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Medical Waste Inspection Action Pian <br />Dameron Hospital <br />Observations and Corrective Actions <br />Observation <br />Corrective Action <br />Attachment Exhibit <br />The medical waste <br />The MWMP was revised to <br />Attachment A <br />management plan (MWMP did <br />include all updated 2015 <br />not contain all the information <br />information listed in HSC <br />listed in HSC 117960. <br />117960. The final draft is <br />submitted for approval by the <br />Infection Control Committee on <br />12/14/15. <br />Records were missing showing <br />Since Stericycle did not provide <br />Attachment B <br />treatment of waste picked up <br />the normal tracking document <br />on 1/16/15 and 2/13/15, <br />for these pickups, the manifest <br />information on file is sufficient. <br />Waste sent off-site for <br />Biohazardous bags meeting <br />Attachment C <br />treatment was not contained in <br />ASTM standards D1709 and <br />a biohazardous bag that met <br />D1922 are now used for waste <br />ASTM standards D1709 and <br />sent off-site. <br />D1922. <br />Biohazardous waste containers <br />Training held with L&D staff, <br />Attachment D <br />in L&D Recovery and Pharmacy <br />Pharmacy staff, and OB <br />IV Room contained <br />Anesthesiologists regarding <br />pharmaceutical waste. Provide <br />proper waste segregation. <br />training to staff on proper <br />segregation of pharmaceutical <br />waste. <br />Interim storage area located <br />Signage and proper labeling of <br />Attachment E <br />outside "Short Stay Surgery" did <br />the perimeter gate and door <br />not have a biohazard label on <br />leading into the building has <br />the perimeter gate and door <br />been added. <br />leading into the building. <br />