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COMPLIANCE INFO_2016-2020
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COMPLIANCE INFO_2016-2020
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Last modified
2/7/2023 1:32:47 PM
Creation date
7/3/2020 10:18:14 AM
Metadata
Fields
Template:
EHD - Public
ProgramCode
4500 - Medical Waste Program
File Section
COMPLIANCE INFO
FileName_PostFix
2016-2020
RECORD_ID
PR0450009
PE
4522
FACILITY_ID
FA0002562
FACILITY_NAME
Sutter Valley Hospitals dba Sutter Tracy Community Hospital
STREET_NUMBER
1420
Direction
N
STREET_NAME
TRACY
STREET_TYPE
Blvd
City
Tracy
Zip
95376
APN
233-081-01
CURRENT_STATUS
01
SITE_LOCATION
1420 N Tracy Blvd
P_LOCATION
03
P_DISTRICT
005
QC Status
Approved
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SJGOV\cfield
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FilePath
\MIGRATIONS\MW\MW_4522_PR0450009_1420 N TRACY_2016-2020.tif
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EHD - Public
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MEDICAL WAST SPECTION REPORT Date: <br /> 11 LZIq /Zay, <br /> Iw. San Joaquin County Environmental Health Department Program <br /> 1868 E. Hazelton Ave.,Stockton,CA 95205 Record: <br /> P (209)468-3420 Program <br /> �rF ?' www.siogv.org/ehd Element: <br /> Observations and Corrective Actions: <br /> 13. This registered large medical waste generator does not maintain individual treatment records and tracking documents for 2 <br /> years. <br /> -A large medical waste generator required to register with the EHD shall maintain individual treatment operation records and <br /> tracking documents for all untreated medical waste shipped offsite for treatment for 2 years. HSC117975(a)— Corrected on <br /> site. <br /> 19. For steam sterilization, a standard written operating procedure for biological indicator is not available. <br /> - Standard written operating procedures shall be established for biological indicators, or for other indicators of adequate <br /> sterilization for each steam sterilizer, including time,temperature, pressure,type of waste,type of container, closure on <br /> container, pattern of loading, water contents, and maximum load quantity. HSC 118215(a)(2)(A)—Establish operating <br /> procedures for proper treatment of waste. Submit by 12/29/2016. <br /> 25. Biohazard bag is not placed in a rigid container that is leak resistant,tightly lid, clean, in good repair and appropriately <br /> labeled. <br /> -Biohazardous waste shall be bagged and placed in a rigid container which is leak resistant,have tight-fitting cover, and be <br /> kept clean and in good repair. Container shall be labeled with the words "Biohazardous Waste"or`BIOHAZARD"on the lid <br /> and on the sides so as to be visible from any lateral direction. HSC 118280(c)—Corrected on site. <br /> 31. Annual training records were not available for review. <br /> -Large quantity generators that treat medical waste onsite using steam sterilization, incineration, microwave technology, or <br /> other department approved treatment technology to treat medical waste shall train the operators of the equipment in its use, <br /> proper protective equipment to wear, if necessary, and how to clean up spills to ensure that the equipment is being operated in a <br /> safe and effective manner. <br /> -Annual training for the operators shall be provided after the initial training has been completed. <br /> -The training shall be documented and the documentation shall be retained at the facility for a minimum of two years. Training <br /> shall comply with applicable federal Occupational Safety and Health Administration regulations, including those found in <br /> Section 1910 of Title 29 of the Code of Federal Regulations. HSC 117967—Facility sterilization log did not match up with <br /> official data roll from the autoclave.Evidence of training was not available for review. Train operators and submit <br /> evidence of training by 12/29/2016. <br /> Notes: <br /> 1.) Facility uses Daniels Sharpsmart Inc. for removal of pharmaceutical waste and Stericycle for removal of pathology <br /> waste. Treatment and tracking records were available for review. <br /> 2.) Biohazardous waste bags meet both ASTM standards (D1709+D1922). <br /> 3.) Errors noted in facility sterilization log were due to human error. These loads were checked in data rolls and found to <br /> be treated properly. <br /> 4.) During this inspection it was noted that both Stericycle and Daniels Sharpsmart are noting date that waste was received, <br /> not the date it was treated, on treatment records. <br /> Reinspecion on/about: A reinspection fee of$130 per hour may be charged. Page 2 of 2 <br /> EH-08/2015 <br />
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