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0 • Singh, Sandip [EH] From: Paul A. Martinez [SJGH] <pmartinez@sjgh.org> Sent: Thursday, January 30, 2020 1:13 PM To: Singh, Sandip [EH] Cc: Cyr, Lori; Jacob McCarty [SJGH]; Susan Ramirez [SJGH]; Easter, Jesse; Jennifer T. Hirai [SJGH]; Krissy T. Hirai [SJGH] Subject: FW: Official Inspection Report See below. Lori please review your finding. Item # 25 From: Singh, Sandip [EH] [mailto:ssingheh@sjgov.org] Sent: Thursday, January 30, 2020 11:09 AM To: Paul A. Martinez [SJGH]; Easter, Jesse Cc: Jacob McCarty [SJGH]; Susan Ramirez [SJGH]; McClellon, Robert Subject: RE: Official Inspection Report Good Morning Paul, I've reviewed the corrections that were submitted. There are a few items that were either not addressed or were addressed incorrectly. Please correct the following items: Verification is needed that the Covidien ChemoPlus CT2100 (20 gallon bag) bags meet the US DOT Standards (ASTM D-1709 and ASTM D-1922). Verification can be obtained from the manufacturer of the product. The other option is to discontinue use of the product, please inform the EHD if you decide to implement this option (please see - Medical Waste Inspection Report pg. 2, #23) Pharmacy is contacting the vendor for this information. I sent you a pic that we are no longer using the chemoplusCT2100. 117630 - Biohazard Bag (b) The biohazard bag that is used to collect medical waste within a facility shall be manufacturer certified to meet the ASTM D1709 dart drop test, provided that when the bag is prepared for transport offsite, it is placed into a USDOT-approved container lined with a biohazard bag that is ASTM D1709 and ASTM D1922 certified. We are working on getting the information from our vendor. (c) The color of the bag shall be red, except when yellow bags are used to further segregate trace chemotherapy waste and white bags are used to further segregate pathology waste. The biohazard bag shall be marked with the international biohazard symbol and may be labeled by reference as authorized by the USDOT. I sent you a pic that we are no longer using the chemoplusCT2100. The chemotherapy waste containers that are shown in the corrections have labels that state "CAUTION — cancer chemotherapy dispose of properly." The labels should state "Chemotherapy Waste" or "CHEMO" on all 4 sides and the top. Please correct the labels and then submit photographic evidence (please see — Medical Waste Inspection Report pg. 2, #24). Working with pharmacy to find a different label. 118275 - Medical Waste Segregation and Storage (4) Trace chemotherapy waste, as defined in paragraph (5) of subdivision (b) of Section 117690, shall be segregated for storage, and, when placed in a secondary container, that container shall be labeled with the words "Chemotherapy Waste," "CHEMO," or other label approved by the department on the lid and sides, so as to be visible from any lateral direction, to ensure treatment of the biohazardous waste pursuant to Section 118222.