Guide to JCAHO Environment of Care Standard 3.10.1
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Introduction Table of Contents Checklist for 3.10.1
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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.
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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:
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General Environmental Management Plan
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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. | |||
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Facility conducts periodic internal compliance
audits
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A
qualified Safety Officer or equivalent has been selected,
together with members of a Safety
Committee.
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The Safety Committee approves the Materials and
Hazardous Waste Management Plan, and the approval is
recorded in meeting minutes.
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Facility has developed an Environmental Management System (EMS). | |||
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Facility is ISO 14000 certified, and maintains the certification. |
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Facility has plans on file, readily accessible by appropriate staff, for: |
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-- creating and maintaining an inventory that identifies and provides the location for all hazardous materials in use throughout the facility, including:
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-- reducing
use of hazardous materials through purchasing policies
and procedures that prefer less hazardous materials.
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-- managing
hazardous materials such as compressed gases, flammable/combustible
materials, acids/bases, ionizing radiation, etc
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identifying all hazardous materials that require employee
monitoring, e.g. asbestos, formaldehyde, ethylene oxide,
carcinogens, etc.
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-- selecting and maintaining personal protective equipment. | ||||||
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-- communicating hazardous chemical handling and use
requirements to employees.
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-- developing a Community-Right-to-Know plan
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Facility has plans on file, readily accessible by appropriate staff, for: |
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Hazardous waste management |
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--
annually determining hazardous waste generator status.
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-- working toward smaller quantity generator status by minimizing hazardous materials and waste. | |||
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making hazardous waste determinations by applying knowledge
or testing.
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-- managing
hazardous waste, including tracking, storing, inspecting,
recycling, treating, and disposing.
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-- eliminating mercury. | |||
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-- recycling of solvents and formalin. | |||
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--
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.
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| Disposal and treatment | ||||
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-- eliminating or reducing incineration as waste treatment method. | |||
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-- packaging, labeling and transporting hazardous waste according to DOT requirements. | |||
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| General hazardous waste resources | ||||
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Regulated Medical (Infectious) Waste
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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.
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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 . | |||
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Facility has a plan
for identifying, segregating, and managing any RMW that contains pathology
waste, or non-hazardous “trace” is chemotherapy
waste.
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Facility has a plan
for packaging, labeling and transporting RMW
according to Department of Transportation requirements.
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Facility has developed provisions for ensuring that RMW arrives at an appropriate destination.. | |||
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Facility has plans on file, readily accessible by appropriate staff, for: |
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Identifying and
managing Universal Waste for recycling (i.e., fluorescent
lamps, batteries, certain pesticides, and thermostats).
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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.
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Facility has plans on file, readily accessible by appropriate staff, for: |
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Application:
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Disposal:
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Petroleum Products (see also Used Oil, below)
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Facility has plans on file, readily accessible by appropriate staff, for: |
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Managing aboveground
and underground storage tanks with petroleum products.
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Eliminating or reducing underground storage tanks. | |||
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Reducing or eliminating the use of diesel fuel | |||
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Complying
with Spill Prevention Control & Countermeasure (SPCC)
requirements for aboveground oil storage tanks with aggregate
of more than 1,320 gallons of petroleum.
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Spill
Containment and Countermeasures plan is in place for
aggregate aboveground storage greater than 1320 gallons.
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Radioactive Materials and Waste
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Facility has plans on file, readily accessible by appropriate staff, for: |
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Managing radioactive materials and waste (10 CFR 35, 70). |
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Eliminating or reducing radioactive materials and waste. |
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Facility has plans on file, readily accessible by appropriate staff, for: |
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Identifying and
managing used oil for recycling.
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Managing
used oil that is destined for disposal as a hazardous
waste.
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Packaging, labeling and transporting used oil destined
for recycling.
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Packing,
labeling and transporting used oil destined for disposal
oil .
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Facility has plans on file, readily accessible by appropriate staff, for: |
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-- controlling and cleaning up hazardous material and waste spills. | |||
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--
controlling and cleaning up spills of universal waste.
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--
controlling and cleaning up spills from used oil.
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--
controlling, cleaning up & exposure monitoring of
spills from radioactive materials.
(10 CFR 20). |
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--
controlling and cleaning up spills from Regulated Medical
Waste.
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complying with Spill Prevention Control & Countermeasure
(SPCC) requirements for aboveground oil storage tanks
with aggregate of more than 1,320 gallons.
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-- minimizing spills. |
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Facility has plans on file, readily accessible by appropriate staff, for: |
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Fulfilling the training
requirements of OSHA, EPA and DOT.
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Identifying departments and personnel that require training.
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Training
on universal waste requirements.
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