Laserfiche WebLink
KAISER PERMANEWEe -Central Valley Area <br />Title: Spore Test Policy <br />Approving Bodies/Committee & Date: <br />Integrated Safety Committee: 03/26/09 <br />Medical Executive Committee: 04/29/09 <br />Department(s): Environmental Health & <br />Original Date: 03/13/04 <br />Service <br />Effective Date: 04/29/09 <br />Next Review Date: 04/29/2011 <br />Review Interval: Biennial <br />Policy Number: EC.SA.081 <br />Location: <br />• KFH Manteca/Modesto <br />• Manteca MOB <br />• Modesto MOB <br />• Stockton MOB <br />• Tracy MOB <br />Custodian: <br />Attachment(s): <br />• CVA Administrative P&P <br />A. Sani-Pak Spore Testing Checklist <br />Committee <br />I. PURPOSE <br />To provide evidence of an effective sterilization process through established procedures and <br />documentation. <br />11. POLICY <br />In compliance with the Medical Waste Management Act, and California State and County regulations, <br />this process ensures that monthly biological indicator testing of treated medical waste occurs to ensure <br />that medical waste treated on-site is rendered non-infectious. All Personnel will follow this procedure for <br />sterilizing, incubating and reading of biological indicators. <br />111. 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 A) <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 <br />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 />Spore Testing/EC.SA.081 Page I of <br />