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Observations and Corrective Actions: 24. Pharmaceutical waste is not segregated for storage. - Nonradioactive and non-RCRA pharmaceutical wastes, that are regulated as medical waste, shall be placed in a container or secondary container labeled with the words "HIGH HEAT OR INCINERATION ONLY" on the lid and sides, so as to be visible from any lateral direction. HSC 118275(a)(6)(B)-Pharmaceutical waste containers on the 3rd and 4th floors and in room 1206 were overflowing with pharmaceutical waste. The soiled utility room in 2 north and room NICU had a pharmaceutical waste container with no "incineration only" top label. Sharps containers on the 4th floor had pharmaceutical waste. Submit evidence of correction by 12/30/15. 25. Biohazard bag is not placed in a rigid container that is leak resistant, tightly lid, clean, in good repair and appropriately labeled. - Biohazardous waste shall be bagged and placed in a rigid container which is leak resistant, have tight -fitting cover, and be kept clean and in good repair. Container shall be labeled with the words `Biohazardous Waste" or "BIOHAZARD" on the lid and on the sides so as to be visible from any lateral direction. HSC 118280(c) -Room 447 had a biohazard container with biohazard waste overflowing out of the container. The soiled utility room in the 3rd floor had a biohazard container with no lid. The soiled utility room in the corridor and the SICU room both had biohazard bags (with biohazard waste) that were stored outside of a biohazard container. Submit evidence of correction by 12/30/15. 26. Sharps waste is not placed in sharp container. Sharps container is not handled and/or labeled appropriately. - Sharps waste shall be placed in a sharps container. Full sharps container ready for disposal shall be taped closed or tightly lid and stored onsite not more than 30 days. Sharps container shall be labeled with the words "Sharps Waste" or BIOHAZARD". HSC 118285 -The soiled utility room on the second floor had a sharps container that was plugged with sharps waste. The lab had sharps containers filled with biohazard waste. Submit evidence of correction by 12/30/15. Notes: 1. Facility was instructed to update and submit their medical waste management plan. 2. A spore test for July 2015 did not indicate that a control was ran with the test. 3. The autoclave broke down in July 2015. Documentation was available showing that the autoclave was repaired. It is recommended that the documentation showing the time and temperature of the loads indicate that the loads that failed were ran again. Reinspecion on/about: A reinspection fee of $130 per hour may be charged. Page 2 of 2 EH -08/2015 MEDICAL WASTAISPECTION REPORT f Date: I 1 3r��15 Q " San Joaquin County Environmental Health Department Program °� Plzo 1868 E. Hazelton Ave., Stockton, CA 95205 Recons: N _ P q<iFOR�'� (209) 468-3420 Program www.siogv.orq/ehd Element: SZZ Observations and Corrective Actions: 24. Pharmaceutical waste is not segregated for storage. - Nonradioactive and non-RCRA pharmaceutical wastes, that are regulated as medical waste, shall be placed in a container or secondary container labeled with the words "HIGH HEAT OR INCINERATION ONLY" on the lid and sides, so as to be visible from any lateral direction. HSC 118275(a)(6)(B)-Pharmaceutical waste containers on the 3rd and 4th floors and in room 1206 were overflowing with pharmaceutical waste. The soiled utility room in 2 north and room NICU had a pharmaceutical waste container with no "incineration only" top label. Sharps containers on the 4th floor had pharmaceutical waste. Submit evidence of correction by 12/30/15. 25. Biohazard bag is not placed in a rigid container that is leak resistant, tightly lid, clean, in good repair and appropriately labeled. - Biohazardous waste shall be bagged and placed in a rigid container which is leak resistant, have tight -fitting cover, and be kept clean and in good repair. Container shall be labeled with the words `Biohazardous Waste" or "BIOHAZARD" on the lid and on the sides so as to be visible from any lateral direction. HSC 118280(c) -Room 447 had a biohazard container with biohazard waste overflowing out of the container. The soiled utility room in the 3rd floor had a biohazard container with no lid. The soiled utility room in the corridor and the SICU room both had biohazard bags (with biohazard waste) that were stored outside of a biohazard container. Submit evidence of correction by 12/30/15. 26. Sharps waste is not placed in sharp container. Sharps container is not handled and/or labeled appropriately. - Sharps waste shall be placed in a sharps container. Full sharps container ready for disposal shall be taped closed or tightly lid and stored onsite not more than 30 days. Sharps container shall be labeled with the words "Sharps Waste" or BIOHAZARD". HSC 118285 -The soiled utility room on the second floor had a sharps container that was plugged with sharps waste. The lab had sharps containers filled with biohazard waste. Submit evidence of correction by 12/30/15. Notes: 1. Facility was instructed to update and submit their medical waste management plan. 2. A spore test for July 2015 did not indicate that a control was ran with the test. 3. The autoclave broke down in July 2015. Documentation was available showing that the autoclave was repaired. It is recommended that the documentation showing the time and temperature of the loads indicate that the loads that failed were ran again. Reinspecion on/about: A reinspection fee of $130 per hour may be charged. Page 2 of 2 EH -08/2015