MCP 659-137-6 Shredding and Recycling.pdf

MEDICAL CENTER POLICY: SHREDDING AND RECYCLING

MCP 659-137-6

W. G. (BILL) HEFNER VA MEDICAL

CENTER

SALISBURY, NORTH CAROLINA

Rescinded Document: 659-137-6, SHREDDING AND RECYCLING

FEBRUARY 25, 2017

Signatory Authority: Effective Date:

Medical Center Director FEBRUARY 25, 2020

Responsible Owner: Recertification Date:

ENVIRONMENTAL MANAGEMENT

SERVICE (EMS) CHIEF

FEBRUARY 25, 2025

1. POLICY

This medical center policy establishes Recycling is an integral part of SVAHCS waste management program. SVAHCS encourages recycling and promotes the responsible management of waste through education and direct action.

A. Electric Paper Shredder Policy:

(1) To Destroy Patient Health Information/Patient Identifiable Information

(PHI/PII) Sensitive Information Containing Documents, Electric Paper Shredders will comply with National Security Agency/ Central Security Service (NSA/CSS) Evaluated Product Listing (EPL) Level 6/7 High Security Crosscut specifications, dated 05/18/2015 or newer. .

(2) Electric paper shredders will not be placed within 25 feet of another electric paper shredder or Shred-It container.

(3) Electric shredders are intended for VA Staff/Departmental use and are not for personal use.

(4) Electric shredders will be readily accessible to other staff members and will not be placed within a staff member's office, preventing use by coworkers.

(5) Electric shredders will not be moved without proper coordination with the Supply Chain Management service/equipment management.

(6) Shredder bags are typical 32 Gallon trash can liners. Filled bags with cross cut shredded materials are no longer considered sensitive material, so this material can be removed and empty liners can be replaced by staff members or the housekeeping staff. High security shredder crosscut material is no longer sensitive material and will be treated as general waste/trash.

(7) Jammed electric shredders, can usually be unjammed by pressing the reverse button and removing the obstruction. Do not place your hands into or near the cutting blades as you may get injured. If jam cannot be cleared by using the reverse function and removing the material , you may have to contact the Engineering equipment shop technician at your location , for assistance.

(8) No food, food wrappings , liquids, tissues, or paper towels are to be put into either the high security electric shredders or Shred-It containers .

February 25, 2020 MCP 659-137-6

B. Shred-It Sensitive Document Container Policy:

(1) Will not be placed within 25 feet of another Electric High Security Shredder or within 16 feet of another Shred-It Container, regardless of whether is located in the same room or another room.

(2) Shred-It Containers are intended for VA Staff/Departmental use and are not personal use. Ensure the container is accessible to other staff members and not placed inaccessibly within a staff members office.

(3) Shred-It Containers must be readily accessible to other staff members and not placed within a staff member's office, preventing use by coworkers.

(4) Shred-It Containers will not be moved without proper coordination with the EMS department.

(a) Requests for a Shred-It Container to be initially placed, for container removals, or requests to relocate a container; must be coordinated properly with the SVAHCS's EMS department at extension 13397. If requesting a container to be moved, proper coordination is required , to ensure the container's new location will be properly serviced. The Contracting Officer's Representative (COR) for the Shred-It contract within EMS must properly coordinate the container movement with the Shred-It vendor to there is no disruption of service. The current EMS Document Shredding Service Contract COR for this requirement can be found via the EMS SharePoint Page.

(5) Shred-It Container placement exceptions must be approved by the Administrative/Medical Director.

(a) If an exception is approved for an offsite location, such as a clinic or

Health Care Center (HCC) to have a Shred-It bin located within an staff member's office, not readily accessible, by other staff members or for servicing; a filled Shred-It container does not constitute an emergency and will be emptied upon the contracted Document Shredding Service Representative's next visit.

(6) The general SVAHCS policy is no document retrievals from the Shred-It containers. This is to safeguard veteran's privacy and prevent improper dissemination of VA Sensitive Information to those that do not have a need to know. Shred-It Containers essentially fulfill the function of an electronic shredder, and hence items placed in the container should be thought of as shredded once they are placed into the container, so staff members should be aware of what they are placing in these containers and not placing items in the containers they may still need.

(7) Document retrieval requests maybe approved by exception, if the department or section chief has deemed an important document has mistakenly been placed in a Shred-It sensitive document container. Department/Section Chiefs may request a document retrieval from a Shred-It container via email coordination to the SVAHCS Privacy Officer. Once the container location and departmental permission have been transmitted via email and properly coordinated thru the Privacy Officer, if the container is located:

February 25, 2020 _ MCP 659-137-6

(a) On the Salisbury VA Campus, the privacy officer will forward the concurrence for the document retrieval to the SVAHCS EMS Chief/Asst Chief for action via the EMS Recycle Team.

(b) Off the Salisbury VA Campus, the privacy officer will forward the concurrence for the document retrieval to the HCC Administrative Director responsible for that location.

C. Procedures: The recycling program will involve three areas:

1. Confidential Material : All confidential paper material to be destroyed either by using an approved high security cross cut electric shredder or by placing the material in the gray locked Shred-It containers placed strategically throughout the SVAHCS. The supervisor of any area requiring additional Shred-It boxes can contact the Chief, Environmental Management Service (EMS) at extension 13397.

a. Approved High Security Shredders convert confidential material into fine particles, that information cannot be reconstituted or recovered , so the particles are no longer considered sensitive information . Depending on the location and usage level , most Shred-It containers are emptied weekly by removing the filled bag inside and exchanging it with and empty bag . Shred-It boxes can only be opened by Certified Shred-It Representatives (CSR) or an EMS employee assigned to recycling duty. The bags are made of a heavy cloth that you cannot see through and If the bag is removed by an EMS recycler, the bag is immediately sealed upon removal from the box and kept under the recycler's personal control until it is secured in the Shred-It Storage Area, to await destruction by a CSR. The CSR comes, on-site, to confetti-cross cut shred all materials in the Shred-It Storage Area and within any of the Shred-It containers serviced on site.

2. Recyclable Paper. There are two methods utilized throughout SVAHCS to ensure there are no sensitive recyclable paper materials removed from the SVAHCS with the possibility of containing any Patient Health Information or Patient Identifiable Information.

a. Electric High Security Paper Shredders can be used for the following items:

confidential or non-confidential paper documents (white or colors) , Carbon paper, computer paper, fax paper, glossy paper, invoice paper, transparencies , Post-it notes, window envelopes. Do not use shredders to dispose of/shred food products, food wrappings, liquids, chemicals , hazardous materials, bio hazardous materials, batteries, wood , metal , plastic, rubber, tissues, or paper towels or any other material that is not generally considered under the general definition of recyclable paper are to be put into either the high security electric shredders or Shred-It containers. For Salisbury, full bagged/shredded material can be removed by the area housekeeper or requested EMS SharePoint Page.

For SVAHCS HCCs or Clinics, full bagged/shredded material can be removed by the contracted janitorial area housekeeper or by contacting building managemenUcontracted janitorial.

b. Shred-It Containers can be used for the following items: Confidential or non~confidential paper documents (white or colors) , File folders, Newspapers, catalogs, brochures, telephone books, magazines, Carbon paper, computer paper, fax paper, glossy paper, invoice papers, transparencies, Post-it notes, window envelopes. Do not use Shred-It containers to dispose of/shred food products, food wrappings, liquids, chemicals, hazardous materials, bio hazardous materials, batteries, wood , metal , plastic, rubber, tissues, or paper towels or any other material that is not generally considered under the general definition of recyclable paper are to be put into either the high security electric shredders or Shred-It containers. The current EMS Document Shredding Service Contract COR for this requirement can be found via the EMS SharePoint Page.

3. Cardboard : All services are responsible for ensuring that cardboard is discarded in the appropriate containers located throughout the SVAHCS.

Cardboard must be broken down by opening the top and bottom of the boxes and flattening the boxes before placing them in the Cardboard Recycling containers. The department or individual that received the shipment or goods is responsible for breaking down their own boxes prior to them being placed in the cardboard recycle containers . Cardboard will not be stored in offices, hallways, lobbies or on top of Shred-It containers. For Salisbury VAMC, if a yellow collection bin is full , supervisors can submit an EMS Electronic Request via the EMS Sharepoint or call EMS at 13397. For SVAHCS HCCs or Clinics, contact building management/contracted janitorial for site specific information on cardboard removal procedures.

4. Plastic Bottles: There are blue recycling containers for plastic bottle recycling available throughout the Salisbury VA Campus. For Salisbury VAMC, if a blue collection bin is full, supervisors can submit an EMS Electronic Request via the EMS Sharepoint or call EMS at 13397. For SVAHCS HCCs or Clinics, contact building management/contracted janitorial for site specific information on cardboard removal procedures.

2. JUSTIFICATION

Defines responsibilities for the disposal of paper and other waste to .be recycled . To assure that all sensitive and confidential information is properly shredded by an approved vendor. To comply with all of the directives for recycling and the appropriate destruction of documents. To educate personnel at the Salisbury VA Health Care System (SVAHCS) regarding the proper disposal of this material. This policy does not contain directives for contaminated waste .

3. RESPONSIBILITIES

a. EMS Chief. The EMS Chief is responsible for:

(1) Will ensure that are sufficient numbers of recycle collection containers are located throughout the SVAMC.

(2) Will ensure that there are sufficient numbers of sensitive document collection containers to support confidential/sensitive document destruction for SVAHCS operations and ultimately reduce or mitigate risks of identity theft or other malicious actions against patients or employees within the SVAHCS.

b. Privacy Officer. The Privacy Officer is responsible for monitoring compliance by SVAHCS employees to complete annual Information Security/Privacy training and supporting this policy as it relates to confidentiality of information.

b. Service Chiefs. The Service Chiefs are responsible for ensuring that all SVAHCS employees are knowledgeable of this policy.

4. DEFINITIONS

a. None.

5. REFERENCES

a. VHA Handbook 1605.1 - Privacy and Release of Information, dated 08/31/2016.

https://www.va.gov/vhapublicationsNiewPubl ication . asp ?pub ID= 3233

b. VHA Directive 1851 - Waste Minimization & Compliance Report (RCN 10-99-904).

https://www.va.govNHAPUBLICATIONSNiewPublication.asp?pub 10=5432

c. VA Directive 7707, VHA Green Environmental Management System (GEMS) and Governing Environmental Policy Statement, dated 12/29/2015.

https://www.va.gov/vhapublicationsNiewPublication.asp?pub I 0=3162

d. Executive Order 13101 - Greening the Government through Waste Prevention, Recycling, and Federal Acquisition. https://www.epa.gov/greenerproducts/executive order-13101-greening-government-through-waste-prevention-recycling-and

e. National Security Agency/Central Security Agency Evaluated Products List for High Security Crosscut Paper Shredders, dated 05/18/2015.

https://www.nsa.gov/resources/everyone/media-destruction/assets/files/epl-18may- 2015.pdf

6. RESCISSION

MCM 659-137-6, SHREDDING AND RECYCLING, dated FEBRUARY 25, 2017, is rescinded .

7. REVIEW

As required or prior to recertification .

8. RECERTIFICATION

This MCP is scheduled for recertification on or before the last working day of February 2025. This MCP will continue to serve as local policy until it is recertified or rescinded .

In the event of contradiction with national policy, the national policy supersedes and controls .

9. SIGNATORY AUTHORITY

~~-0.;.- Joseph P. Vaughn , MBA, FACHE W. G. "Bill" Hefner VA Medical Center Director Date Approved: February 25, 2020

NOTE: The signature remains valid until rescinded by an appropriate administrative action.

DISTRIBUTION: Entered into the Leaf Portal for review/approval on January 17, 2020.

MCPs are available at:

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