Guide to JCAHO Environment of
Care Standard 3.10.7
Please note: this page is under development. Contact
(603) 795-9966,
if you have questions or
suggestions.
Introduction
Table of Contents Checklist
for 3.10.7
|
Environment of Care Standard 3.10: The
organization manages hazardous materials and waste
risks
Element of Performance 7.
Hazardous Material and Hazardous Waste
Documentation
The
organization maintains documentation, including permits,
licenses,
and adherence to other regulations.
|
This page
provides a set of criteria for evaluating a
facility's system for determining what documentation is required, and
ensuring that required documentation is
on-hand and accessible.
Hazardous Materials
| |
Copies of
the following reports are on site and
available for review: |
|
 |
-- inspection reports (e.g. tours, insurance,
OSHA, College of American Pathologists (CAP), fire marshal, US
EPA, state environmental and/or health departments,
etc.)
|
|
|
-- facility response and mitigation of
deficiencies on inspection |
|
|
-- results of employee monitoring for
exposure to hazardous materials such as:
|
|
|
-- records of industrial hygiene
monitoring of noise, dust and mold [need
OSHA
cite] |
|
|
-- records for clean up for hazardous
materials spills (e.g. mercury) including air
monitoring, proper clean up, reporting to authorities [need
OSHA
cite] |
|
 |
The
number of exposure monitoring
reports required is reduced due to the reduction or
elimination of hazardous materials
(such as pesticides, disinfectants, cold sterilants, blood borne
pathogens, etc.). |
|
|
Records indicate
that staff are trained on hazards of materials used, including
training on:
-
asbestos
-
blood and body fluids
-
chemicals
-
disinfectants
-
pesticides
-
petroleum products
and on appropriate handling and use of
protective equipment.
(HR 2.10,
29
CFR 1910.132-139,
1910.1030,
1910.1200). |
|
|
Records indicate
that staff preparing hazardous materials for shipment are trained
on Dept of Transportation rules for marking, packaging,
shipping papers, placarding and transport. |
|
|
Records indicate
that staff are trained in, and are thoroughly familiar with, proper waste
handling and emergency procedures relevant to their jobs.
|
Top
Hazardous
Waste
|
|
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
|
|
|
The basis for
hazardous waste determinations is documented.
|
|
|
Copies of reports sent regularly (either
annually or biennially) to state or federal authorities
regarding hazardous waste generation are
kept on site for a minimum of three
years.
|
|
|
The facility
maintains documentation verifying that
hazardous waste storage inspections have been performed.
|
|
|
Hazardous waste
manifests and other documents from waste hauler and disposal
facility are kept on site and maintained appropriately
for a minimum of three years.
|
|
|
Quantities of
hazardous wastes shipped on
manifests, and number of hazardous
waste shipments, are reduced. |
|
|
Records are kept
indicating recycling of universal waste and used oil.
|
|
|
Land Disposal
Restriction notices are kept for a minimum of three years.
|
| |
Chemotherapeutic Waste |
|
|
Chemotherapeutic
wastes are evaluated for hazardous waste classification.
Process for evaluation is documented.
|
|
|
Chemotherapy
hazardous wastes are reported biennially to the EPA,
and reports are kept on site for at least three years.
|
|
|
Chemotherapy
hazardous wastes are reported as required by state and
local authorities.
|
Regulated Medical (Infectious) Waste
|
|
Facility is
registered with state and local authorities if required,
and has obtained all required permits.
|
|
|
Regulated medical
waste is tracked and documentation kept
per state
rules, to ensure the material arrives at an
appropriate destination for treatment and final disposal.
|
|
|
Facility maintains documentation of
annual reviews carried out to identify safer medical devices
designed to eliminate or minimize occupational exposure
to bloodborne pathogens. Frontline workers should be
solicited for input.
|
|
|
Facility
maintains employee medical and training records.
|
|
|
Facility
tracks and documents the amount of RMW
generated monthly to identify opportunities
for reduction. |
|
|
|
|
|
Sources and
quantities of regulated medical waste are measured and
documented to facilitate RMW reduction. |
|
|
Employee exposure
reports for blood borne pathogen splashes due to pouring of
suction canisters is reduced through the use of fluid management
systems that eliminate or reduce use of suction
canisters. |
Materials of Concern
| |
Asbestos [need basic compliance
info] |
|
|
Abated asbestos is
disposed of at an approved (either EPA or state)
facility.
|
|
|
Ten day prior
notification is given to local authorities for large asbestos projects and records of
the notice are retained.
|
|
|
Air monitoring is
conducted during and post abatement, records are kept and
clearance obtained.
|
|
|
Manifests are
complete (e.g. no information missing) and are appropriately routed.
|
| |
Pesticides |
|
|
Records indicate
staff using disinfectants, cold sterilants and pesticides have
been trained on their hazards and appropriate use.
|
|
|
Pesticide
applicator licenses are maintained or are part of pest
management contract.
|
|
|
Documentation of
pesticides applied maintained to ensure appropriate exposure
monitoring and to ensure restricted pesticides are not used.
|
|
|
An Integrated Pest
Management (IPM) program is in place. |
|
|
|
|
|
If the organization
is a federal facility, documentation that an integrated pest
management program is in place. CHECK THIS REQUIREMENT |
|
|
Pesticide
applicator licenses are no longer needed due to no pesticides
being applied at facility. |
| |
Petroleum Products |
|
|
Tanks are permitted
or registered with either EPA or local
authorities. |
|
|
Number of tank
permits required is reduced due to minimized use of petroleum
products (or hazardous waste/material
storage). |
Facilities and
equipment
| |
Air (general) [need
basic compliance info] |
|
|
Up to date air
permits are available on site for review. Permits may be
required for:
- boilers
- incinerators
- fume
hoods
- ethylene oxide sterilizers
|
|
|
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). |
| |
Boilers |
|
|
Air permits are
modified when fuel usage changes.
|
|
|
Certificates to
Operate and Permits are not permitted to expire.
|
|
|
Air permits are
modified when fuel usage changes (40 CFR 70).Certificates to
Operate and Permits are not permitted to expire (40 CFR
70). |
|
|
Permits for boilers are not
needed due to energy efficient boilers. |
| |
Incinerators |
|
|
Incinerator is
operated within permit parameters and records are kept (40 CFR
70). |
|
|
Hazardous waste is
not burned in the incinerator unless allowed by permit (40 CFR
70). |
|
|
No on-site incineration is carried out at the
facility. |
| |
Ethylene oxide
sterilizers |
|
|
Ethylene oxide has been
eliminated as a sterilant.
|
| |
Wastewater |
|
|
Facility has
wastewater discharge permit indicating all discharges to sewer
have been reported and are permitted. (local permits, 40
CFR 403).[not a CFR citation] |
|
|
Facility maintains
copies of wastewater monitoring results (local permits, 40 CFR
403). |
|
|
Wastewater
monitoring requirements are diminished due to minimized
discharges to sewer. |
Top
| |
