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. |
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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, |
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.
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The criteria are divided into several topic areas. |
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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:
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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A RCRA hazardous
waste determination has been made for all solid
waste that is generated. Examples
of potential sources of hazardous waste include:
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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. |
| 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. | |||
| 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). |
