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Guide to JCAHO Environment of Care Standard 3.10.10

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Introduction        Table of Contents        Checklist for 3.10.10

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

Element of Performance 10. Separation of hazardous materials and waste storage

The organization effectively separates hazardous materials and waste storage and processing areas from other areas of the facility.
© 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 how well a facility complies with regulations covering the separation of hazardous materials and waste.  The idea is to ensure that anyone passing through a location where hazardous materials and wastes are processed or stored is aware of the presence of and can easily distinguish containers of these materials, and is alert to the hazards they can pose.

The criteria are divided into several topic areas.

= Compliance
= Environmental Improvement
= Tools and Resources

Hazardous Materials Management

Storage cabinets and/or storage rooms are available for the storage of flammable liquids and other hazardous chemicals as appropriate..

   

=Implementation: EC3.10.3

=Space: EC3.10.4

Accidental ignition or reaction: 40 CFR 265.17

Contracts can include take back provisions for items such as computers, batteries, pharmaceuticals, etc. because there is adequate space to collect the items.

Hazardous materials use is diminished to reduce spill and exposure risk.
Space is provided for the distillation or recovery of laboratory solvents such as xylene, alcohol, and formalin
Emergency spill hotline number is readily available.

Hazardous Waste Management

Containers of hazardous waste are marked with the words �Hazardous Waste�, and a descriptive name of the waste.

   

=Implementation: EC3.10.3

=Space: EC3.10.4

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

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

Adequate space is available to segregate and appropriately handle incompatible wastes and hybrid wastes (e.g. radioactive mixed with hazardous wastes, infectious mixed with hazardous wastes).

   

 

Accidental ignition or reaction: 40 CFR 265.17

Incompatible wastes: 40 CFR 265.177 (c)1(ii)

Hazardous waste storage areas are secure and prevent release to the environment (e.g. secondary containment of containers is in use, floor drains are sealed, containers are not leaking, and containers are kept closed).

   

=Implementation: EC3.10.3

=Space: EC3.10.4

Security: 40 CFR 265.14 (c)1(ii)

 

Adequate aisle space is maintained in hazardous waste storage area to ensure access to containers in event of spill or leak.

   

=Implementation: EC3.10.3

=Space: EC3.10.4

Adequate aisle space: 40 CFR 265.35

 

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.

   

=Implementation: EC3.10.3

=Space: EC3.10.4

Inspection: 40 CFR 265.15

Storage cabinets and/or storage rooms are available for the storage of flammable liquids.

   

=Space: EC3.10.4

Accidental ignition or reaction: 40 CFR 265.17

Hazardous waste use is diminished to reduce spill and exposure risk.
Hazardous waste generator size is reduced.

Regulated Medical (Infectious) Waste

Adequate medical waste storage areas are provided and kept secured.  Door is labeled with OSHA biohazard symbol.

   

=Space: EC3.10.4

 

Refrigeration available when necessary to prevent putrefaction of medical waste.

   

=Space: EC3.10.4

 

Adequate medical waste storage area is provided near shipping location, and kept secured.  Door to storage areas and loading dock is labeled with OSHA biohazard symbol.
  Blood Borne Pathogens
Specimens of blood or other potentially infectious materials are placed in a container which prevents leakage during collection, handling, processing, storage, transport, or shipping
When moving containers of contaminated sharps from the area of use, the containers are closed immediately prior to removal or replacement to prevent spillage or protrusion of contents during handling, storage, transport, or shipping
Certified biological safety cabinets (Class I, II, or III) where needed are available and used

Universal Waste

Storage space for universal waste is maintained.

   

=Implementation: EC3.10.3

=Space: EC3.10.4

 

Containers are structurally sound.

   

<Implementation: EC3.10.3

=Space: EC3.10.4

 

Recycling occurs within one year of initial accumulation.

   

Implementation EC3.10.3

=Space EC3.10.4

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

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

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

   

=Implementation: EC3.10.3

=Space: EC3.10.4

=Labeling: EC3.10.9

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

Records, documents, and procedures indicate that Universal Waste (e.g., batteries) are not stored or accumulated on site for longer than one year.

   

=Space: EC3.10.4

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

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


Materials of Concern

  Radioactive Materials and Waste
Radioactive materials are safely stored and secured in area(s) labeled with appropriate hazard warning signs

Facilities and Equipment

bullet Tanks are located a safe distance from other areas of the facility.

   

=Implementation: EC3.10.3

 

Facility design provides ample and convenient space for staging hazardous materials and waste that facilitates recycling.

Facility design incorporates appropriate spaces throughout the building for recycling, reuse and accumulation of items for manufacturer take-back
©2015 Healthcare Environmental Resource Center
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