Guide to JCAHO Environment of Care Standard 3.10.8
© 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 3.10.8
Environment of Care Standard 3.10: The organization manages hazardous materials and waste risks Element of Performance 8. Hazardous Waste Manifests The organization maintains required manifests for handling hazardous materials and waste. |
This page provides
a set of criteria for evaluating whether
a facility is in compliance with regulations covering the paperwork
(manifests) required when shipping hazardous wastes.
The criteria are divided into several topic areas. |
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All hazardous waste shipments are accompanied by a hazardous waste manifest.
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Manifests and shipping
papers indicating proper hazardous waste management are
kept on site for a minimum of three years.
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Manifest
copies are managed properly (e.g. appropriate copies
are received from the treatment facility and are routed
to the regulatory authority).
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The hospital files
hazardous waste exception report if final disposition
copy of hazardous waste manifest is not received within
45 days.
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Manifests indicate a reduction in the quantity of hazardous waste being shipped. | ||||
Number of hazardous waste shipments is reduced. | ||||
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Regulated medical
waste is shipped using a shipping paper or manifest.
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Documents (including
manifests) indicating proper RMW disposal are available.
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Manifests and documentation indicate that the quantity of RMW being shipped is reduced. | |||
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For Universal Waste
that is recycled, copies of receipts indicating recycling
are available.
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For Universal Waste that is managed as hazardous waste, manifests are used (see “Hazardous Waste” above). | |||
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Manifests or receipts indicate quantity of batteries recycled or disposed is reduced. | |||
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Manifests indicate quantity of fluorescent bulbs recycled or disposed of as on, is reduced. | |||
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Asbestos | ||||
Manifests are complete
(e.g. no information missing) and appropriately routed.
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Used oil | ||||
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For Used Oil that
is recycled, copies of receipts indicating recycling
are available.
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For Used Oil that is managed as hazardous waste, manifests are used (see “Hazardous Waste” above). |