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• <br />KAISER PERMANEWE® -Central Valley Area <br />Title: Spore Test Policy <br />Approving Bodies/Committee & Date: <br />Medical Executive Committee: TBD xx/xx/xx <br />Department(s): Environmental Services and <br />Original Date: 03/13/04 <br />Engineering <br />Effective Date: 02/20/09 <br />Next Review Date: 02/2010 <br />Review Interval: Biennial FEB 2 0 <br />Policy Number: TBD <br />ENVIROMIEN T <br />HERMIT/$ER <br />Location: <br />® KFH Manteca/Modesto <br />€ Manteca MOB <br />€ Modesto MOB <br />® Stockton MOB <br />€ Tracy MOB <br />Custodian: <br />Attachment(s): <br />6d CVA Administrative P&P Committee <br />Sani-Pak Spore Testing Checklist <br />€ CVA Patient Care Services P&P <br />Committee <br />I. Purpose <br />To provide evidence of an effective sterilization process through documentation. <br />VED <br />K. <br />IEALTH <br />CES <br />II. Policy <br />In compliance with the Medical Waste Management Act, and California State and County regulations, this <br />process ensures that monthly biological indicator testing of treated medical waste occurs to ensure that <br />medical waste treated on-site is rendered non-infectious. All Engineering Personnel will follow this procedure <br />for sterilizing, incubating and reading of biological indicators. <br />III. Procedure <br />This procedure will be performed every 30 days or earlier if necessary due to the 30th day falling on a <br />weekend./ Holiday. <br />A. Spore Testing Checklist (Attachment #1) <br />1. Will be filled out as each step is completed. <br />2. Once the load is complete, the test and checklist will be verified by a second engineer. <br />3. Photo copy and attach load printout to the spore test checklist. <br />B. Location of the Incubator <br />1. The 3MTm AttestTm Auto -reader is located in the Laboratory. <br />2. The 3MTm AttestTm Auto -reader will remain plugged in at all times. <br />3. If found unplugged, allow 30 minutes warm up time. <br />C. Biological Indicator <br />1. Utilize the 1296 Rapid Readout tubes. <br />2. Tubes will be discarded as medical waste 30 days prior to the expiration date. <br />3. New tubes will be ordered 45 days prior to the expiration date of the stock on hand Environmental <br />Services. <br />Sani-Pak Spore Testing Policy <br />MEC Approved TED xx/xx/xx Page 1 of 3 <br />