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MEDICAL WAST&SPECTION REPORT Date: d o2 �l G >' 1 9 San Joaquin County Environmental Health Department Program 1868 E. Hazelton Ave., Stockton, CA 95205 Record: PRO 5 cloo i (209) 468-3420 Program E . ✓ www.siogv.org/ehd Element: Observations and Corrective Actions: 12. The medical waste management plan (MWMP) does not contain all information listed in HSC 117960. - MWMP shall contain all information listed in HSC 117960. HSC117960 — A MWMP was not available. Submit an updated copy of the MWMP to the EHD. 13. This registered large medical waste generator does not maintain individual treatment records and shipping and tracking documents for 2 years. - A large medical waste generator required to register with the EHD shall maintain individual treatment operation records, and shipping and tracking documents for all untreated medical waste shipped offsite for treatment for 2 years. HSC117975(a) — The "Treatment Facility" section of the tracking documents were incomplete (see attachment; PHOTO 1). Ensure tracking documents are complete. 19. For steam sterilization, the temperature does not reach 250 F for 30 minutes. Thermometer is not calibrated annually. - Recording or indicating thermometers shall be checked during each complete cycle to ensure the attainment of 250 F for at least 30 minutes. HSC118215(2)(B) - Thermometers, thermocouples, or other monitoring devices shall be checked for calibration annually. Records of the calibration checks shall be maintained as part of the facility's files and records for 2 years. HSC 118215(a)(2)(B) - Records of thermometer calibration was not available for the autoclave. Submit record of calibration to the EHD, maintain 2 years of records on site. 19. For steam sterilization, the biological indicator Geobacillus stearothermophilus is used at least monthly. - The biological indicator Geobacillus stearothermophillus or approved indicator shall be placed at the center of a load processed under standard operating conditions at least monthly to confirm the attainment of adequate sterilization conditions. HSC 118215(a)(2)(D) — Spore test documents were not available for January, September, or December 2018 and January 2019. The directions on the spore test (Spordi) was not being followed. On a spore test the "date of test" was 512/18 and the "date/ time strips were cultured" was 5/10/18, according to the directions the strips should be cultured within 2 hours of the sterilization process (see attachment; PHOTO 3). The information on the spore test envelopes were also not complete, the "date/time strips were cultured" was missing from a few envelopes (see attachment, PHOTO 4). The test administered on June 2018 is missing the date that it was signed. Provide spore test results from the months indicated above, submit results to the EHD. Ensure all spore tests have complete and accurate information. 19. For steam sterilization, records of treatment procedures are not available. - Records of treatment procedures shall be maintained for 2 years. HSC 118215(a)(2)(E) — The treatment record for 4/20/18 to 4/27/18 had a time discrepancy on Wednesday and Friday (see attachment; PHOTO 2) and the treatment record for 7/5/19 to 7/11/19 had a time and temperature discrepancy on Thursday and Friday, there were no explanations for the discrepancies. Ensure there is an explanation for the discrepancies stated on the treatment records. 24. Trace chemotherapy waste is not segregated for storage. The secondary container is not labeled appropriately. - Trace chemotherapy waste shall be segregated for storage, and the secondary container shall be labeled with the words "Chemotherapy Waste" or "CHEMO" on the lid and sides, so as to be visible from any lateral direction. HSC 118275(a)(4) — The chemotherapy waste container in the utility room of the Surgical ICU (2nd floor) was not labeled appropriately (see attachment; PHOTO 7). Label chemotherapy container appropriately, then submit photographic evidence to the EHD. Reinspecion on/about: A reinspection fee of $152 per hour may be charged. Page 2 of 4 EH -11/17