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Guide to JCAHO Environment
of Care Standard 3.10.7
© 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. |
Please
note: this page is under development. Contact
(734) 995-7989,
if you have questions or suggestions.
Introduction Table of Contents Checklist
for 3.10.7
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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
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Copies of the following
reports are on site and available for review: |
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-- inspection reports (e.g. tours, insurance,
OSHA, College of American Pathologists (CAP), fire marshal,
US EPA, state environmental and/or health departments,
etc.)
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-- facility response and mitigation of deficiencies
on inspection |
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-- results of employee monitoring for
exposure to hazardous materials such as:
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-- records of industrial hygiene monitoring
of noise, dust and mold [need
OSHA cite] |
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-- records for clean up for hazardous
materials spills (e.g. mercury) including
air monitoring, proper clean up, reporting to authorities [need
OSHA cite] |
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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.). |
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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). |
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Records indicate
that staff preparing hazardous materials for shipment
are trained on Dept of Transportation rules for marking,
packaging, shipping papers, placarding and transport.
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Records indicate
that staff are trained in, and are thoroughly familiar
with, proper waste handling and emergency procedures
relevant to their jobs.
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Hazardous Waste
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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
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The basis for hazardous
waste determinations is documented.
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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.
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The facility maintains
documentation verifying that hazardous
waste storage inspections have been performed.
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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.
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Quantities of hazardous wastes shipped
on manifests, and number of hazardous
waste shipments, are reduced. |
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Records are kept
indicating recycling of universal waste and used oil.
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Land Disposal Restriction
notices are kept for a minimum of three years.
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Chemotherapeutic Waste |
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Chemotherapeutic
wastes are evaluated for hazardous waste classification. Process
for evaluation is documented.
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Chemotherapy hazardous
wastes are reported biennially to the EPA,
and reports are kept on site for at least three years.
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Chemotherapy hazardous
wastes are reported as required by state and local authorities.
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Regulated Medical (Infectious)
Waste
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Facility is registered
with state and local authorities if required,
and has obtained all required permits.
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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.
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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.
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Facility
maintains employee medical and training records.
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Facility tracks
and documents the amount of RMW generated monthly
to identify opportunities for reduction. |
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Sources
and quantities of regulated medical waste are measured
and documented to facilitate RMW reduction. |
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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
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Asbestos [need basic compliance info] |
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Abated asbestos
is disposed of at an approved (either EPA or state) facility.
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Ten day prior notification
is given to local authorities for large asbestos projects and records of
the notice are retained.
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Air monitoring is
conducted during and post abatement, records are kept
and clearance obtained.
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Manifests are complete
(e.g. no information missing) and are appropriately routed.
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Pesticides |
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Records indicate
staff using disinfectants, cold sterilants and pesticides
have been trained on their hazards and appropriate use.
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Pesticide applicator
licenses are maintained or are part of pest management
contract.
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Documentation of
pesticides applied maintained to ensure appropriate exposure
monitoring and to ensure restricted pesticides are not
used.
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An
Integrated Pest Management (IPM) program is in place. |
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If the organization
is a federal facility, documentation that an integrated
pest management program is in place. CHECK THIS REQUIREMENT |
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Pesticide applicator
licenses are no longer needed due to no pesticides being
applied at facility. |
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Petroleum Products |
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Tanks are permitted
or registered with either EPA or local authorities. |
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Number of tank permits
required is reduced due to minimized use of petroleum
products (or hazardous waste/material storage). |
Facilities and equipment
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Air (general) [need
basic compliance info] |
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Up to date air permits
are available on site for review. Permits may be
required for:
- boilers
- incinerators
- fume
hoods
- ethylene oxide sterilizers
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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). |
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Boilers |
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Air permits are
modified when fuel usage changes.
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Certificates to
Operate and Permits are not permitted to expire.
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Air permits are
modified when fuel usage changes (40 CFR 70).Certificates
to Operate and Permits are not permitted to expire (40
CFR 70). |
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Permits for boilers are not
needed due to energy efficient boilers. |
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Incinerators |
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Incinerator is operated
within permit parameters and records are kept (40 CFR
70). |
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Hazardous waste
is not burned in the incinerator unless allowed by permit
(40 CFR 70). |
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No on-site incineration is carried out at the facility. |
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Ethylene oxide sterilizers |
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Ethylene oxide has been
eliminated as a sterilant. |
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Wastewater |
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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] |
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Facility maintains
copies of wastewater monitoring results (local permits, 40
CFR 403). |
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Wastewater monitoring
requirements are diminished due to minimized discharges
to sewer. |
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