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MEDICAL WASTL .,4SPECTION REPORT <br /> Date: l L f t 9 <br /> San Joaquin County Environmental Health Department Program <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205 Record: t?R Q S 3 7 R 5 A <br /> • �» r/ (209)468-3420 Program <br /> www.siogv.org/ehd Element: —o2 <br /> Observations and Corrective Actions: <br /> 12. The medical waste management plan(MWMP)does not contain all information listed in NSC 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 END shah maintain individual treatment operation records, and <br /> shipping and tracking documents for all untreated medical waste shipped offsite for treatment for 2 years. HSC117g75(a)— <br /> Tracking records were not available for April 2018 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 Geobachlus stearothermophilus is used at least monthly. <br /> -The biological indicator Geobacillus stearothermophilius 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 /> 118218(a)j2KD)—Spore tests were not available for the sterilization equipment for the year 2010.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 /> oelast <br /> 30 minutes. HSC118215(2)(B)—Annual calibration records for the thermometer was not available.Provide annual <br /> libration records to the EHD. <br /> 24. Pharmaceutical waste is not segregated for storage. <br /> -Pharmaceutical waste shall be segregated for storage in accordance nce with the facility's medical waste management pian. <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 Nd and skies, so as to be visible <br /> from any lateral direction. HSC 118275(a)(6)(8)—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 DIA 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 DIS(see attachment, PHOTO 5)and D76(see attachmaK <br /> PHOTO 8).Corrected on site. <br /> Reinspecion ontabout: A reinspection fee of$152 per hour may be charged. Page 2 d 3 <br /> EH-11117 <br />