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.
= Compliance
= Environmental Improvement
= Tools and Resources

Hazardous Waste Management

All hazardous waste shipments are accompanied by a hazardous waste manifest.

   

<Implementation: EC3.10.3

Manifests (EPA): 40 CFR 262.20

Hazardous waste manifest (DOT): 49 CFR 172.205
Manifests and shipping papers indicating proper hazardous waste management are kept on site for a minimum of three years.

   

=Documentation: EC3.10.7

 Hazardous waste recordkeeping: 40 CFR 262.40
Manifest copies are managed properly (e.g. appropriate copies are received from the treatment facility and are routed to the regulatory authority).

   

=Implementation: EC3.10.3 Manifests (EPA): 40 CFR 262.20
The hospital files hazardous waste exception report if final disposition copy of hazardous waste manifest is not received within 45 days.

   

  Exception reporting: 40 CFR 262.42
Manifests indicate a reduction in the quantity of hazardous waste being shipped.
Number of hazardous waste shipments is reduced.

Regulated Medical Waste

Regulated medical waste is shipped using a shipping paper or manifest.

   

  Shipping Papers: 49 CFR 172.201

Shipping Papers (HazMat descriptions): 49 CFR 172.202

Documents (including manifests) indicating proper RMW disposal are available.

   

  HERC: State RMW Locator

Manifests and documentation indicate that the quantity of RMW being shipped is reduced.

Universal Waste

 For Universal Waste that is recycled, copies of receipts indicating recycling are available.

   

Documentation: EC3.10.7 Universal waste accum. time (SQG): 40 CFR 273.15

Universal waste accum. time (LQG): 40 CFR 273.35

For Universal Waste that is managed as hazardous waste, manifests are used (see “Hazardous Waste” above).

Manifests or receipts indicate quantity of batteries recycled or disposed is reduced.

Manifests indicate quantity of fluorescent bulbs recycled or disposed of as on, is reduced.

Materials of Concern

  Asbestos
Manifests are complete (e.g. no information missing) and appropriately routed.

   

Implementation: EC3.10.3

Documentation: EC3.10.7

Manifests (EPA): 40 CFR 262.20
  Used oil

For Used Oil that is recycled, copies of receipts indicating recycling are available.

   

Documentation: EC3.10.7 Used oil definition: 40 CFR 279.10

Used oil specifications: 40 CFR 279.11

Used oil practices: 40 CFR 279.20

Used oil storage: 40 CFR 279.22

Used oil off-site shipments: 40 CFR 279.24

For Used Oil  that is managed as hazardous waste, manifests are used (see “Hazardous Waste” above).