S02_Attachment_7_VHA_Directive_7705_Managment_of_Hazardous_Chemicals.pdf

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Department of Veterans Affairs VHA DIRECTIVE 7705 Veterans Health Administration Transmittal Sheet Washington, DC 20420 August 14, 2015

MANAGEMENT OF HAZARDOUS CHEMICALS

1. REASON FOR ISSUE: This Veterans Health Administration (VHA) Directive establishes policy to ensure that hazardous chemicals are purchased, stored, handled, used, and disposed of in a manner consistent with applicable regulatory, statutory, and accreditation requirements, as well as accepted safe practices. This Directive also provides the policy for the evaluation, reporting, and oversight requirements.

2. SUMMARY OF MAJOR CHANGES: This updated Directive establishes responsibilities and oversight of the Occupational Safety, Health and Green Environmental Management System Program, and establishes requirements to ensure adequate resources are made available to ensure VA is in compliance with established standards.

3. RELATED ISSUES: VHA Directive 7701 and VHA Handbook 7701.01.

4. RESPONSIBLE OFFICE: The Deputy Under Secretary for Health for Operations and Management (10N) is responsible for the contents of this Directive. Questions may be directed to the Director, Occupational Safety, Health and GEMS Programs (10NA8) at 202-632-7889.

5. RESCISSIONS: VHA Directive 2003-030, dated June 11, 2003 is rescinded.

6. RECERTIFICATION: This VHA Directive is scheduled for recertification on or before the last working day of August 2020.

David J. Shulkin, M.D.

Under Secretary for Health

DISTRIBUTION: Emailed to the VHA Publications Distribution List on 8/18/2015.

August 14, 2015 VHA DIRECTIVE 7705

MANAGEMENT OF HAZARDOUS CHEMICALS

1. PURPOSE: This Veterans Health Administration (VHA) Directive establishes policy to ensure that hazardous chemicals are purchased, stored, handled, used, and disposed of in a manner consistent with applicable regulatory, statutory, and accreditation requirements, as well as accepted safe practices. This Directive also provides policy for evaluation, reporting, and oversight requirements. AUTHORITY: 38 U.S.C. 7301(b); 29 CFR 1960.8.

2. BACKGROUND:

a. Title 29 United States Code (U.S.C.) 668 specifies that Federal agencies must comply with safety and health standards published by Occupational Safety and Health Administration (OSHA). VHA must also comply with all elements of collective bargaining agreements. In addition, Title 29 Code of Federal Regulations (CFR)

1910.1200 defines a hazardous chemical as any chemical which is classified as a physical hazard or a health hazard, a simple asphyxiant, combustible dust, pyrophoric gas, or hazard not otherwise classified by the Health Hazard Criteria in 29 CFR

1910.1200 Appendix A, as posing one of the following hazardous effects:

(1) Acute toxicity (any route of exposure),

(2) Skin corrosion or irritation,

(3) Serious eye damage or eye irritation,

(4) Respiratory or skin sensitization,

(5) Germ cell mutagenicity,

(6) Carcinogenicity,

(7) Reproductive toxicity,

(8) Specific target organ toxicity (single or repeated exposure), or

(9) Aspiration toxicity.

b. OSHA regulates hazard communication programs, which include container labeling and other forms of warning, safety data sheets, and employee training.

c. The Joint Commission’s Environment of Care Standards require education and monitoring of personnel who manage or regularly come into contact with hazardous materials or wastes, as well as a documented management program.

d. The Environmental Protection Agency regulates the use, storage, and disposal of hazardous chemicals; under the Clean Water Act, Clean Air Act, and the Resource Conservation and Recovery Act.

VHA DIRECTIVE 7705 August 14, 2015

e. The Department of Transportation (DOT) regulates the interstate transport of hazardous materials.

NOTE: Federal Agency Safety and Health Program requirements are further delineated under 29 CFR 1960.

3. POLICY: It is VHA policy that each VA medical facility must maintain a Hazardous Chemicals Management Program that fulfills the intent of this Directive and includes, at a minimum, the safe purchasing, storage, handling, use, disposal, and reduction of hazardous chemicals and wastes.

4. RESPONSIBILITIES:

a. Under Secretary for Health. The Under Secretary for Health (10) is responsible for:

(1) Overseeing the VHA Occupational Safety and Health (OSH) Program, and

(2) Establishing OSH Program performance standards for the Deputy Under Secretary for Health for Operations and Management.

b. Deputy Under Secretary for Health for Operations and Management. The Deputy Under Secretary for Health for Operations and Management (10N) is responsible for:

(1) Developing and implementing VHA OSH Program and policies, and

(2) Establishing OSH Program performance standards for the Assistant Deputy Under Secretary for Health for Administrative Operations.

c. Assistant Deputy Under Secretary for Health for Administrative Operations.

The Assistant Deputy Under Secretary for Health for Administrative Operations (10NA) is responsible for:

(1) Establishing and overseeing the Office of Occupational Safety, Health and Green Environmental Management Systems (GEMS) Programs, and

(2) Ensuring that staffing and funding are adequate to implement the Hazardous Chemicals Management Program.

d. Director, Office of Occupational Safety, Health and Green Environmental Management System Programs. The Director, Office of Occupational Safety, Health and Green Environmental Management System Programs (10NA8) is responsible for:

(1) Reviewing the results of the Veterans Integrated Service Network (VISN) evaluation of the facilities’ Hazardous Chemicals Management Program(s),

(2) Developing national guidelines for training on hazardous chemical handling, storage and disposal and training requirements, to include hazard assessment, protective equipment, injury prevention and spill response,

(3) Determining whether there are national trends that require intervention, and

(4) Recommending appropriate actions to improve Hazardous Chemicals Management Programs to the Assistant Deputy Under Secretary for Health for Administrative Operations.

e. VISN Directors. VISN Directors are responsible for ensuring that:

(1) Adequate resources are provided for the implementation of this Directive within the facilities within their jurisdiction, and

(2) The Hazardous Chemicals Management Program at each facility is evaluated as part of the Annual Workplace Evaluation (AWE), to include the criteria described in Appendices A and B of this Directive.

NOTE: The AWE is required by VHA Handbook 7701.01.

f. VA Medical Facility Directors. VA medical facility Directors are responsible for:

(1) Ensuring that a Hazardous Chemicals Management Program is developed and maintained at facilities under their authority,

(2) Ensuring that hazardous chemicals are ordered, stored, labeled, used, and disposed of appropriately,

(3) Providing adequate resources for implementation of the facility Hazardous Chemicals Management Program,

(4) Designating a Hazardous Chemicals Management Program Coordinator, and

(5) Ensure facility personnel are provided training on the specific chemical hazards to which they may be exposed.

g. Facility Hazardous Chemicals Management Program Coordinator. The facility Hazardous Chemicals Management Program Coordinator, in consultation with facility safety, radiation safety, industrial hygiene personnel, and others as appropriate, is responsible for:

(1) Developing an ongoing, comprehensive evaluation of the work processes of the facility with the goals of reducing the reliance on toxic materials and minimizing the quantities of hazardous chemicals and wastes and potential employee exposures,

(2) Documenting that employees who use or come in contact with hazardous chemicals are provided training concerning established policies and procedures, and

VHA DIRECTIVE 7705 August 14, 2015 that the employee name, date, and adequacy of the response(s) to an employee questionnaire (see Appendix B) are documented, NOTE: Deficiencies and recommended corrective actions are referred to the responsible official (Hazardous Chemicals Management Program Coordinator) identified by the medical facility Director.

(3) Assessing routinely that employees have assimilated knowledge and understanding concerning established policies and procedures,

(4) Ensuring printed or electronic copies of Safety Data Sheets (SDS) for each hazardous chemical on-site are maintained and made readily available to all workers, NOTE: Facilities may search for and download an online SDS for use at their local site through VHA’s Center for Engineering and Occupational Safety and Health (CEOSH).

(5) Developing and maintaining an inventory listing of all hazardous chemicals at the facility, including their purchase, storage, use, and disposal, and

(6) Including the results of the AWE in the annual Waste Minimization and Compliance Report.

5. REFERENCE(S):

a. 29 CFR 1910.

b. 29 CFR 1960.

c. 29 CFR 1910.1200

d. 40 CFR 260-265.

e. 29 U.S.C. 668

f. The Joint Commission Environment of Care Standards, EC.01.01.01, EP 5.

g. Collective Bargaining Agreements.

h. VHA Directive 7701, Occupational Safety & Health.

i. VHA Handbook 7701.01, Occupational Safety and Health Program Procedures.

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APPENDIX A

MIMINUM CRITERIA FOR EVALUATING HAZARDOUS CHEMICALS

MANAGEMENT PROGRAMS DURING ANNUAL WORKPLACE EVALUATIONS

1. Each employee using hazardous chemicals in the performance of assigned duties has been identified.

NOTE: Employees who use, or may reasonably be expected to come in contact with hazardous chemicals, shall be identified by their supervisor for a risk assessment by facility occupational health and safety staff. The results of the Hazardous Chemicals Management Program Evaluation, when completed as part of an annual review or routine program evaluation, must be documented to indicate either that safe work practices are being followed, or that corrective actions have been taken when indicated.

2. Each employee’s need for training concerning hazardous chemicals has been assessed, training has been provided, and the amount and content of training provided has been documented. Records should be readily accessible to supervisor, employees, and facility safety, industrial hygiene, and Green Environmental Management Systems (GEMS) staff.

3. Employees are knowledgeable concerning the chemicals and personal protective equipment (PPE) that they use (see Appendix B).

4. Each area where hazardous chemicals or hazardous waste is produced or stored has been identified, and an inventory of hazardous chemicals has been completed.

Records should be readily accessible to area supervisor, affected employees, and facility safety, industrial hygiene, and GEMS staff.

5. All storage areas have been inspected at least twice each year and more frequently if required, to identify hazardous materials stored in inappropriate locations or stored with incompatible substances.

6. Types and quantities of hazardous waste generated have been identified and methods used to dispose of each type of waste comply with applicable requirements.

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APPENDIX B

EMPLOYEE QUESTIONNAIRE (EXAMPLE)

1. The Annual Hazardous Chemicals Management Surveillance Survey must include supervisory interviews with those employees who use or come in contact with hazardous chemicals during their tour of duty.

2. The following questions are representative of those to be asked of employees to determine if they are knowledgeable concerning the chemicals and personal protective equipment (PPE) that they use. Employee knowledge can be determined by asking several employees any or all of the questions, i.e., if several questions are answered correctly by an employee who has evident command of the policy and procedure, the interview may be shortened.

a. Why are the chemicals being handled considered hazardous?

b. What precautions must be taken when using the chemical?

c. What PPE must be used for protection from the chemical?

d. What are symptoms of overexposure to the chemical(s)?

e. How would one treat chemical overexposure resulting in acute symptoms?

f. How would one deal with a chemical leak or spill?

g. Where is the Safety Data Sheet (SDS) of a specific chemical located?

3. The employee name, date, and adequacy of the response(s) must be documented.

NOTE: Additional questions may be added as appropriate for job task complexity.

Deficiencies and recommended corrective actions must be reported to the responsible official (Hazardous Chemicals Management Program Coordinator) identified by the medical facility Director.