JCAHO EC 3.10.9

Guide to JCAHO Environment of Care Standard 3.10.9

© 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.

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Introduction Table of Contents Checklist for 3.10.9

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

Element of Performance 9. Labeling

The organization properly labels hazardous materials and waste.

This page provides a set of criteria for evaluating how well a facility complies with labeling requirements.

The criteria are divided into several topic areas.

	= Compliance
	= Environmental Improvement
	*= Tools and Resources*

Hazardous Materials Management

All hazardous chemical products have labels that indicate name of the chemical product, and any hazard warnings. Labels may also identify recommended PPE and/or use the diamond NFPA 704 hazard warning numbering system.

Labels (hazardous chemicals, OSHA): 29 CFR 1910.1200 (f)

Hazardous Waste Management

Containers of hazardous waste are marked with the words “Hazardous Waste” and a descriptive name of the waste and the accumulation start date.

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

All satellite accumulation hazardous waste containers are properly labeled with the words, “Hazardous Waste” and a descriptive name of the waste . The date need not be placed on the container until after it is full.

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

Hazardous waste shipping containers are labeled with the proper DOT shipping name, DOT primary and subsidiary hazards.

Labeling (DOT): 49 CFR 172.400

Regulated Medical (Infectious) Waste

Medical waste is clearly defined, identified, and labeled.

HERC: State RMW Locator

Warning labels and signs shall be affixed to containers of regulated waste, refrigerators and freezers containing blood or other potentially infectious material; and other containers used to store, transport or ship blood or other potentially infectious materials.

Implementation EC3.10.3

Bloodborne pathogens 29 CFR 1910.1030

Medical waste bags are color coded (usually red) and/or labeled with the universal biohazard symbol.

HERC: State RMW Locator

Signs are posted to identify restricted areas.

Regulated medical waste shipping containers are labeled with the proper DOT shipping name, DOT primary and subsidiary hazards.

Labeling (transportation) 49 CFR 172.400

OSHA eTool for Hospitals describes standard requirements for healthcare facilities [add link]
Practice Greenhealth:
- 10-Step Guide to RMW Reduction
- Waste Reduction Guide: Cutting Costs and Minimizing Waste From Your Facility (includes guidance for reducing RMW)
MnTAP: Suction Canister Waste Reduction

Universal Waste

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

=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

Materials of Concern

Asbestos

All asbestos containing, or assumed asbestos containing, building materials are labeled with words similar to the following:

Caution – Contains Asbestos –
Do not disturb without proper training & equipment –
Cancer & lung disease hazard – Authorized Personnel Only

Implementation: EC3.10.3

Occupational exposure, asbestos: 29 CFR 1910.1001

NESHAP, asbestos, demolition and renovation: 40 CFR 61.145

Managing Asbestos in Place: A Building Owner’s Guide, EPA

Ethylene Oxide

Any areas using ethylene oxide having potential risk for overexposing that would be considered regulated areas must have the following warning sign (29 CFR 1910.1047 ( j ) (1) (i): would the same hold true for formaldehyde and the other HM that have separate standards for them?

DANGER
ETHYLENE OXIDE
CANCER HAZARD AND REPRODUCTIVE HAZARD
AUTHORIZED PERSONNEL ONLY
RESPIRATORS AND PROTECTIVE CLOTHING MAY BE REQUIRED
TO BE WORN IN THIS AREA

Replacing Ethylene Oxide and Glutaraldehyde, EPA Region 9 Pollution Prevention Program.
Hospitals for a Healthy Environment (Practice Greenhealth): Mercury Virtual Elimination Plan

Petroleum Products

Aboveground storage tank parts are labeled with appropriate American Petroleum Institute (API) code (e.g. Hexagon for #2 Fuel Oil) (40 CFR 280).

US EPA Energy Star for Healthcare (Rationale: energy efficient equipment and buildings minimize use of petroleum products.)
Guidance on Aboveground Storage Tanks

Used Oil

Containers holding used oil are labeled with the words “Used Oil”.

Used oil storage: 40 CFR 279.22