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MEDICAL WASTSPECTION REPORT Date: <br /> San Joaquin County Environmental Health Department Program <br /> a 1868 E. Hazelton Ave.,Stockton,CA 95205 Record: PRO-6379,63 <br /> -* (209)468-3420 Program <br /> www.siogv.oM/ehd Element: <br /> Observations and Corrective Actions: <br /> 12. The medical waste management plan (MWMP) does not contain all information listed in HSC 117960. <br /> -MWMP shall contain all information listed in HSC 117960. HSC117960—The Medical Waste Management Plan was not <br /> updated. Update the MWMP and submit to the EHD. <br /> 13.This registered large medical waste generator does not maintain individual treatment records and shipping and tracking <br /> documents for 2 years. <br /> -A large medical waste generator required to register with the EHD shall maintain individual treatment operation records, and <br /> shipping and tracking documents for all untreated medical waste shipped offsite for treatment for 2 years. HSC117975(a)— <br /> Tracking records were not available for April 2019 to June 2019. Maintain tracking records on site for 2 years. Provide <br /> tracking records for the months of April, May and June of 2019 to the EHD. <br /> 19. For steam sterilization, the biological indicator Geobacillus stearothermophilus is used at least monthly. <br /> -The biological indicator Geobacillus stearothermophillus or approved indicator shall be placed at the center of a load processed <br /> under standard operating conditions at least monthly to confirm the attainment of adequate sterilization conditions. HSC <br /> 118215(a)(2)(D)—Spore tests were not available for the sterilization equipment for the year 2019. Provide a minimum of <br /> two spore test results for each month beginning from January 2019 to December 2019 to the EHD. <br /> 19. For steam sterilization, the temperature does not reach 250 F for 30 minutes. Thermometer is not calibrated annually. <br /> - Recording or indicating thermometers shall be checked during each complete cycle to ensure the attainment of 250 F for at <br /> least 30 minutes. HSC118215(2)(B)—Annual calibration records for the thermometer was not available. Provide annual <br /> calibration records to the EHD. <br /> 24. Pharmaceutical waste is not segregated for storage. <br /> - Pharmaceutical waste shall be segregated for storage in accordance with the facility's medical waste management plan. <br /> Shipping container shall be in compliance with DOT and DEA. HSC 118275(a)(6) <br /> - Nonradioactive and non-RCRA pharmaceutical wastes, that are regulated as medical waste, shall be placed in a container or <br /> secondary container labeled with the words "HIGH HEAT OR INCINERATION ONLY" on the lid and sides, so as to be visible <br /> from any lateral direction. HSC 118275(a)(6)(B)—A pharmaceutical waste container in the GP medication room in ECHO <br /> was incorrectly labeled with a hazardous waste label (see attachment, PHOTO 9).Also, the pharmaceutical waste <br /> container located in med room 1 of the EOP building was not properly closed (see attachment, PHOTO 11). Properly <br /> label all pharmaceutical containers and ensure the lids are closed and tight fitting. Corrected on site. <br /> 24. Trace chemotherapy waste is not segregated for storage. The secondary container is not labeled appropriately. <br /> -Trace chemotherapy waste shall be segregated for storage, and the secondary container shall be labeled with the words <br /> "Chemotherapy Waste" or"CHEMO" on the lid and sides, so as to be visible from any lateral direction. HSC 118275(a)(4)—The <br /> chemotherapy waste container located in the medication room of the D1A building was not labeled on all 4 sides and <br /> on top (see attachment, PHOTO 7). Properly label all trace chemotherapy waste containers. <br /> 25. Biohazard bag is not placed in a rigid container that is leak resistant, tightly lid, clean, in good repair and appropriately labeled. <br /> - Biohazardous waste shall be bagged and placed in a rigid container which is leak resistant, have tight-fitting cover, and be kept <br /> clean and in good repair. Container shall be labeled with the words "Biohazardous Waste" or"BIOHAZARD" on the lid and on the <br /> sides so as to be visible from any lateral direction. HSC 118280(c)—A biohazardous bag was placed in a solid waste <br /> collection bin/receptacle in the soiled utility room of building DIB (see attachment, PHOTO 5) and 13713 (see attachment, <br /> PHOTO 8). Corrected on site. <br /> Reinspecion on/about: A reinspection fee of$152 per hour may be charged. Page 2 of 3 <br /> EH-11/17 <br />