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Guide to JCAHO Environment of Care Standard 3.10.1

Please note: this page is under development. Contact (734) 995-7989,
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Introduction        Table of Contents       Checklist for 3.10.1

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

Element of Performance 1: Hazardous Materials and Hazardous Waste Management Plan

The hospital develops and maintains a written management plan describing the processes it implements to effectively manage hazardous materials and wastes.

© 2005 Joint Commission on Accreditation of Healthcare Organizations. Any use of any or all of the Joint Commission standards and elements of performance beyond this particular tool is strictly forbidden without the written permission of the Joint Commission.  Citations from JCAHO standards are ©2005 Joint Commission on Accreditation of Healthcare Organizations. Any use of any or all of the Joint Commission standards and elements of performance beyond this particular tool is strictly forbidden without the written permission of the Joint Commission. These pages do not reflect any changes in the standards made after 2005.

This page provides a set of criteria for evaluating a facility's written plans for hazardous materials and waste management.  In addition to an overall plan, specialized plans covering certain critical issues or materials may also be required by regulations.

Implementation of these plans is covered under EC3.10.3.  Aspects of worker and patient safety are covered in Element of Performance EC1.10.1.

Criteria providing evidence of compliance and of environmental improvement are listed below for the following topics:

= Compliance
= Environmental Improvement
= Tools and Resources

General Environmental Management  Plan

Facility has a comprehensive environmental plan that includes a statement of commitment, self assessment, performance improvement goals and objectives, methods of measurement, accountability, and continuous improvement.
Facility conducts periodic internal compliance audits
  . (EC 9.10.1, 9.10.4).  
  • Sample Environmental Commitment Statement [need link]

A qualified Safety Officer or equivalent has been selected, together with members of a Safety Committee.

   

Safety Coord.: EC1.10.2

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

The Safety Committee approves the Materials and Hazardous Waste Management Plan, and the approval is recorded in meeting minutes.

   

Safety Coord.: EC1.10.2

Facility has developed an Environmental Management System (EMS).
Facility is ISO 14000 certified, and maintains the certification.

Hazardous Materials

 

Facility has plans on file, readily accessible by appropriate staff, for:

-- creating and maintaining an inventory that identifies and provides the location for all hazardous materials in use throughout the facility, including:

  • asbestos
  • chemicals (laboratory, cleaning, etc.)
  • disinfectants and sterilants
  • hazardous gases

   

Gases: EC3.10.5

  • pesticides
  • petroleum products
  • pharmaceuticals and chemotherapeutic agents
  • polychlorinated biphenyl (PCB)-containing equipment
  • radioactive agents and associated wastes

   

Inventory:  EC 3.10.2

Implementation: EC3.10.3

-- reducing use of hazardous materials through purchasing policies and procedures that prefer less hazardous materials.

   

Inventory:  EC 3.10.2

Implementation: EC3.10.3

Impl. (Univ. Waste): EC3.10.3

Roles (Risk Min.): HR2.20.2

-- managing hazardous materials such as compressed gases, flammable/combustible materials, acids/bases, ionizing radiation, etc

   

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

-- identifying all hazardous materials that require employee monitoring, e.g. asbestos, formaldehyde, ethylene oxide, carcinogens, etc.

   

Hazard identification (OSHA): 29 CFR 1910.120 (c)

-- selecting and maintaining personal protective equipment.

   

Personal protective equipment selection: 29 CFR 1910.120 (g)(3)

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

-- communicating hazardous chemical handling and use requirements to employees.

   

Hazard communication (OSHA): 29 CFR 1910.1200

-- developing a Community-Right-to-Know plan

   

Safety plan: EC1.10.1

Emergency planning: 40 CFR 355.30


Hazardous Waste

 

Facility has plans on file, readily accessible by appropriate staff, for:

 

Hazardous waste management

-- annually determining hazardous waste generator status.

   

  Hazardous waste definition: 40 CFR 261.3

Standards for CESQGs 40: CFR 261.5

Hazardous waste (standards for generators, index page): 40 CFR 262

-- working toward smaller quantity generator status by minimizing hazardous materials and waste.

-- making hazardous waste determinations by applying knowledge or testing.

   

Implementation: EC3.10.3

Documentation: EC3.10.7

Hazardous waste definition: 40 CFR 261.3

Standards for CESQGs: 40 CFR 261.5

-- managing hazardous waste, including tracking, storing, inspecting, recycling, treating, and disposing.

   

  Hazardous waste (standards for generators, index page): 40 CFR 262
-- eliminating mercury.
-- recycling of solvents and formalin.
-- specifying actions to be taken in response to fires, explosion or any unplanned releases of hazardous waste, required if the facility is a Large Quantity Generator.

   

Emergency: EC3.10.6 Contingency plan (emergency procedures): 40 CFR 265.56
  Disposal and treatment
-- eliminating or reducing incineration as waste treatment method.
-- packaging, labeling and transporting hazardous waste according to DOT requirements.

   

 

Hazardous waste packaging: 40 CFR 262.30

Hazardous waste labeling: 40 CFR 262.31

Hazardous waste marking: 40 CFR 262.32

Hazardous waste, general: 49 CFR 171.3

HazMat table (DOT): 49 CFR 172.101

Hazardous waste manifest: 49 CFR 172.205

Labeling (DOT): 49 CFR 172.400

Placarding: 49 CFR 172.500

Lab pack exception: 49 CFR 173.12

  General hazardous waste resources


Regulated Medical (Infectious) Waste

bullet A Bloodborne Pathogens (BBP) Exposure Control Plan is in place that includes identification and proper segregation of waste from generation to disposal according to a management plan that identifies and describes the appropriate waste containers, manner of waste disposal and methods to reduce exposure and waste generation.

   

=Implementation EC3.10.3

HERC: State RMW Locator

Bloodborne pathogens: 29 CFR 1910.1030

Facility has formulated a comprehensive medical waste minimization plan, that might include choosing reusable medical devices and supplies over disposables, reducing the volume of laboratory samples .
Facility has a plan for identifying, segregating, and managing any RMW that contains pathology waste, or non-hazardous “trace” is  chemotherapy waste.

   

 

HERC: State RMW Locator

Bloodborne pathogens: 29 CFR 1910.1030

Facility has a plan for packaging, labeling and transporting RMW according to Department of Transportation requirements.

   

Safety plan EC1.10.1

RMW definitions (DOT): 49 CFR 173.134

Standards for CESQGs: 40 CFR 261.5

Hazardous materials transport (index page): 49 CFR 172 (Subparts C,D,E,G)

Infectious Substances Packaging 49: CFR 173.196

RMW Packaging: 49 CFR 173.197

Facility has developed provisions for ensuring that RMW arrives at an appropriate destination..


Universal Waste

 

Facility has plans on file, readily accessible by appropriate staff, for:

Identifying and managing Universal Waste for recycling (i.e., fluorescent lamps, batteries, certain pesticides, and thermostats).

   

  Universal waste (index page): 40 CFR 273
  Establishing procedures for packaging, labeling, storing and transporting Universal Waste (e.g., structurally sound container labeled “Universal Waste - Lamps"), and for recycling within one year of initial accumulation.

   

Space: EC3.10.4

Documentation: EC3.10.7

Manifests: EC3.10.8

Labeling: EC3.10.9

Separation: EC3.10.10

Hazardous waste transport: 49 CFR 171.3

HazMat table (DOT): 49 CFR 172.101

Hazardous waste manifest: 49 CFR 172.205


Pesticides

 

Facility has plans on file, readily accessible by appropriate staff, for:

Application:
  • selecting chemicals used in grounds keeping (7 USC 6, Sec 136i.).
  • ensuring that restricted or prohibited pesticides are not used

   

 

Pesticides classified for restricted use: 40 CFR 152.175
  • ensuring pesticide applicators are appropriately trained and licensed

   

 

Pesticides, criteria for restriction: 40 CFR 152.170
  • posting warning signs when pesticides are applied
  • EPA:  Pesticide Registration Notice -- contains information on labeling requirements and (implicitly) on good pesticide handling and disposal practices
  • implementing an Integrated PM program.

Disposal:
  • managing waste pesticides as hazardous waste
  • triple rinsing pesticide containers
  • managing the rinsate as hazardous waste if it is not used

   

 

Pesticide Registration (PR) Forms

  • managing disinfectants and sterilants as pesticides

   

 

Definition of "pest": 40 CFR 152.5


Petroleum Products (see also Used Oil, below)

 

Facility has plans on file, readily accessible by appropriate staff, for:

Managing aboveground and underground storage tanks with petroleum products.

   

 

Oil pollution prevention (index page): 40 CFR 112

Underground storage tanks (index page): 40 CFR 280

Eliminating or reducing underground storage tanks.
Reducing or eliminating the use of diesel fuel
Complying with Spill Prevention Control & Countermeasure (SPCC) requirements for aboveground oil storage tanks with aggregate of more than 1,320 gallons of petroleum.

   

Implementation: EC3.10.3

SPCC plan requirement: 40 CFR 112.3

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

   

Implementation: EC3.10.3

SPCC plans: 40 CFR 112.7


Radioactive Materials and Waste

 

Facility has plans on file, readily accessible by appropriate staff, for:

Managing radioactive materials and waste (10 CFR 35, 70).

Eliminating or reducing radioactive materials and waste.


Used Oil

 

Facility has plans on file, readily accessible by appropriate staff, for:

Identifying and managing used oil for recycling.

   

 

Used oil practices: 40 CFR 279.20

Managing used oil that is destined for disposal as a hazardous waste.

   

 

Hazardous waste determination: 40 CFR 262.11

Used oil practices: 40 CFR 279.20

Used oil mixtures: 40 CFR 279.21

Packaging, labeling and transporting used oil destined for recycling.

   

 

Used oil off-site shipments: 40 CFR 279.24

Packing, labeling and transporting used oil destined for disposal oil .

   

 

Universal waste off-site shipments (SQG): 40 CFR 273.18


Spills

 

Facility has plans on file, readily accessible by appropriate staff, for:

-- controlling and cleaning up hazardous material and waste spills.

   

Impl. (HazMat): EC3.10.3

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

-- controlling and cleaning up spills of universal waste.

   

Universal waste, response to releases: 40 CFR 273.17
-- controlling and cleaning up spills from used oil.

   

 

Used oil, response to releases: 40 CFR 279.22 (d)

-- controlling, cleaning up & exposure monitoring of spills from radioactive materials.

   

 

 

 (10 CFR 20).

-- controlling and cleaning up spills from Regulated Medical Waste.

   

HERC: OSHA Standards for Bloodborne Pathogens

HERC: State RMW Locator

Bloodborne pathogens: 29 CFR 1910.1030

-- complying with Spill Prevention Control & Countermeasure (SPCC) requirements for aboveground oil storage tanks with aggregate of more than 1,320 gallons.

   

Emergency: EC3.10.6

SPCC plans: 40 CFR 112.7

-- minimizing spills.


Training

 

Facility has plans on file, readily accessible by appropriate staff, for:

Fulfilling the training requirements of OSHA, EPA and DOT.

   

 

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

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

Universal waste training (SQG): 40 CFR 273.16

Universal waste (LQG): 40 CFR 273.33

HazMat training (DOT): 49 CFR 172.704

Identifying departments and personnel that require training.

   

 

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

Training on universal waste requirements.

   

Implementation: EC3.10.3

Emergency: EC3.10.6

Roles (Risk Min.): HR2.20.2

Universal waste training (SQG): 40 CFR 273.16

Universal waste training (LQG): 40 CFR 273.36

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