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MEDICAL WASTIOSPECTION REPORT • Date: ILS 6 O <br />San Joaquin County Environmental Health Department Program <br />1868 E. Hazelton Ave., Stockton, CA 95205 Record: <br />•,•, e . -3420(209)468 <br />Program <br />VAM.siogv.orq/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 – Submit revised MWMP by 12/7/2015. <br />13. This registered large medical waste generator does not maintain individual treatment records and tracking <br />documents for 2 years. <br />- A large medical waste generator required to register with the EHD shall maintain individual treatment operation <br />records and tracking documents for all untreated medical waste shipped offsite for treatment for 2 years. <br />HSC 117975(a) – Obtain records showing treatment of waste picked up in on 1/16/15 and 2/13/15. Submit by <br />12/7/2015. <br />23. Biohazard bag does not meet the standard set forth in HSC 117630. <br />- Ensure that the biohazard bag is a red disposable film bag that is impervious to moisture and tear -resistant. HSC <br />117630 – Waste that will be sent offiste for treatment must be contained in a biohazardous bag which meets <br />ASTM standards D1709 and D1922. Submit evidence of compliance by 12/7/2015. <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 <br />plan. Shipping container shall be in compliance with DOT and DEA. HSC 118275(x)(6) <br />- Nonradioactive and non-RCRA pharmaceutical wastes, that are regulated as medical waste, shall be placed in a <br />container or secondary container labeled with the words "HIGH HEAT" OR "INCINERATION ONLY" on the lid <br />and sides, so as to be visible from any lateral direction. HSC 118275(a)(6)(B) – Biohazardous waste containers in <br />L&D recovery and Pharmacy IV Room contained pharmaceutical waste. Provide training to staff on proper <br />segregation of pharmaceutical waste. Submit evidence of compliance by 12/7/2015. <br />29. Intermediate storage area is not secured or marked with proper signage. <br />- Intermediate storage area shall be either locked or under direct supervision or surveillance and marked with the <br />international biohazard symbol or the warning signs, "CAUTION—BIOHAZARDOUS WASTE STORAGE <br />AREA—UNAUTHORIZED PERSONS KEEP OUT", in English and in another language determined to be <br />appropriate by the infection control staff or LEA. HSC 118307 – Interim storage area located on the outside of the <br />"Short Stay Surgery" building did not have biohazard label on the perimeter gate and door leading into the <br />building. Add proper labeling and submit evidence of compliance by 12/7/2015. <br />Notes: <br />1.) Chemotherapy waste containers must be labeled "Chemotherapy waste" or "chemo waste" on lid and all sides. <br />2.) Pathology waste containers must be labeled "Path waste" or "Pathology waste" on lid and all sides. <br />3.) Facility contracts with Stericycle for the removal of medical waste. <br />4.) Facility treats biohazardous waste onsite with the exception of biohazardous sharps waste which is removed by <br />Stericycle. <br />Reinspecion on/about: A reinspection fee of $130 per hour may be charged. Page 2 of 2 <br />EH -08/2015 <br />