Guide to JCAHO Environment of Care Standard 3.10.4

© 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 3.10.4

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

Element of Performance 4. Storage of Hazardous Materials and Hazardous Waste

 The organization provides adequate and appropriate space and equipment for safely handling and storing hazardous materials and waste.

This page provides a set of criteria for evaluating a facility's hazardous materials and hazardous waste storage 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

=Separation: EC3.10.10

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.
Space is provided for the distillation or recovery of laboratory solvents such as xylene, alcohol, and formalin.
Hazardous materials use is diminished to reduce spill and exposure risk.
Space and equipment are provided for safe handling and storage of hazardous materials.


Hazardous Waste Management

Hazardous waste is stored in non-leaking, sturdy, compatible containers.

   

<Implementation: EC3.10.3

Hazardous waste accumulation time: 40 CFR 262.34

Condition of hazardous waste containers: 40 CFR 265.171

Compatibility of hazardous waste and containers: 40 CFR 265.172

Management of hazardous waste containers: 40 CFR 265.173

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

   

=Implementation: EC3.10.3

=Separation: EC3.10.10

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

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

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

   

>Implementation: EC3.10.3

=Separation: EC3.10.10

Hazardous waste accumulation time: 40 CFR 262.34

Condition of hazardous waste containers: 40 CFR 265.171

Compatibility of hazardous waste and containers: 40 CFR 265.172

Management of hazardous waste containers: 40 CFR 265.173

Security: 40 CFR 265.14

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

   

=Implementation: EC3.10.3

=Separation: EC3.10.10

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

=Separation: EC3.10.10

Hazardous waste storage inspections (LQG): 40 CFR 265.174

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

   

=Separation: EC3.10.10

Accidental ignition or reaction: 40 CFR 265.17

Hazardous waste use is diminished to reduce spill and exposure risk.
Space and equipment are provided for safe handling and storage of hazardous waste.
Hazardous waste generator size is reduced.
  Spills

Spill control and decontamination equipment is readily available in areas where hazardous waste is handled or stored.

   

=Implementation: EC3.10.3

Required equipment for HazWaste facilities: 40 CFR 265.32

Emergency spill hotline number is readily available.


Regulated Medical (Infectious) Waste

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

   

 =Separation :EC3.10.10  

Refrigeration available when necessary to prevent putrefaction of medical waste.

   

=Separation: EC3.10.10

 

Specimens of blood or other potentially infectious materials are placed in a container which prevents leakage during collection, handling, processing, storage, transport, or shipping.

   

 

Bloodborne pathogens: 29 CFR 1910.1030

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. 

   

 

Bloodborne pathogens: 29 CFR 1910.1030

Certified biological safety cabinets (Class I, II, or III) where needed are available and used.

   

 

Bloodborne pathogens: 29 CFR 1910.1030


Universal Waste

Storage space for universal waste is maintained.

   

=Implementation: EC3.10.3

=Separation: EC3.10.10

 

Containers are structurally sound

   

<Implementation: EC3.10.3

=Separation: EC3.10.10

 

Recycling occurs within one year of initial accumulation.

   

Implementation: EC3.10.3

=Separation: EC3.10.10

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

=Labeling: EC3.10.9

=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

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

   

=Separation: EC3.10.10

 


Radioactive Materials and Waste

Radioactive materials are safely stored and secured in area(s) labeled with appropriate hazard warning signs
U.S. Nuclear Regulatory Commission, Program-Specific Guidance about Medical Use


Facilities and Equipment

Facility design incorporates appropriate spaces throughout the building for recycling, reuse and accumulation of items for manufacturer take-back
Facility design provides ample and convenient space for staging hazardous materials and waste that facilitates recycling