MCP 659-138-2 Hazardous Materials and Waste Managment Program-Change 1.pdf

HAZARDOUS MATERIALS AND WASTE MANAGEMENT PROGRAM

MCP 659-138-2 Change 1

W.G. (Bill) Hefner VA Medical Center Salisbury, NC 28144

Signatory Authority:

W.G. (Bill) Hefner VA Medical Center Executive Director

Responsible Owner:

Engineering Service

Rescinded Document:

MCM 659-138-2, Hazardous Materials and Waste Mgmt. Program, dated July 8, 2017

Effective Date:

July 8, 2020

Recertification Date:

July 31, 2025

1. POLICY

The purpose of the Hazardous Materials and Waste Management Program (HMWMP) is to establish comprehensive policy and guidance for compliance with Department of Veterans Affairs, American Federation of Government Employees (AFGE), Occupational Safety and Health Administration (OSHA), Environmental Protection Agency (EPA), North Carolina Department of Environmental Quality (NCDEQ), National Fire Protection Association, and The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) requirements concerning the purchase, management, storage, use, and disposal of hazardous materials.

2. JUSTIFICATION

a. The mission of the Salisbury VA Health Care System (SVAHCS) is to properly manage hazardous workplace materials, from the point of requisition to the point of disposal. Mitigate exposures to patients, personnel, visitors, and the environment from any adverse effects and to reduce occupational illness and health problems through education, awareness, standard operating procedures, and by reducing exposure to levels as low as reasonably achievable. Hazardous materials are classified as such because of their corrosiveness, flammability, radioactivity, toxicity, or any combination of these properties. Locations of hazardous materials are listed in Attachment E of this plan.

b. These policies and procedures are applicable to all employees of all the Salisbury VA Health Care System (SVAHCS) where hazardous materials and wastes are handled.

3. RESPONSIBILITIES

All employees at the SVAHCS must become involved and hold some responsibility to ensure that this program is effective.

July 8, 2020 MCP 659-138-2

a. Medical Center Director (MCD) . The Medical Center Director (MCD) is responsible for:

(1) the safety of employees, patients, and visitors to the SVAHCS and other areas of jurisdiction and the overall administration of the disposal of all hazardous wastes generated by the SVAHCS in compliance with all federal, state, and local regulations.

The MCD receives regular reports on the activities of the HMWMP from the Environment of Care Committee (EOCC) and communicates concerns back to the committee and the Facility Safety Officer (FSO).

b. Associate Medical Center Director (AMCD). The Associate Medical Center Director (AMCD) is responsible for:

(1) the day-to-day oversight of the HMWMP.

c. Chief, Engineering Service (ES) and Safety Manager (SM). The Chief, Engineering Service (ES) and Safety Manager (SM) are responsible for:

(1) Oversight of HMWMP to establish written criteria consistent with applicable laws and regulations to identify, evaluate, and inventory hazardous materials and waste used or waste generated. This includes all program areas except those concerning the Radiation Safety Officer and the Laser Safety Officer.

(2) Ensuring that an annual assessment of the HMWMP is performed and the reported findings are referred to the EOCC for comment/implementation.

(3) Assuring the maintenance of records and manifest documents for infectious waste that has been processed through the medical waste contractor for disposal.

(4) Ensuring that adequate and appropriate space and equipment for the safe handling and storing of hazardous materials, chemicals, and/or waste products is provided to the using service.

d. Industrial Hygienist (IH). Industrial Hygienist (IH) is responsible for:

(1) Oversight of HCHWMP to establish written criteria consistent with applicable laws and regulations to identify, evaluate, and inventory hazardous materials and waste used or waste generated. This includes all program areas except those concerning the Radiation Safety Officer and the Laser Safety Officer.

(2) Ensuring that an annual assessment of the HCHWMP is performed and the reported findings are referred to the EOCC for comment/implementation.

(3) Assuring the maintenance of records and manifest documents for infectious waste that has been processed through the medical waste contractor for disposal.

(4) Ensuring that adequate and appropriate space and equipment for the safe handling and storing of hazardous materials, chemicals, and/or waste products is provided to the using service.

e. Radiation Safety Officer (RSO). The Radiation Safety Officer (RSO) is responsible for:

(1) Maintaining, controlling, inventorying, and monitoring off all materials associated with patient related activities involving radioactive materials and radioactive waste.

f. Green Environmental Management System Coordinator (GEMSC). The Green Environmental Management System Coordinator (GEMSC) is responsible for:

The coordination, technical support, and day-to-day management of the HCHWMP.

He/she will oversee and assist the temporary storage of hazardous wastes in the specified storage area in compliance with federal, state, and local guidelines until a licensed disposal contractor removes waste for proper disposal. The GEMSC also decides for all permitting requirements prior to this disposal and maintains these records in the safety office.

(1) Ensuring all hazardous materials are disposed of and eliminated properly.

(2) Maintaining all permits/records associated with waste management at the

SVAMC.

(3) Performing annual evaluation of the HCHWMP and reporting to the EOCC the results of the evaluation.

(4) Investigating all hazardous material spills and completing the Chemical Incident Report, VA Form 10-0114a-OP 138-209, maintain all records of the spill incident and report information to the EOCC.

g. EOCC. The EOCC is responsible for:

(1) periodically reviewing the HMWMP to evaluate its effectiveness and recommend modifications.

h. Service Chiefs and Supervisors . The Service Chiefs and Supervisors are responsible for:

(1) With input and assistance by the GEMSC and IH, for the development of service specific policies/procedures for selecting, handling, storage, collection, transporting, and disposing of all hazardous waste generated in their areas including emergency procedures in the event of a spill or leak. (Refer to Attachment I, Hazardous Materials Spill Response Procedures.)

(2) Responsible for identifying materials used in the service that may be considered hazardous and ensuring proper collection of hazardous waste and medical waste.

Ensuring that under no circumstances is any hazardous or medical waste being improperly disposed of via the sanitary sewer system or by any other inappropriate means (i.e., improperly placed in a red bag and being incinerated). (Refer to Attachment E, Hazardous Materials Locations.)

(3) Maintaining a current, accurate inventory of all the hazardous materials identified in the service. Inventory should be updated bi-annually with assistance by the IH, and to maintain a current copy of SDS. (Refer to Attachment B, Hazardous Communication Procedure.)

(4) Providing the IH with a copy of the current chemical inventory for the IH to ensure appropriate SDSs are maintained in the service. With assistance by the IH, obtain SDS from the manufacturer or distributor or via internet sites such as the VA (CEOSH) SDS system (located on the SVAMC homepage) of all materials found on the inventory.

Maintain a SDS file in their service that is readily accessible to all employees assigned to the area and inform them where this file is located. Review and evaluate all SDSs for hazard content prior to purchasing the product.

(5) Sending a copy of the service chemical inventory to the IH after all changes or updates. The service chemical inventory program will be evaluated by the IH for technical input and assistance.

(6) Sending email notification of each new/updated SDS, as it is obtained, to the IH.

The IH maintains a Master Index of all SDSs on station; therefore, it is crucial that each service or department supply the IH with information including name and manufacturer of all SDSs maintained in the SDS book in each service or department as soon as received.

(7) Providing employees with a copy of the SDSs, when it is requested.

(8) Having copies of all SDSs available to all employees in the work area, service and/or department.

(9) Coordinating and implementing the initial department specific and job specific training for their employees regarding the chemical and physical hazards of the job, including the information found on the SDS.

(10) Giving training, with assistance from the GEMS/IH upon initial assignment with annual refresher, as necessary, or then work procedures or processes change.

Training will include the requirements of the HMWMP, emergency procedures, emergency equipment, and the location and use of personal protective equipment (PPE). Assess employee's knowledge and answer questions regarding safe use, storage, and disposal of hazardous materials.

(11) Training must include the contents of this written program, the lists of hazardous materials, the SDS, and how employees may use them, as well as the physical and health hazards of the materials, and how employees can protect themselves from these hazards. Training must include proper handling and spill cleanup procedures specific to the products used by the employees and required in the event of a small spill. (Refer to Attachment B, and the Medical Surveillance Guidelines and Personal Protective Equipment.)

(12) Ensuring that all containers and collection vessels are labeled, tagged, or marked with the identity of the hazardous material, its specific hazard potential and, if possible, the manufacturer or emergency telephone number. The supervisors must notify the IH or GEMSC when a collection vessel is full, or materials are no longer being used so that they may be picked up for temporary storage prior to final disposal. (Refer to Attachment D, Hazardous Materials and Waste Handling Procedures.)

(13) Enforcing the use of safe work practices in the use of hazardous materials among employees.

(14) Informing employees of the hazards and procedures to follow in performing non-routine tasks that could develop in an emergency or an unexpected situation.

(15) Working with ES to ensure that adequate space and equipment are available for safe handling and storage of hazardous materials, hazardous chemicals, or hazardous waste.

i. Employees. The Employees are responsible for:

(1) Following all established requirements of the HMWMP and maintaining awareness of and promptly reporting the hazards or unsafe conditions within their work areas. It is important that employees participate in all training provided on hazardous materials and special handling precautions on materials they use in the performance of their job. Employees should immediately report all spills to the SM that would result in an exposure to VA personnel or patients either through their supervisor or directly.

j. Services. The Services are responsible for:

(1) Small spill cleanup if employees have been trained. The trained personnel in the safety office will respond to all large hazardous materials incidents, spills and emergencies and receive all appropriate training. If an incident is beyond the scope of clean up capabilities of the safety office personnel, the City of Salisbury Fire Department/Hazardous Materials Team will be notified to respond.

k. Contracting Officer. The Contracting Officer is responsible for:

(1) Inserting the Federal Acquisition Regulation 52.2233, Hazardous Material Identification and Safety Data Sheets, into all solicitations and contracts.

(2) Ensuring that the proper SDS is provided by the manufacturer/contractor, five days prior to delivery of that material and whenever an extremely hazardous material is to be ordered, for notifying the SM before it is received, and prior to distribution. The SDS for the extremely hazardous material will accompany the material at the point it is received through the warehouse for storage and distribution and remain ultimately with the user and using service. Proper procedure for its storage and disposal must be established prior to receiving the material.

(3) Obtaining contract services to dispose of hazardous materials as specified by the FSO, GEMSC, or IH.

4. FUNDAMENTALS OF THE PLAN

a. SDS: hazardous materials and wastes are defined by law or regulation and identified by FSO, GEMSC or IH.

(1) The SDS is provided by manufacturers or distributors that supply hazardous chemicals. These sheets provide valuable information on how to utilize the product safely. The VA must ensure that an SDS is provided for every hazardous chemical at the SVAHCS. The SVAHCS is not responsible for developing or modifying an SDS.

(2) SDS are required for materials that are carcinogenic, toxic, mutagenic, explosive, flammable, combustible, corrosive, oxidizers, unstable, reactive, or likely to be inhaled, ingested, or absorbed through the skin. To determine if a material is hazardous, its inherent toxicity, physical characteristics, manner of use, control measures and required work tasks must be evaluated. (Refer to Attachment L, Safety Data Sheets [SDS].)

(3) Materials that are excluded from the definition of a hazardous chemical include food, drugs (that are not processed or crushed prior to dispensing), cosmetics, distilled spirits, and tobacco. Antineoplastic agents must have an SDS.

(4) SDS provide all the information an employee needs to know to handle a material properly. Because of the importance of these documents to the HMWMP, an explanation of the information found on an SDS shall be communicated to the employees. (Refer to Attachment L.)

(5) Spill, Leak and Disposal Procedures: Rapid effective response is crucial if a spill, release or exposure to a hazardous material or waste material occurs. A small spill may be contained by employees using the material if proper PPE is available and the department personnel are trained in proper spill cleanup procedures. The SVAHCS policy for large spills of hazardous materials is to contact the safety office at extensions 12243,14480, 12343,13230,12328 or contact the Secretary at:13338 or Emergency Dispatch line at: 12259 for action. Report all spills to the supervisor at once, he/she will determine the proper course of action.

b. Identification and Handling of a Hazardous or Medical Waste(Including Hazardous Medications):

(1) Hazardous waste will be identified in accordance with applicable federal, state, and local requirements. Generally, the EPA determines hazardous wastes by their characteristics of ignitibility, corrosiveness, reactivity, and toxicity. Antineoplastic drug waste shall be considered hazardous waste and disposed of properly. All waste products will be properly labeled prior to storage and disposal. The contracting waste hauler will properly fill out waste manifests. Copies of the manifests and certificates of disposal will be maintained in the Safety Office indefinitely. If you are in doubt, contact the Safety Office for assistance. (Refer to Attachment C, Handling of Toxic and Hazardous Chemicals in the Workplace.)

(2) Regulated Medical Waste, which includes contaminated sharps, laundry, used bandages, grossly contaminated dressings, and liquid contaminated waste, and other potentially infectious material, items that are caked with dried or semi-dried blood that could contaminate will be defined by North Carolina Statutory Authority G.S. 130-A-

309.26 effective October 1, 1990, and by Standard Universal Precautions Guidelines published by Center for Disease Control. The biological waste is disposed of in red, puncture-resistant, leak-resistant plastic bags bearing the orange and black biohazard label. The bags are then put into a red plastic biological box for transport. The containers are located conveniently throughout the SVAHCS within easy access of employees and as close as possible to the sources of potentially infectious waste. The waste containers are maintained upright, not overfilled, and routinely cleaned by the contracting company. The sharps containers are made of rigid plastic, have a secure closure for safe needle disposal and are labeled with a biohazard label. These containers are closed when filled to two thirds capacity. The red boxes are collected by Environmental Management Service (EMS) and transported to a centralized location on the ground level dock areas of Buildings 2, 21 and 42. These boxes are picked up from the dock area by EMS employees and transported to the central storage area in Building 28. They are maintained at a constant temperature and are removed from the SVAHCS by a waste management contractor at least twice a week and will be taken for incineration. The GEMSC maintains the manifests for the waste. (Refer to Attachment C and Attachment F.)

(3) Radioactive Waste/Materials/Dosimetry Monitoring: Radioactive waste that is produced in the Nuclear Medicine Department will be stored in the Nuclear Medicine Department storage decay for ten (10) half-lives. The records are documented in the Nuclear Medicine Information System located in the Nuclear Medicine department. Any questions should be directed to the Nuclear Medicine Department at extension 12416 or to the Radiation Safety Officer at extension 31056. The Radiation Safety Officer (RSO)is responsible for all radiation safety activities at the SVAHCS including ensuring that these materials are selected, handled, stored, transported, used, and disposed of properly in order to minimize the risk associated with them.

(4) Contaminated laundry is handled as little as possible and is not sorted or rinsed where it is used. There is no presorting of laundry before it is washed. The SVAHCS considers all soiled laundry to be contaminated and it should be handled as such.

(5) Cytotoxic Waste/Hazardous Medications: At least one specially designated receptacle for cytotoxic and hazardous waste will be located in each area where these agents are prepared or administered. Corrugated disposal containers will be lined with leak proof and puncture resistant plastic liners and used exclusively for the collection of cytotoxic and hazardous waste including cytotoxic and hazardous containers, syringes, gowns, gloves, etc. Only cytotoxic and hazardous waste should be placed in this container. The container should be clearly marked Cytotoxic and Hazardous Waste Only. (Refer Attachment K, Cytotoxic and Hazardous Drug Handling Procedures.)

(6) Used Batteries: Used batteries are universal waste. Contact the GEMSC to arrange for proper recycling or disposal of all batteries. (This refers to batteries larger than 9 volts.)

(7) Toxic Material: The use of toxic materials shall be such that personnel are not exposed to airborne concentrations exceeding recommended exposure limits. PPE shall be provided where required. Manufacturer’s recommendations shall be followed.

Quantities of toxic materials shall be limited in that stocks are used within one year after delivery or before an expiration date is reached. Supply shall be dated upon receipt.

(8) Employees exposed to anesthetic gases, xylene, formaldehyde, glutaraldehyde, or ethylene oxide will be monitored in accordance with ES IH Procedures (Attachment A). Employees exposed to other toxic gases and vapors will be monitored as required.

(9) Compressed Gases: The capacity of individual cylinders shall not exceed:

• LP gases 5 lb.

• Acetylene 350 cu.ft.

• Other flammable gases 365 cu.ft.

(10) Bulk storage of cylinders shall be in an approved room used exclusively for that purpose. Gas containers being held for prompt use in a laboratory shall not exceed one

(1) extra cylinder or two (2) days working needs. All cylinders shall be secured. Caps shall be in place on all cylinders not in use. No more than 12 E type oxygen cylinders may be stored on the nursing unit or in a smoke compartment at any time unless the storage area is rated for additional tanks. Storage must be in carriers, in locked areas that have a 1-hour fire rating and are fully sprinklered.

(11) Cytotoxic Drugs and other Hazardous Medications: Cytotoxic drugs (antineoplastic medications) will be handled in accordance with Attachment K to this plan.

(12) Hazardous Energy Sources: The facility minimizes the risks associated with selecting and using hazardous energy sources. Energy sources included are those generated while using ionizing or non-ionizing radiation equipment. The Radiation Safety Officer is responsible for managing the program associated with these hazardous energy sources.

(13) Dosimetry Monitoring: The Radiation Safety Officer has overall responsibility for the monitoring of dosimetry policies and procedures for computed tomography (CT) and positron emission tomography (PET), provides nuclear medicine services and fluoroscopy services for Salisbury VA Medical Center Group using the policies and procedures contained in MCP 659-114-2, Radiation Safety Officer Duties and Employee Radiation Safety Procedures and reviews the staff dosimetry results at least quarterly.

c. Labeling: All hazardous materials and medical waste must be labeled always.

Always read the label of the chemical or product prior to working with or using that product.

(1) Those labels affixed by the manufacturer must not be removed or defaced.

(2) Labels must include the chemical and common name, specific warnings for physical and health hazards, the name and address of the manufacturer and any other appropriate warnings. All manufacturers’ recommendations shall be followed.

Hazardous Waste labels shall be affixed to a collection vessel used for collecting waste.

The label shall have the start date when the first amount of waste was added and the end date when the vessel was filled and capped.

d. Collection Storage and Disposal: (Refer to Attachment E and Attachment G.)

(1) Collection Containers: Hazardous and medical waste shall be collected in suitable containers. The container shall be compatible for the waste, must be in good condition, and must have a leak proof seal. Often the container of the virgin material can be used as the collection device. Chemicals of the same waste stream may be bulked together in the same container such as flammables or solvents if they are compatible.

Containers must be kept closed always except when material is added. A visual inspection of the condition of the containers shall be made periodically. Waste must be collected and stored, awaiting disposal, in an appropriate storage area. A written record of these inspections is recommended.

(2) Storage: Containers may be stored per compatibility with other chemicals in the cabinet or on the shelf. They do not require a special area away from virgin materials.

The primary concern is to store safely and per compatibility. If you have questions about compatibility, contact the IH in the Safety Office. As in all cases, no waste shall be stored where potential contact with food, pharmaceuticals, or nutritional items may occur. Hazardous waste may be stored at or near the point of generation up to 55 gallons or if the waste is Acute Hazardous Waste, up to one quart before it must be removed to the Waste Storage Area. The storage of all hazardous materials shall be in accordance with all Fire and Safety regulations and codes, and reviewed and approved by the Chief, ES, or a Safety Office official.

(3) Disposal: When the waste container is full, the material expires, or the chemical is determined to be a waste (retention of the chemical is no longer desired), an inventory listing of those chemicals needs to be filled out and given to the GEMSC. The waste shall be characterized for a hazardous waste determination and logged per requirements of 40 CFR 261.The GEMSC will arrange to pick up the waste and have it transported to the Waste Storage Area. The waste will be stored in the Waste Storage Area per compatibility and in compliance with all applicable Federal, State, and local regulations. Under no circumstances will a hazardous waste be released to the environment. The GEMSC will make all necessary arrangements with a licensed hazardous waste disposal contractor for removal and ultimate destruction of the

SVAHCS hazardous waste at a properly permitted treatment, storage, and disposal facility in accordance with applicable Department of Transportation regulations.

e. Emergency Guidelines: In the event of an emergency such as a leak or a spill, employees should proceed with emergency procedures already established for their service and for the specific hazard. If the material is a hazard to persons working in the area, begin evacuation, seal off the area, and contact the Safety Office immediately.

Spills of hazardous materials, exposures, or other incidents that involve patients, visitors, employees, or property, will be reported to the Safety Office immediately.

During non-administrative hours, hazardous material spills will be reported to the Administrative Officer of the Day (AOD) and the appropriate safety official will be contacted. (Refer to Attachments H and I.)

f. Employee Rights and Training: Employees have certain rights under the VA HMWMP and will be trained in these rights. Employees have the right to report any unsafe act or working conditions at any time. The report may be made to the Supervisor, the Service Chief, the SM, the Safety Officer, their employee representative, the AMCD, the Chief of Staff, the Associate Director for Patient Care Service/Executive Nurse, or the MCD. Employees must be given, upon request:

(1) Access to the inventory list of hazardous materials in their area.

(2) Access to SDSs used in their workplace.

(3) An explanation of the means for detecting hazardous materials.

(4) An explanation of the labeling system.

(5) An explanation of the PPE available, their limitations and proper use.

(6) Access to their exposure records, with the right to examine and copy. This includes environmental monitoring, analytical procedures, and biological monitoring.

(Ref. MCP 659-11A-2, Medical Surveillance Program.)

(7) The employee's own medical file with the right to examine and copy, including medical history, examination results, medical opinions, treatments, prescriptions, and employee complaints. (Ref. MCP 659-11A-2.)

(8) Exposure records will be provided within 15 days of request and will be maintained for 30 years by the Safety Office. A copy of all employee exposure records will be provided to Employee Health for inclusion into employee medical records. (Ref.

MCP 659-11A-2.)

(9) Medical records are maintained by Employee Health and will be kept for 30 years after termination of employment or to the age 78, whichever is longer. (Ref. MCP 659- 11A-5, Occupational Health Services.)

(10) The supervisor will inform the employee of these rights, record existence, and access to standards at the time of employment and annually thereafter.

(11) All new employees will receive general training on the HMWMP and related policies in New Employee Orientation.

(12) All employees involved with hazardous waste handling and disposal shall receive pre-assignment training and annual training thereafter by their supervisor. The training will be provided in accordance with the State and Federal hazard communication legislation and in compliance with 40 CFR 265.16. The training will include:

(a) Information regarding the hazardous materials/wastes employees will be working with.

(b) A brief discussion of the SVAHCS hazardous materials policy, and instructions on how to read and interpret the hazardous materials policy.

(c) Protective clothing and equipment necessary in handling hazard wastes and how to use PPE.

(d) Service-level emergency response procedures in case of spill or other unforeseen accident.

(e) Response to fire or explosion.

(f) Records of training.

g. Annual Review:

(1) Any policies and procedures relating to the HCHWMP will be reviewed annually by the EOCC. Infectious hazards will be reviewed by the Medical Center Committee on Infections. Radioactive Hazards will be reviewed by the Radiation Safety Committee.

The Chief, (Engineering Service) will ensure that an annual effectiveness evaluation of the objectives, scope, performance, and effectiveness of hazardous materials program is conducted.

(2) All hazardous materials and waste incidents will be reported on VA Form 10- 0114a-OP 138-209, the Chemical Incident Report form, by the GEMSC or IH, and reported to the SM to be reviewed by the EOCC.

(3) Established performance improvement standards, which objectively measure the HMWMP will be reviewed on an as needed basis and results reported to the EOCC.

The results of the program will be compared with applicable standards during the annual review to evaluate the effectiveness of the program and to determine if new performance improvement standards need to be implemented.

h. Procedures: Specific procedures are outlined in detail in the document attachments and shall be adhered to.

i. Performance Standards: At a minimum, the EOCC will develop and monitor one Performance (Improvement) Standard for Hazardous Materials and Waste.

5. DEFINITIONS

None

6. REFERENCES

a. U.S. Dept. of Labor, OSHA, Fed. Register, Part IV (Hazard Communication: Final Rule)

b. OSHA Act of 1970

c. VA DM&S Circular 00-86-21

d. VA DM&S Circular 00-86-3 Hazardous Waste Disposal

e. VA DM&S Circular 00-86-6 Management, Abatement, and Removal of Asbestos

f. TJC Comprehensive Accreditation Manual for Hospitals

g. VA Directive 7700

h. VA Handbook 7701.1

i. AFGE Master Agreement

7. RESCISSION

MCM 659-138-2, Hazardous Materials and Waste Mgmt. Program, dated July 8, 2017 is rescinded.

8. REVIEW

Review required at recertification and including when there are changes to the governing document, national policy, or a health care accreditation body mandate.

9. RECERTIFICATION

This MCP is scheduled for recertification on or before the last working day of July 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.

10. SIGNATORY AUTHORITY

Joseph P. Vaughn, MBA, FACHE W.G. “Bill” Hefner VA Medical Center Executive Director

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

DISTRIBUTION: MCP will be published on the Salisbury SharePoint Portal.

Attachment A

INDUSTRIAL HYGIENE AND ENVIRONMENTAL MONITORING

PROCEDURE

1. PROCEDURE

a. Identify, evaluate, monitor, document, and maintain surveillance of potentially health hazardous operations and situations existing within activities assigned to an area including noise, toxic materials, extremes of temperature and humidity, biological agents, and illumination problems.

b. Respond in a timely manner to all requests for surveys and consultations and formulate and provide recommendations for the control of hazardous situations, which can affect the health, well-being, and efficiency of the employees.

c. Refer all personnel exposed to workplace hazards to the Occupational Health Provider for hazard related medical surveillance. Formulate and provide recommendations for periodic medical surveillance of employees deemed to be at risk of occupational health hazards. (Refer to MCP 05-30, Medical Surveillance Program and MGM 05-8, Employee Health Services.)

d. Conduct training classes for all personnel on workplace hazards and the proper use of personal protective equipment.

e. Maintain liaison with and provide for industrial hygiene support to safety personnel and appropriate authorities concerning environmental health and pollution control matters which may affect employees and/or the surrounding communities.

2. ELEMENTS

For planning, monitoring, and record keeping purposes, the industrial hygiene effort will be addressed through the following elements:

a. Equipment:

(1) It is the responsibility of the Industrial Hygienist or designee to ensure that equipment being used is maintained and calibrated and records kept to document maintenance, calibration, and service.

All sampling pumps will be calibrated before and after each use per the manufacturer's guidelines and instructions. The calibration log shall be maintained for each calibration. All battery-powered equipment shall be kept charged and ready for use always.

(2) Malfunctioning equipment will be taken out of use and repaired as soon as possible.

b. Air Monitoring for contaminants/exposure:

(1) All sampling data will be collected and recorded properly and kept indefinitely.

(2) On-site air monitoring, acceptable levels, and precautions to be followed for monitoring and working with such hazards are as follows:

(3) Any monitoring procedure that results in air contamination levels of hazardous vapors or gases above the action level or the PEL or levels otherwise potentially dangerous to employees will result in requiring the I.H to take immediate action in reducing the employee exposure and preventing the hazardous material from adversely affecting employees.

(a) ASBESTOS: (Refer to Facilities Management Service Memorandum 138-2, Engineering Asbestos Removal Policy)

1) Only properly authorized and trained personnel will be allowed to remove asbestos material from this facility. This will be accomplished through contracted services now. The GEMS Coordinator will be responsible for the medical center asbestos maintenance and removal procedures.

2) Employees who encounter situations, which involve the possibility of contact with asbestos material, shall notify the GEMS Coordinator or Safety Office/I.H. prior to performing an action, which could result in contamination of asbestos.

3) Anyone required to work in an area where asbestos material may become airborne and result in contamination will be required to wear personal protective equipment and be trained and fitted properly for use of this equipment. The I.H.

is responsible for the respirator program.

4) Areas where asbestos contamination is possible shall be restricted and signage shall be posted restricting access.

5) All asbestos containing material shall be double bagged properly. Final disposal shall be in an authorized disposal site or landfill.

6) Training shall be acquired by the Safety Office for initial and refresher training in Asbestos to meet AHERA guidelines.

7) Environmental monitoring shall be performed routinely and as needed by a Professional Industrial Hygienist (PIH) and records of fiber counts maintained in the Safety Office.

8) Employees who perform inspections or maintenance in suspect areas and performed removal procedures shall be provided annual medical exams as outlined in Medical Center Policy 659-05-8 and the Occupational Health Manual and will remain on the medical surveillance program for the duration of employment. These employees should be given Asbestos Awareness Training.

(b) Ethylene Oxide: (Refer to SPS ETO Emergency Procedure, Internal SPS Policy.)

1) All personnel who are exposed to the possible hazards of ethylene oxide shall be trained in the proper procedures for sterilization of supplies, operation of the sterilizer, and safety procedures in case of a leak or spill of the hazardous chemical.

2) Ethylene oxide will be monitored for an initial baseline level and then periodically (annually) using a vapor analyzer and or passive dosimeters for periodic, short term monitoring. Upon completion of the monitoring, results will be made available to the using service line/service d copies of results placed in employees' medical records.

3) Because of the potential toxicity, the OSHA 8-hour threshold limit value (TLV) for ETO is 1 ppm. Medical surveillance for workers exposed to greater than 1 ppm is required. All employees who are exposed to greater than 1 ppm with ETO in the regular course of their duties shall be placed on medical surveillance to acquire a baseline ETO level.

4) All employees who come in-contact with ETO in the regular course of their duties shall be placed on medical surveillance to acquire a baseline ETO level.

5) Personnel working with ETO should always wear personal protective equipment when working with ethylene oxide.

6) If a spill occurs, evacuate the area, seal the area, and call the Safety Office, ext.

13338 immediately.

(c) Formaldehyde: (Refer to MCM 113-4, Chemical Hygiene Plan)

1) The OSHA permissible exposure limit for formaldehyde is 0.75 ppm threshold limit value. Its action level is 0.5 ppm. Medical surveillance is required for workers exposed to greater than 1 ppm TLV per 8-hour TWA.

2) Monitoring of air concentrations in the laboratory, morgue, and dental clinic will be performed initially for a baseline value and then periodically (annually) using a passive monitor and passive dosimeters for periodic, short term monitoring. Upon completion, of the monitoring, a completed report will be made available to the using service and copies of the results will be placed in the employees' medical records.

3) In case of an accidental spill or employee contamination, clean the spill immediately with paper towels and allow the formaldehyde-soaked towels to evaporate under a fume hood system for at least one hour. If an employee is contaminated, flush with copious amounts of water immediately and seek medical attention. Report the incident to the Safety Office. If the spill is too large to contain with paper towels or spill pillows, close off the area, evacuate all personnel, and call the Safety Office, ext. 13338 immediately.

4) Always wear personal protective equipment when handling formaldehyde or any other hazardous material.

(d) Mercury:

1) Mercury is not recommended for use at this facility as part of a mercury reduction program. Wherever possible alternative devises that do not contain mercury shall be used. Any devises that are found to contain mercury shall be turned in to the GEMS Coordinator. for disposal.

2) In case of an accidental spill or exposure, only trained personnel should perform the clean-up procedures. Mercury Spill Clean-Up Kits are available, and the clean-up procedure should be followed carefully. In the event of a spill of any size, evacuate all personnel and seal off the area. Notify the Safety Office at ext.

13338 immediately and they will perform the clean-up if the involved service line/service has not been trained in clean up procedures.

3) In case of skin or clothing contamination, remove clothing and wash skin thoroughly with soap and water. Avoid breathing the vapors if possible. Place contaminated clothing in a sealed plastic bag to be decontaminated.

4) Always wear personal protective equipment when using mercury and cleaning spills. Utilize a fume hood when the possibility of breathing vapors exists.

(e) Waste Anesthetic Gases:

1) The recommended NIOSH permissible limit for nitrous oxide for an 8 hour TWA is 25 ppm and a level of 2 ppm for halogenated agents is acceptable. Medical surveillance is recommended for any employee exposed to greater than 25 ppm of nitrous oxide or greater than 2 ppm of a halogenated gas.

2) Nitrous oxide is a colorless, sweet smelling, non-combustible gas which acts as a narcotic when found in high concentrations.

3) Monitoring of the air concentrations of waste anesthetic gases in the operating room and recovery room will be performed initially for a baseline value and then periodically using passive organic vapor monitors and passive dosimeters for periodic, short term monitoring. Upon completion of the monitoring a completed report will be made available to the using service line/service and copies of the results will be placed in the employees' medical records. All personnel routinely exposed to nitrous oxide or other anesthetic gases will be placed on a medical surveillance program to monitor exposer levels.

4) The Biomedical Shop is responsible for maintenance of the anesthetic gas equipment. Upon the discovery of a leak or small release of nitrous oxide or other gas, steps will be taken to limit the amount of gas allowed to escape. The emergency shut off for the affected operating room will be used to control escaping gas. The affected room should be evacuated and purged using the

O.R. exhaust system. All personnel will be evacuated. The Safety Office will be notified immediately upon discovery of a major release or leak of nitrous oxide or other anesthetic gas.

c. Antineoplastic Monitoring: (Refer to Attachment K of Hazardous Materials and Waste Management Plan and Cytotoxic and Hazardous Drug Handling Procedures).

(1) Only properly trained and authorized personnel will be allowed to handle antineoplastic agents. Pharmacy Department will ensure that personnel are trained in the safe handling procedures for this type of drug through written procedures, policies and hands-on training dealing with storage, preparation, and clean-up procedures.

Nurse Managers will ensure that the nursing personnel responsible for administering the drugs are qualified and trained in the proper procedures.

(2) Employee personal protective equipment will be utilized always when dealing with preparation, administration, and disposal procedures of antineoplastic agents. This will include disposable gowns, chemotherapy gloves tested to American Society for Testing and Materials (ASTM) standard D6978 (or its successor), eye protection, and respirators when necessary. Compounding of antineoplastic drugs must be performed in a properly vented Containment Primary Engineering Control (C-PEC), such as a compounding aseptic containment isolator (CACI) or biological safety cabinet (BSC) located in a dedicated, externally vented, negative pressure room.

(3) All materials used in preparation and/or administration of antineoplastic agents will be considered as infectious and hazardous waste and will be incinerated. This waste will be labeled "CHEMOTHERAPY WASTE ONLY” and will be placed in yellow chemotherapy waste containers. Bulk chemotherapy waste defined as chemically contaminated supplies or materials from spill response, disposal of expired or unused drug products, or containers of U- listed chemicals that are not RCRA empty, will be disposed of in black RCRA containers.

(4) Involved services will coordinate development of clean-up procedures with the Safety Office for preparedness in the event of an accidental spill. Any accident, spill, or unsafe action or condition will be reported immediately to the Safety Office at extension 13338. Safety staff will coordinate clean-up procedures with EMS and Pharmacy Service.

(5) A medical surveillance program will be developed which will outline the medical history of all involved employees and be maintained as part of the employee health record. The program will include periodic health monitoring results for antineoplastic drug exposure. A permanent record listing all employees currently involved in preparing, administering, and/or disposing of antineoplastic drugs will be maintained.

d. Confined Space Entry Monitoring: (Refer to FMM 138-19, Confined Space Entry Permit). Entry into confined spaces is prohibited to staff and contractors that have received a permit which authorizes them to enter such spaces. Permits are only issued by IH/Safety staff.

e. Lead:

(1) Lead is a hazardous material and hazard to the environment. There shall be no dry sanding. grinding or burning of any lead containing materials. Any debris shall be picked and labeled as lead containing debris. Construction debris may be removed in whole and disposed in a construction landfill. Removal of lead paint shall be conducted by a license contractor.

(2) Contact the Safety Office prior to any demolition or repair to determine if there is any lead hazard at extension 12243 GEMS Manager or Safety Manager: 13230.

(3) In case of a potential incident of exposure to lead or lead fume, contact the Safety Office at extensions 12243, 13230, 12328, 14480, 13832 or dispatch line 12259 immediately.

f. Radioactive Materials:

(1) All employees engaged in the use of fluoroscopy are required to wear a lead apron and a radiation dosimeter.

g. Respirator Program and Monitoring: Respirator usage is prohibited to staff that have been identified as either required usage or voluntary usage. All respirator usage must be approved by the I.H. Specific requirements for the facility Respiratory Protection Program will be found in MCP 659-138-26, Respiratory Protection Program.

h. Medical Surveillance Monitoring:

(1) Once an employee has been assigned to a position that is in a regulated area or may involve hazardous materials, he will be given a pre-assignment physical exam by a physician and a baseline evaluation made of his condition prior to exposure.

The examination shall include the personal and medical history of the employee, family, and occupational background, including genetic and environmental factors. The supervisor should contact Occupational Health and arrange the exam.

(2) All employees working in areas of possible hazard exposure will receive periodic physical exams pertaining to the specific hazard involved. The medical record will show that the specific hazard has been addressed by the examining physician and will show any effects of possible exposure. The exam shall determine whether there exist conditions of increased risk, including reduced immunological competence, those undergoing treatment with steroids or cytotoxic agents, pregnancy, and cigarette smoking.

(3) Any employee who is unexpectedly exposed to a hazardous material should notify his/her supervisor and report to the Occupational Health Service immediately so that a physical exam can be performed, and evaluations can be made as to whether the employee needs to be placed on a surveillance program. Notify the Safety Office of all exposures to hazardous material in the workplace.

(4) All records of medical surveillance and environmental or personal monitoring of hazardous materials for that employee will become part of the employees' medical record and shall be maintained at least 30 years beyond the employee's separation from service.

(5) Any physician who conducts a medical examination required by the medical surveillance program shall furnish to the employer a statement of the employee's suitability for employment in the specific exposure.

i. Hazardous Communications/Safety Data Sheets: (Refer to Attachment 8, Hazard Communication Procedures).

(1) All materials of a hazardous nature that are received at this facility shall require a Safety Data Sheet (SDS) to be obtained from the provider. If SDS is not sent with the product, it is the using service line/service's responsibility to contact Acquisition & Materiel Management or the company and request that one be sent immediately, and the hazardous product should not be used by employees until the SDS is received in the service line/service. If the SDS is not available and the product is required by the using service before the SDS is available, the supervisor must inform employees of the hazards and any special requirements for using the products.

(2) Federal and State regulations specifically require manufacturers of toxic and/or hazardous chemicals or materials containing toxic/hazardous chemicals to provide SDS's to customers.

(3) SDS's are maintained in the Safety Office and in each using service line/service easily accessible by the employees. If a using service line/service receives an SDS, the supervisor should immediately contact the Safety Office so that a copy of the SDS can be added to the files in the Safety Office and the information can be entered in the SDS computer files. Please contact the Industrial Hygienist, ext. 13832, concerning SDS sheets.

(4) Upon receipt of an SDS on a product, the supervisor in each service line/service will review the SDS for new or significant health and safety information. The supervisor will then ensure that any new information is passed on to affected employees, and the supervisor will ensure that any training required by the SDS will be accomplished and documented.

(5) SDS will be readily available to all employees during each tour of duty. If an SDS is not available, immediately notify the supervisor for that service so that the SDS can be obtained. An employee wishing to obtain information relating to hazardous or toxic chemicals that he/she is using and cannot locate the SDS in his/her service line/service, can notify the Industrial Hygienist in the Safety Office, ext. 2343, and the information will be obtained from the master files.

3. NON-ROUTINE TASK ASSIGNMENTS

All service line/services must develop a policy statement that addresses what steps to take in the event that the performance of a non-routine task occurs. This statement must appear in each policy and be specific for the type of work addressed in the policy.

4. REFERENCES

a. OSHA Standard 1910.1030

b. OSHA Standard 1910.1001

c. OSHA Standard 1910.134

d. MCP 659-138-14

e. OSHA Instruction PUB 8-1.1 dated Jan. 29, 1996, 'Work Practice Guidelines for Personnel

f. Dealing with Cytotoxic (Antineoplastic) Drugs." DM&S Circular 1082-219

g. OSHA Standards 1910.134

h. OSHA 7700 & 7700.1

Attachment B

HAZARD COMMUNICATION PROCEDURES

1. PURPOSE

To establish procedures to ensure the safe handling of hazardous materials (toxic harmful physical agents) through proper labeling, provision of Safety Data Sheets (SDS) and employee training throughout this medical center. This involves management of hazardous materials from the point of requisition to the point of disposal in a manner that will protect patients, visitors, and the environment from any adverse effect. This also reduces occupational illness and health problems through education, awareness, standard operating procedures, and by reducing exposure to levels as low as reasonably achievable.

2. RESPONSIBILITES

a. Medical Center Director is responsible to ensure that all provisions of this policy are upheld throughout the SVAHCS and that effective hazard communication procedures are practiced.

b. Safety Manager,…