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<br /> <br /> <br /> <br />Reinspection on/about:__________________. A reinspection fee of $156 per hour may be charged. Page 2 of 2 <br />EH-2/2023 <br /> MEDICAL WASTE INSPECTION REPORT <br />San Joaquin County Environmental Health Department <br />1868 E. Hazelton Ave., Stockton, CA 95205 <br />(209) 468-3420 <br />www.sjogv.org/ehd <br /> <br />Date: 12/16/2024 <br />Program <br />Record: PR0450009 <br />Program <br />Element: 4525 <br />_ <br /> <br />Observations and Corrective Actions: <br /> <br />13. HSC 117935 - LQG shall maintain treatment and tracking documents for 2 years. <br /> <br />OBSERVATION: <br />The facility is missing tracking documents from November 2023 (between11/7/23-11/17/23) , June 2024 (between 5/31/24- <br />6/11/24), and November 2024 (between 11/22/24-12/3/24). <br /> <br />CORRECTIVE ACTION: <br />A large quantity medical waste generator is required to maintain tracking documents of all untreated medical wastes shipped <br />offsite for a minimum of 2 years. Submit the missing tracking documents. If waste was not picked-up during the timeframes listed <br />above, provide a statement explaining how the facility will ensure biohazardous waste is not stored for more than seven days per <br />HSC 118280(e)(1)(A). <br /> <br />24. HSC 118275 - Medical, biohazardous, sharps, trace chemo, pathology, or pharmaceutical waste shall be segregated and <br />contained pursuant to this section. The container shall be properly labeled. <br /> <br />OBSERVATION: <br />1. The following pharmaceutical waste containers contained mixed waste: One container in room 3 of Wound Care (paper towels <br />observed inside container) and one container in the ICU nurse station (gauze observed inside container). <br />2. The following pharmaceutical waste containers were missing “Incineration only” or “high heat” labels on the lids: 3 container s in <br />lab, 1 container in the ICU nurse station, and 1 container in room 1104 of OB/GYN. <br />3. Two pathological waste containers in Ultrasound 1 were missing “PATH” or “Pathology Waste” labels on 3 sides (front, side, & <br />back). Corrected on site. <br /> <br />CORRECTIVE ACTION: <br />1. Pharmaceutical waste, as defined in paragraph (3) of subdivision (b) of Section 117690, shall be segregated for storage . <br />Provide training and submit training records. <br />2. Pharmaceutical waste shall be labeled with the words “HIGH HEAT” or “INCINERATION ONLY,” or with another label <br />approved by the department, on the lid and sides, so as to be visible from any lateral direction . Place required labels on containers <br />and submit photos of correction. <br />3. No further action, corrected on site. <br /> <br />Correct all violations and submit evidence of corrections <br />To the EHD by 01/02/2025. <br />NOTES: <br />1. Report was emailed to dawn.kent@sutterhealth.org & garrib1@sutterhealth.org on 12/18/2024. <br />2. Medical waste hauler is Stericycle. Stericycle hauls pharmaceutical and pathology waste. <br />3. Biohazardous waste bags meet both ASTM D1709 & D1933 standards. <br />4. Autoclave bags have heat sensitive tape. <br />5. Biohazardous waste are autoclaved by steam sterilization on-site using SaniPak. <br />6. Reviewed medical waste management plan (MWMP), biological indicator logs (10/18/23-12/10/24), tracking records <br />(10/13/23-12/13/24), Sanipak cycle reports (10/21/23-12/15/24), SaniPak annual calibration record, and operating <br />procedures for SaniPak. <br />7. Areas inspected: woundcare, lab, radiation, nuclear medicine, ultrasound 1 & 2, x-ray 1 & 2, ICU, ICU soiled utility, ER, <br />2nd floor soiled utility, and OB/GYN. <br />8. Per the medical waste management plan, the biological indicator is tested weekly. Ensure biological indicator testing is <br />tested in accordance to the MWMP.