 

HERC:  Managing Hazardous (RCRA) Wastes (Generator status)

Determining generator status is an implicit requirement for compliance with Hazardous waste accumulation time: 40 CFR 262.34

Reporting for SQGs: 40 CFR 262.44, and other regulations.

bullet
Facility is working toward moving to smaller quantity generator status by minimizing hazardous materials present on site.
bullet The basis for hazardous waste determinations is documented.

   

 

HERC: Hazardous Waste Determination

Hazardous waste determination: 40 CFR 262.11

Hazardous waste recordkeeping: 40 CFR 262.40

bullet Facility submits Biennial Reports on EPA Form 8700-13A each even-numbered year.

   

 

HERC:  Managing Hazardous (RCRA) Wastes (Biennial Report)

Biennial reports: 40 CFR 262.41

bullet Manifest copies are managed properly (e.g. appropriate copies are received from the treatment facility and are routed to the regulatory authority).

   

=Manifests: EC3.10.8

Manifests: 40 CFR 262.20

Hazardous waste recordkeeping: 40 CFR 262.40

bullet Manifests, Biennial Reports, and records of test results and analyses are kept on site for a minimum of three years.

   

>Documentation: EC3.10.7

>Manifests: EC3.10.8

Hazardous waste recordkeeping: 40 CFR 262.40

bullet Land Disposal Restriction notices are kept for a minimum of three years.

   

=Documentation: EC3.10.7

Land disposal restrictions (index page): 40 CFR 268

Land disposal restrictions, recordkeeping: 40 CFR 268.7

bullet Weekly inspections of the hazardous waste storage areas are performed and documented according to written procedures  Inspections include checking for leaks, corroded containers, and other potential problems.

   

=Space: EC3.10.4

=Separation: EC3.10.10

Hazardous waste storage inspections (LQG): 40 CFR 265.174

 

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  Hazardous waste determination
bullet A RCRA hazardous waste determination has been made for all solid waste that is generated.  Examples of potential sources of hazardous waste include:
  • waste pharmaceuticals  HERC:  Pharmaceutical Wastes
  • laboratory chemicals and reagents
  • formalin
  • chemicals/anesthetics used in surgery
  • waste rags with solvent
  • aerosols
  • disinfectants
  • sterilants
  • x-ray contrast media
  • waste electronics

   

 

HERC: Hazardous Waste Determination

Hazardous waste definition: 40 CFR 261.3

Hazardous waste determination: 40 CFR 262.11

bullet Containers with hazardous materials, (e.g. aerosol cans, chemotherapy agents) are completely emptied or managed as hazardous waste.

   

  Hazardous waste residues in empty containers: 40 CFR 261.7
bullet Containers that held P-listed wastes are managed as hazardous waste.

   

  Hazardous waste residues in empty containers: 40 CFR 261.7
bullet Mixed wastes (e.g., radioactive and hazardous wastes, infectious and hazardous wastes) are properly evaluated and disposed of. 

   

  Low level mixed waste (index page): 40 CFR 266.210-360
bullet Facility is minimizing hazardous waste generation to avoid making and documenting determinations.
  • National Cancer Institute:  Information page on Mixed Waste.  (The waste management procedures in the table at the bottom of the page should be considered to apply only to the facility that produced the page.)
 

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  Storage
bullet Hazardous waste storage areas are secure, and are operated to prevent releases to the environment (e.g. facility has provided for secondary containment of containers).

   

<Space: EC3.10.4

<Separation: EC3.10.10

Security: 40 CFR 265.14
bullet Hazardous waste is stored in non-leaking, sturdy, compatible containers that are kept closed unless adding or removing waste.

   

>Space: EC3.10.4

Hazardous waste accumulation time: 40 CFR 262.34

Condition of hazardous waste containers: 40 CFR 265.171

Compatibility of hazardous waste and containers: 40 CFR 265.172

Management of hazardous waste containers: 40 CFR 265.173

bullet Storage areas are clean and organized.
bullet Containers are protected from weather, fire, physical damage, and vandals.
bullet Adequate aisle space is maintained in the hazardous waste storage area to ensure access to containers in event of spills or leaks.

   

=Space: EC3.10.4      

=Separation: EC3.10.10

Adequate aisle space: 40 CFR 265.35
bullet Weekly inspections of the hazardous waste storage areas are performed, and are documented according to written procedures, to check for leaks, corroded containers, or other problems.

   

=Space: EC3.10.4

=Separation: EC3.10.10

Hazardous waste storage inspections (LQG): 40 CFR 265.174
bullet Containers of hazardous waste are marked with the words “Hazardous Waste”, and a descriptive name of the waste.

   

=Space: EC3.10.4 

=Separation: EC3.10.10

HERC:  Managing Hazardous (RCRA) Wastes (Main Storage Area)

Hazardous waste accumulation time: 40 CFR 262.34 (c)1(ii)

bullet Incompatible wastes are segregated.

   

  Incompatible wastes: 40 CFR 265.177
bullet Precautions are taken to prevent accidental ignition of ignitable waste, or reaction of reactive waste, by (among other measures) separating the waste from sources of ignition or reaction (e.g. open flames, smoking, sparks, welding, hot surfaces).

   

  Accidental ignition or reaction: 40 CFR 265.17
 

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  Satellite accumulation
bullet Containers are located within the immediate operator control and are inspected daily.

   

 

Hazardous waste accumulation time: 40 CFR 262.34 (c)1

bullet Containers are labeled with a descriptive name of the waste and  the words “Hazardous Waste”. 

   

 

HERC:  Managing Hazardous (RCRA) Wastes (Satellite Accumulation Area)

Hazardous waste accumulation time: 40 CFR 262.34 (c)1(ii)

bullet When satellite accumulation containers are full they are moved to the hazardous waste storage area within three days and marked with the accumulation start date. 

   

 

Hazardous waste accumulation time: 40 CFR 262.34 (c)(2)

 

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  Spills
bullet Spill clean up procedures are in place in all areas where hazardous waste is handled and/or stored

   

Space: EC3.10.4 Hazardous waste accumulation time: 40 CFR 262.34
bullet Spill clean up residues are managed as hazardous waste.

   

=Emergency: EC3.10.6

Hazardous waste definition: 40 CFR 261.3

bullet Spills are reported to local authorities and National Response Center, if necessary.

   

=Emergency: EC3.10.6

Hazardous waste accumulation time: 40 CFR 262.34

bullet Spill control and decontamination equipment is readily available in areas where hazardous waste is handled or stored.

   

=Space: EC3.10.4

Required equipment for HazWaste facilities: 40 CFR 265.32

bullet Spill control equipment is maintained in usable condition.

   

=Emergency: EC3.10.6

Maintaining equipment for HazWaste facilities: 40 CFR 265.33

bullet Eyewashes and showers (ANSI approved) are available in all areas where hazardous waste is routinely handled and/or stored, and are checked regularly.

   

 

Medical services, first aid: 29 CFR 1910.151 [check GPO link]

bullet All employees who may be involved in spills are appropriately trained.  Spill response team members are HAZWOPER trained.

   

Impl. (HazWaste): EC3.10.3

Emerg. (HazWaste): EC3.10.6

Emerg. (RMW): EC3.10.6

Roles (Risk Min.): HR2.20.2

Roles (Incident): HR2.20.3

Hazardous waste operations (HAZWOPER) training: 29 CFR 1910.120 (e)

Emergency response plan (OSHA): 29 CFR 1910.120 (l)(1)

Emergency procedures (SQG): 40 CFR 262.34 (d)(5)

Contingency plan (emergency procedures): 40 CFR 265.56

 

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  Disposal and Transportation
bullet Hazardous waste is shipped offsite for treatment or disposal within appropriate timeframes based on generator status (90 days Large Quantity Generator or 180 days Small Quantity Generator).

   

 

Hazardous waste accumulation time: 40 CFR 262.34

bullet Determination of treatment requirements for land disposal of hazardous waste have been performed.

   

 

Land disposal treatment standards: 40 CFR 68.40

bullet Hazardous waste must be shipped to a facility permitted to handle the waste.

   

 

Manifests (EPA): 40 CFR 262.20 (b)

bullet Hazardous waste must be shipped using a hazardous waste manifest.

   

Manifests: EC3.10.8 Manifests (EPA): 40 CFR 262.20

Hazardous waste manifest (DOT): 49 CFR 172.205

bullet Waste is properly marked and packaged for transportation.

   

 

Hazardous waste packaging: 40 CFR 262.30

Hazardous waste labeling: 40 CFR 262.31

Hazardous waste marking: 40 CFR 262.32

HazMat table (DOT): 49 CFR 172.101

Labeling (DOT): 49 CFR 172.400

Lab pack exception: 49 CFR 173.12

bullet Hazardous waste transport vehicle is properly placarded if necessary.

   

 

Hazardous waste placarding: 40 CFR 262.33

Placarding: 49 CFR 172.500

 

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  Contingency Planning
bullet A Contingency plan is in place if the facility is a Large Quantity Generator.

   

 

Contingency plan (purpose): 40 CFR 265.51

Contingency plan (content): 40 CFR 265.52

Contingency plan (copies): 40 CFR 265.53

Contingency plan (amendment): 40 CFR 265.54

Contingency plan (emergency coordinator): 40 CFR 265.55

Contingency plan (emergency procedures): 40 CFR 265.56

bullet An emergency coordinator is designated and has authority to commit resources if necessary.

   

=Emergency: EC3.10.6

Safety Coord.: EC1.10.2

Emergency coordinator responsibilities: 40 CFR 262.34 (d)(5)(C)(iv)

Contingency plan (emergency coordinator): 40 CFR 265.55

bullet The provisions of the hazardous waste contingency plan are carried out immediately whenever there is a fire, explosion, or release of hazardous waste or hazardous waste constituents which could threaten human health or the environment.

   

  Contingency plan (emergency procedures): 40 CFR 265.56
bullet Emergency information is posted near the telephone in the hazardous waste storage area.

   

  Hazardous waste accumulation time: 40 CFR 262.34 (5)
bullet Arrangements are made with local authorities to respond to a hazardous waste emergency.

   

  Arrangements with local authorities: 40 CFR 265.37 (5)
 

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  Training
bullet TRACER Staff can describe appropriate response for hazardous waste spill.

   

Competence: HR2.10.9 Arrangements with local authorities: 40 CFR 265.37 (5)
bullet Staff are trained in, are thoroughly familiar with, and competency has been tested in, proper waste identification, handling and emergency procedures relevant to their jobs.

   

Documentation: EC3.10.7

Competence: HR2.10.9

Roles (Incident): HR2.20.3

HERC: Managing Hazardous (RCRA) Wastes

Hazardous waste operations (HAZWOPER) training: 29 CFR 1910.120 (e)

Employees familiar with HazWaste handling: 40 CFR 262.34 (d)(5)(C)(iii)

HazMat employee training (DOT): 49 CFR 172.704

bullet Personnel are trained regarding satellite accumulation.

   

 

HERC: Managing Hazardous (RCRA) Wastes

Employees familiar with HazWaste handling: 40 CFR 262.34 (d)(5)(C)(iii)

bullet Staff is periodically reminded that hazardous waste should never be improperly disposed of down the drain or as solid or infectious waste.

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Nonhazardous solid waste

bullet
Facility promotes recycling all potential recyclable materials (e.g., paper, cardboard, aluminum, steel, solvents, construction wastes, grease or food scraps, etc.).  Bins are clearly labeled, and are conveniently located throughout the facility.
bullet Facility promotes reduction of solid waste by choosing products with less packaging, using less materials (source reduction).
bullet Materials and equipment are reused and/or reprocessed to the greatest possible extent.
bullet Food and organic waste is composted.

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Regulated Medical (Infectious) Waste

bullet A comprehensive medical waste management plan, "Bloodborne Pathogens (BBP) Exposure Control Plan", is in place that includes identification, proper segregation, and management of waste from generation to disposal.

   

Plan EC3.10.1

HERC: State RMW Locator

Bloodborne pathogens: 29 CFR 1910.1030

bullet Facility has done a risk assessment to identify employee risks to BBP exposures and other related BBP risks
bullet Infectious waste is properly segregated according to state-specific definitions.

   

 

HERC: State RMW Locator

bullet

The facility's RMW segregation plan ensures that

  • RMW that includes chemotherapy waste products are identified and segregated from other regulated medical waste

  • RMW that includes those chemotherapy waste products that are also classified as hazardous waste are properly manifested and disposed of via licensed hazardous waste hauler and permitted treatment and disposal facility :
bullet Infectious waste containers are sturdy and labeled with the universal biohazard symbol.

   

 

Bloodborne pathogens: 29 CFR 1910.1030

bullet
Signs to assist with proper segregation of infectious waste are placed above containers.

   

 

Labeling: EC3.10.9

  • Examples of suitable signage are available from [link]
bullet Staff is trained and competency tested on proper segregation and disposal of infectious waste.

   

 

HERC: State RMW Locator

Bloodborne pathogens: 29 CFR 1910.1030

bullet Infectious waste containers are stored onsite in secured area away from public areas, and are kept on site for no longer than period of time permitted by applicable state regulation.

   

 

HERC: State RMW Locator

bullet Infectious waste containers intended for transport are properly packaged and marked.

   

 

RMW packaging: 49 CFR 173.6 (B) (ii)

Infectious substances packaging: 49 CFR 173.196

RMW packaging (non-bulk): 49 CFR 173.197

HazMat table (DOT): 49 CFR 172.101

Lab Pack Exception: 49 CFR 173.12

bullet Waste is placarded for transport, if necessary.

   

 

Placarding: 49 CFR 172.500

bullet Facility is registered as generator of RMW with state and local authorities if required.

   

 

HERC: State RMW Locator

bullet Regulated medical waste is tracked and documentation kept in accordance with state rules.

   

 

HERC: State RMW Locator

bullet Facility performs a waste assessment and documents the amount of RMW generated per month to identify opportunities for reduction.
bullet
Using non-polyvinyl chloride IV bags, tubing and other equipment to diminish dioxin emissions and reduce when waste is incinerated
bullet

Facility has developed and implemented a comprehensive RMW minimization plan that provides for:

  • comprehensive staff training that includes
    • clear definitions of RMW
    • plain language explanations of RMW disposal procedures
    • guidance to identify hazardous chemicals or other inappropriate wastes and to ensure that they not included in the RMW waste stream
  • comprehensive data collection and reporting

and includes measures such as:

  • replacing disposal equipment with reusable equipment
  • using equipment designed to eliminate suction canisters
  • using reusable sharps containers
  • using waste reduction as a method to reduce exposure (e.g., formaldehyde, xylene)
  • reducing blood sample volumes to minimize quantities of infectious waste and reduce risk of nosocomial anemia
  • using automated technology for disposal of contents of suction canisters into sanitary sewer
  • Other elements of a comprehensive program that may result in performance improvement outcomes include:
    • using non-PVC equipment will minimize DEHP exposure and dioxin formation
    • ensuring hazardous chemicals or other inappropriate wastes are not included in this waste stream
    • using waste reduction as a method to reduce occupational exposure
  If RMW is incinerated or otherwise treated on site:
bullet Incinerator is operated within permit parameters and records are kept (40 CFR 70).[not specific to incinerators]
bullet Design capacity of the incinerator is not exceeded (40 CFR 70).
bullet Hazardous waste is not burned in the incinerator unless allowed by permit (40 CFR 70).
bullet
Facility renders RMW non-infectious through autoclaving or other non-incineration technologies to reduce the dioxin, heavy metal, and particulate emissions associated with incineration.

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Universal Waste

bullet Waste fluorescent lamps, batteries, mercury thermostats and certain pesticides are either managed as Universal Waste or are evaluated for hazardous waste management.

   

 

HERC: Hazardous Waste Determination

HERC: State Universal Waste Locator

Universal Waste (SQG) 40 CFR 273.13

Universal Waste (LQG) 40 CFR 273.33

bullet Containers holding Universal Waste are structurally sound and kept closed except when adding or removing waste.

   

>Space: EC3.10.4

>Separation: EC3.10.10

Universal waste (SQG): 40 CFR 273.13

Universal waste (LQG): 40 CFR 273.33

bullet Containers are properly labeled with the name of the universal waste and the accumulation start date. (e.g., “Universal Waste Batteries”).

   

=Space: EC3.10.4

=Labeling: EC3.10.9

=Separation: EC3.10.10

Universal waste labeling (SQG): 40 CFR 273.14

Universal waste labeling (LQG): 40 CFR 273.34

Universal waste accum. time (SQG): 40 CFR 273.15

Universal waste accum. time (LQG): 40 CFR 273.35

bullet Storage space for universal waste is maintained.

   

=Space: EC3.10.4

=Separation: EC3.10.10

 
bullet All hospital staff who handle Universal Wastes e.g., (batteries) are trained in proper handling and emergency response procedures.

   

Competence: HR2.10.9

Roles (Risk Min.): HR2.20.2

Universal waste training (SQG): 40 CFR 273.16

Universal waste training (LQG): 40 CFR 273.36

bullet Records, documents, and procedures indicate that universal waste is recycled within one year of initial accumulation.

   

Space: EC3.10.4

Separation: EC3.10.10

Universal waste accum. time (SQG): 40 CFR 273.15

Universal waste accum. time (LQG): 40 CFR 273.35

bullet Crushed fluorescent lamp residue is evaluated for hazardous waste characteristics.

   

 

HERC: Hazardous Waste Determination

 

bullet Compact fluorescent bulbs are in use, and purchasing policy and practices indicate preference for compact fluorescent bulbs.
bullet
Purchasing policy and practices indicate preference for rechargeable batteries and equipment.
bullet
Procedures for recharging batteries and equipment are in place and are actually being carried out.

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Materials of Concern

  Asbestos
bullet An asbestos assessment has been done to confirm any asbestos containing building materials (ACBM) present in the facility, including sampling results if appropriate.

   

Inventory:  EC 3.10.2

 

bullet Employees who may potentially disturb or come into contact with asbestos been trained at least to the "awareness level" with the required OSHA 2hr Asbestos Awareness training.

   

Competence: HR2.10.9

Occupational exposure, asbestos: 29 CFR 1910.1001

bullet Areas accessible to the public having asbestos-containing building materials with the potential for being disturbed have been properly labeled.

   

Labeling: EC3.10.9

NESHAP, asbestos, demolition and renovation: 40 CFR 61.145

bullet Manifests are complete (e.g. no information missing) and appropriately routed.

   

Documentation: EC3.10.7

Manifests: EC3.10.8

 

 (=EC3.10.7, =EC3.10.8, 40 CFR 150 (d)).

bullet Abated asbestos is disposed of at an approved (either EPA or state) facility.

   

Documentation: EC3.10.7

NESHAP, asbestos, waste disposal: 40 CFR 61.150

bullet Ten day prior notification is given to local authorities prior to large asbestos projects and records of the notice are retained.

   

=Documentation: EC3.10.7

NESHAP, asbestos, demolition and renovation: 40 CFR 61.145

bullet When conducting asbestos abatement, proper separation from occupied areas is maintained and appropriate clearance monitoring conducted prior to opening the area for occupancy.
bullet Air monitoring is conducted during and post abatement, records are kept and clearance obtained.

   

=Documentation: EC3.10.7

NESHAP, asbestos, demolition and renovation: 40 CFR 61.145

 

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  CFCs
bullet Air conditioning systems having over 50 pounds of CFC (chlorofluorocarbons) refrigerant charge are maintained free from leaks of CFC and records of leaks and maintenance are kept.

   

 

Refrigerant recycling practices: 40 CFR 82.156 (i)(1)

bullet All technicians conducting repair and maintenance activities on CFC air conditioning and refrigerant systems are EPA-certified.

   

 

Refrigerant technician certification: 40 CFR 82.161

bullet Refrigerant recovery devices meet EPA standards.

   

 

Refrigerant recycling standards: Clean Air Act, Section 608

bullet
Efficient systems are used for air conditioning to minimize pollution from chlorofluorocarbon use and air emissions.
 

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  Ethylene Oxide

The facility properly maintains ethylene oxide abaters and refreshes scrubber catalysts on schedule.

Facility has a valid air quality permit for any EtO sterilizer or aerator.

   

 

EtO Sterilizer permit requirements: 40 CFR 63.360 (f)

Areas utilizing EtO are provided with a continuous alarm monitor.

An up-to-date, written EtO emergency plan is in place, with annual training implemented and records kept.
bullet
Ethylene oxide is eliminated from the facility.  
 

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  Glutaraldehyde

Glutaraldehyde-based high level disinfectants are properly monitored, effectively contained, and safely handled.
bullet To reduce exposures and the amount of glutaraldehyde used, operating procedures are reviewed and improved with use of overhead hoods, employee training and monitoring
bullet Glutaraldehyde is replaced with less hazardous material.
 

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  Mercury
bullet
Sanitary sewer drainpipes suspected to contain mercury are cleaned or replaced. Old pipes, biofilm and/or water used to clean pipes are recovered, tested for mercury content, and disposed of properly.
bullet
Facility has conducted a mercury inventory, and has established a mercury elimination plan that includes a schedule for the removal and replacement of known mercury-containing items.
bullet
Facility participates in the H2E Making Medicine Mercury Free Award program.
 

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  Pesticides
bullet Pesticides classified for restricted use are applied only by licensed applicators.

   

 

Pesticides classified for restricted use: 40 CFR 152.175

bullet Restricted pesticides are not used.

   

 

Pesticides classified for restricted use: 40 CFR 152.175

bullet Pesticide containers are triple rinsed.

   

 

Hazardous waste residues in empty containers: 40 CFR 261.7

Pesticide Registration (PR) Notice 83-3

40 CFR 162.10 [many references to this, but can't find on GPO site]

bullet The rinsate is managed as hazardous waste if it is not used.

   

 

Pesticide Registration (PR) Notice 83-3

[can't find 40 CFR 162.10 on GPO site]

bullet A hazardous waste determination is made and documented for pesticides that have not been used up and are being discarded.

   

 

Hazardous waste determination: 40 CFR 262.11

bullet Warning signs are posted and staff notified when pesticides are applied.
bullet Facility has instituted an Integrated Pest Management program with the following elements:
  • Pesticide application is used only as a last resort
  • Only the least toxic pesticides are used
  • The primary focus of the program is pest identification and monitoring
  • Non-chemical methods are used for pest control (e.g. traps, barriers)
  • The program has a staff training component (e.g. actions that help prevent pests on the premises)
  • Pesticide applicators are licensed and trained by appropriate authorities
  • Staff, patients, and visitors are informed whenever pesticide is applied
 

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  Petroleum Products (see also Used Oil and Tanks below)
bullet
Energy is conserved, thereby reducing the use of oil and petroleum products.
bullet
Purchasing policy and other evidence indicates a preference for energy efficient equipment, that does not burn oil or diesel fuel.
bullet
Bio-diesel is used in place of diesel in generators and other equipment.
 

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  Pharmaceuticals and chemotherapeutic agents
bullet Chemotherapeutic and pharmaceutical wastes are evaluated for hazardous waste classification. Process for evaluation is documented.

   

 

Hazardous waste determination: 40 CFR 262.11
bullet Waste containers holding U-listed chemotherapeutic and pharmaceutical materials  are completely empty or managed as hazardous waste.

   

 

Hazardous waste residues in empty containers: 40 CFR 261.7
bullet Waste containers holding the P-listed chemotherapeutic drug arsenic trioxide and P-listed pharmaceuticals are managed as a hazardous waste, and in many situations also as RMW.
bullet Used syringes containing RCRA-regulated hazardous waste are managed as RMW.
bullet TRACER Pharmacy, oncology and nursing staff are proficient in identifying and managing hazardous chemotherapeutic and pharmaceutical waste.

   

 

Employees familiar with HazWaste handling: 40 CFR 262.34 (d)(5)(C)(iii)
bullet TRACER Staff can describe process used for chemotherapeutic and pharmaceutical waste evaluation and basis for choice of disposal.
bullet Overt amounts of chemotherapeutic drugs are managed as hazardous waste
bullet Trace amounts of chemotherapeutic drugs are incinerated at a permitted RMW incinerator.
bullet A waiver for federal exclusion for nitroglycerin in finished dosage forms has been submitted and is on file.
bullet Pharmacy and oncology staff are trained regarding waste reduction and pollution prevention opportunities and practices.
bullet Non-regulated chemotherapeutic wastes are managed in the same way as regulated chemotherapeutic wastes.
bullet IV bags and related equipment that are polyvinyl chloride (PVC)- and DEHP-free are used.  Reasons include:
  • PVC weighs more than polyolefin or other plastic.  Using lighter plastic reduces waste weight.
  • PVC contributes to dioxin formation when manufactured and incinerated.
  • DEHP is a reproductive toxin and endocrine disruptor.  Minimizing its use improves patient safety.
 

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  Polychlorinated Biphenyls (PCB)
PCB equipment is properly labeled, and inspected. need citations
Disposal of PCB containing items are handled as appropriate.
bullet
PCB-containing equipment and oil is eliminated.
 

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  Radioactive Materials and Waste

Inventory and management plans for hazardous energy sources; ionizing and non-ionizing radiation, lasers, microwaves and ultrasound devices are available.

   

 

Occupational exposure, ionizing radiation: 29 CFR 1910.1096

Staff is trained and competency tested in appropriate spill response for radioactive materials and waste.
bullet
The facility is eliminating or reducing the use radioactive material, to the extent that it is possible to substitute non-radioactive or less radioactive isotopes (e.g. using isotopes with lower level radiation or shorter half-lives for non-therapeutic laboratory applications).
bullet
The facility is eliminating the use of radioactive materials with longer half-lives to the greatest possible extent for all applications.
 

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  Used Oil
The organization properly collects used oil from vehicles, and physical plant equipment (emergency generators, compressors, etc.)

   

 

Used oil practices: 40 CFR 279.20
Used oil is stored in sturdy compatible containers labeled “used oil” that are kept closed.

   

 

Used oil storage: 40 CFR 279.22

Oil-containing equipment is not leaking.

   

 

Used oil storage: 40 CFR 279.22

Spill control equipment is available and used when necessary.

   

 

Used oil storage: 40 CFR 279.22

Spills are reported to local and federal authorities.

   

 

Oil spill facility response plan: 40 CFR 112.20

Used oil is recycled and receipts are kept indicating such.

   

 

Used oil off-site shipments: 40 CFR 279.24
Staff is trained and competency tested in appropriate spill response for used oil.

   

 

Oil spill facility response plan: 40 CFR 112.20
A hazardous waste determination is made and documentation is kept for used oil that is destined for disposal.

Used oil filters are drained for a minimum of twelve hours to ensure all residual oil is collected before disposing of the filters as scrap metal.

   

 

Hazardous waste exclusions (used oil filters): 40: CFR 261.4 (b)(13)


Facilities and equipment

  Recordkeeping and reporting
bullet Air permits are modified when fuel usage changes.

   

=Documentation: EC3.10.7

State air permit programs (index page): 40 CFR 70

bullet Certificates to Operate and Permits are not permitted to expire.

   

=Documentation: EC3.10.7

State air permit issuance and revisions:  40 CFR 70.7

bullet Calculations are done and kept on site verifying air permit requirements for boilers, incinerators, generators or other releases to the air( e.g. ethylene oxide). (40 CFR 70).

   

Documentation: EC3.10.7

State air permit applications:  40 CFR 70.5

 

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  Boilers, generators
bullet
Bio diesel is considered and possibly used with emergency generators.
bullet Oil burning equipment is well maintained. Logs and documentation evident.
bullet
Energy efficient boilers and generators are used to minimize air pollution (Documentation: EC3.10.7).
bullet
Policies indicate preference for energy efficient equipment and practices throughout the facility to minimize fuel use.
 

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  Incinerator
bullet Incinerator is operated within permit parameters and records are kept (40 CFR 70) [not specific to incinerators].
bullet Design capacity of the incinerator is not exceeded (40 CFR 70).
bullet Hazardous waste is not burned in the incinerator unless allowed by permit (40 CFR 70). 
bullet
Incineration is eliminated or reduced as a waste treatment or disposal method.  (Incineration creates air pollution such as dioxins, acid gases (such as hydrogen chloride), carbon monoxide, and heavy metals.  Air pollution from incinerators is deleterious to community health.)
bullet
All waste is minimized to eliminate emissions to air.  
 

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  Tanks
bullet Spill Containment and Countermeasures plan is in place for aggregate aboveground storage greater than 1320 gallons.

   

Plan EC3.10.1

SPCC plan requirement: 40 CFR 112.3

SPCC plans: 40 CFR 112.7

bullet Tanks are permitted or registered with either EPA or local authorities.
bullet Underground storage tanks must have been upgraded or replaced by 12/22/98 to meet integrity, cathodic protection, leak and overfill protection requirements.

   

 

Underground storage tanks, required upgrades: 40 CFR 280.21

bullet Maintenance and calibrating procedures are enacted to ensure tank monitors are working appropriately.
bullet Tanks are inspected on weekly/monthly basis as per EPA or local regulations.
bullet Tank alarm system can be heard or otherwise adequately communicated to operators.
bullet Procedures are written and available for steps to be taken when tank alarm sounds.
bullet Tank overfill protection equipment is monitored.

   

 

Underground storage tanks, spill and overfill control: 40 CFR 280.30

bullet Corrosion protection for tanks is adequate.  If cathodic protection is used it is inspected and replaced as required.

   

 

Underground storage tanks, corrosion protection: 40 CFR 280.31

bullet Release detection equipment for tanks and piping is adequate and up to date.  Monitor and record condition.

   

 

Underground storage tanks, release detection: 40 CFR 280.40

bullet Suspect releases or spills are reported to EPA or appropriate local authority.

   

 

Underground storage tanks, release reporting: 40 CFR 280.50

bullet TRACER Staff respond appropriately regarding steps to be taken in the event of tank alarm, spill, or leak.
bullet Tank parts are appropriately labeled with appropriate American Petroleum Institute (API) code. E.g. Hexagon for #2 Fuel Oil (40 CFR 280)
bullet Equipment on tank to shut down when tank reaches 95% of capacity during fueling.
bullet Tanks are located a safe distance from other areas of the facility.

   

=Separation: EC3.10.10

 

bullet Use of underground storage tanks is eliminated, minimizing risk of leaks and spills.
 

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  Wastewater
bullet Review of local rules and codes to ensure all discharges to sewer (laboratories, pharmacy, surgery, dialysis, central processing, nutrition services, etc.) are permitted and/or if pretreatment is required (40 CFR 403). [can't find 403]
bullet All discharges to sewer are reported to local wastewater authority (local permits, 40 CFR 403).
bullet Spill Prevention Control and Countermeasure Plans are in place, including adequate secondary containment of storage tanks.

   

 

SPCC plans: 40 CFR 112.7

bullet All discharges to the sewer are evaluated assure conformance with local, state and federal restrictions, e.g. formalin, glutaraldehyde, pharmaceuticals, alcohols, laboratory discharges, x-ray chemicals (40 CFR 403).
bullet All discharges to the sewer are evaluated for hazardous waste and reported to local sewer are evaluated for hazardous waste and reported to local sewer and hazardous waste authorities. (40 CFR 403)
bullet Direct, point source discharges are required to obtain National Pollution Discharge Elimination System (NPDES) permits under 402 of the Clean Water Act (CWA)
bullet If the facility has any septic tanks, drain fields, lagoons, or other on-site wastewater disposal areas, they are properly permitted
bullet Hazardous materials or waste storage or process areas DO NOT have floor drains that might allow a release of a hazardous chemical to the environment
bullet Wastewater is monitored, tested and reported as per local, state and/or federal permit requirements, and exceedances are managed appropriately.
bullet Wash water from kitchen cleaning or other cleaning operations is not discharged to the storm sewer without a National Pollutant Discharge Elimination Permit.

   

 

NPDES permits, stormwater discharges: 40 CFR 122.26

bullet
Discharges to sewer are reduced or eliminated.

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