Guide to JCAHO Environment of Care Standard 3.10.2

© 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 3.10.2

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

Element of Performance 2. Hazardous Materials and Hazardous Waste Inventory

The organization creates and maintains an inventory that identifies hazardous materials and waste used, stored or generated using criteria consistent with applicable law and regulation. 

This page provides a set of criteria for evaluating a facility's inventory system for tracking hazardous materials and waste. 

= Compliance
= Environmental Improvement
= Tools and Resources
 

Hazardous Materials Management

bullet The facility has instituted a purchasing protocol that discourages hazardous materials from being purchased.

   

Plan: EC3.10.1

Implementation: EC3.10.3

Impl. (Univ. Waste): EC3.10.3

Roles (Risk Min.): HR2.20.2

The facility's hazardous materials inventory contains an accurate list of all hazardous materials stored or present on site, including:

   

Plan: EC3.10.1

Emergency: EC3.10.6

>Implementation: EC3.10.3

  • asbestos

   

Implementation: EC3.10.3

 

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

   

Gases: EC3.10.5

 

  • pesticides

   

Plan: EC3.10.1

Implementation: EC3.10.3

Documentation: EC3.10.7

 

  • petroleum products

   

Plan: EC3.10.1

Implementation: EC3.10.3

Documentation: EC3.10.7

Labeling: EC3.10.9

 

  • pharmaceuticals and chemotherapeutic agents

   

Implementation: EC3.10.3

Emergency: EC3.10.6

Documentation: EC3.10.7

 

  • polychlorinated biphenyl (PCB)-containing equipment
  • radioactive agents and associated wastes
The quantity of hazardous materials used over successive time periods has been tracked and documented. 
The size of the hazardous materials inventory has been reduced. 
bullet
Inventory records indicate that mercury-containing equipment, chemicals, lab reagents and pharmaceuticals are being substituted or eliminated. 
bullet
Inventory records demonstrate the use of substitutes for hazardous chemicals (e.g. less hazardous or non-hazardous alternatives to formalin, xylene, and other reagents and solvents). 
bullet
Inventory records indicate that PCB-containing equipment such as transformers, elevator oil, light ballasts, etc. is being replaced or eliminated. 
bullet
Inventory records indicate that petroleum product storage and use has been minimized. 
The facility maintains a readily accessible file of Material Safety Data Sheets (MSDSs) that are less than five years old. 
bullet The facility maintains an accurate list of all asbestos containing building materials.

   

Occupational exposure, asbestos: 29 CFR 1910.1001

Friable asbestos has been eliminated or is being abated 
The facility can document that an annual physical hazardous material/waste review and audit has been performed.

   

 (EC 1.20, 9.10) 


Hazardous Waste Management

The facility maintains a record of all hazardous waste generated for each calendar month (required to determine hazardous waste generator status).

   

  Implicit requirement for compliance with Hazardous waste accumulation time: 40 CFR 262.34 and other regulations that depend on generator status.
The facility maintains documentation verifying that hazardous waste storage inspections have been performed.

   

Emergency: EC3.10.6

Documentation: EC3.10.7

Hazardous waste storage inspections (LQG): 40 CFR 265.174


Regulated Medical (Infectious) Waste

The facility maintains a list of all locations where regulated medical (infectious) waste is generated and stored.

   

Emergency (RMW): EC3.10.6