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St. Joseph's Medical Center <br />2017 CUPA Inspection Return to Compliance <br />Hazardous Waste Generator Inspection Report April 21, 2017 <br />Violation: Item # 102 CCR 66262.11 <br />Failed to determine if a waste is a hazardous waste. <br />a. Nurses, including charge nurse, in different departments, when asked about dropped pills stated they <br />were either thrown in the blue bin (incineration only) or thrown in the trash, without a hazardous waste <br />determination. <br />Nurses, including charge nurses, in different departments, when asked about packaging of nicotine <br />patches and warfarin tablets stated they were thrown in the trash, without a hazardous waste <br />determination. <br />Correction: Items A and B will be addressed by utilizing an interdisciplinary approach which will consist of the <br />following: <br />a. Monthly nursing education during Skills Day presented by a Pharm D addressing proper handling and <br />disposal of hazardous medication. <br />b. Education will be disseminated during nursing weekly huddles and in nursing leadership team meetings. <br />Each nursing department leader will be required to submit 100% staff compliance of staff Hazardous <br />Waste Determination understanding to their respective VP. <br />c. RCRA bins will be labeled and readily available on all patient units. <br />d. An education module will be developed and assigned to all new hires and completed annually for all <br />clinical and EVS staff. <br />e. Timeline for completion is on or before December 15, 2017. <br />Violation: Item # 106 CCR66262.34(d)(2) <br />Failed to train employees on waste handling and emergency procedures. <br />a. It could not be demonstrated that employees that handle hazardous waste were properly trained. <br />Correction: Laboratory staff handling small quantity hazardous waste have completed mandatory education <br />required by Dignity Health: <br />b. Dignity Health FY17 ACE for staff <br />c. Hazardous Material Awareness Course <br />d. Clinical laboratory Hazardous Waste Disposal policy — attachment #1 <br />e. Clinical Laboratory Competency — Chemical Hazardous Waste Storage and Removal — attachment #2. <br />Violation: Item # 203 HSC 25189.5(c) <br />Transported or caused transportation of hazardous waste to an unauthorized point. <br />a. St. Joseph's Hospital is using Inmar, Med-Turn Inc. as their reverse distribution company. <br />Correction: Effective Friday, April 21S1, the pharmacy department reviewed the contents of the expired <br />medications bin to ensure there were no RCRA Hazardous Waste medications. Communication was provided to <br />the pharmacy staff during a weekly departmental meeting and minutes were disseminated to all pharmacy staff. <br />The Pharmaceutical Waste Program policy was updated to include the following statement: RCRA <br />pharmaceutical waste will be handled by a TSDF (Treatment Storage and Disposal Facility) licensed company. <br />