Maintaining a Safe Environment of Care – conformance to Joint Commission Standards and avoiding accreditation citations Reply

Joint Commission accreditation is intended to ensure that hospitals provide the highest level of performance and service to their patients. The Joint Commission’s accreditation process seeks to help organizations identify and resolve problems and to inspire them to improve the safety and quality of care and services provided. The process focuses on systems critical to the safety and the quality of care, treatment, and services.

Joint Commission publishes a list of the top deficiency citations about every 6 months. The top ten citations for the first half of 2014 were recently highlighted in the December 2014 issue of the New England Healthcare Engineers’ Society (NEHES) newsletter. One of the top ten citations is specifically related to management of hazardous materials and waste. The Joint Commission Standards include Environment of Care Standard EC.02.02.01, the management of hazardous materials and waste. This standard includes several elements of performance to ensure that hospitals are maintaining a safe environment for their patients, health care professionals, and support staff. Hospitals must be able to demonstrate that they do the following:

– Maintain a written, current inventory of hazardous materials and waste that it uses, stores, or
generates
– Have written procedures, including the use of precautions and personal protective equipment, to
follow in response to hazardous material and waste spills or exposures
– Implement its procedures in response to hazardous material and waste spills or exposures
– Minimize risks associated with selecting, handling, storing, transporting, using, and disposing
of hazardous chemicals, radioactive materials (radiation, x-rays), hazardous energy sources
(lasers, MRIs), and hazardous gases and vapors
– Minimize risk associated with disposing of hazardous medications
– Monitor levels of hazardous gases and vapors to determine that they are in safe range
– Have the permits, licenses, manifests, and MSDSs required for managing hazardous materials and
waste
– Label hazardous materials and waste, identifying the contents and hazard warnings

Demonstrating conformance to this standard includes compliance with several regulations, covering a diverse range of hazardous materials and hazardous waste sources, or “streams.” In addition, there is overlap among the many applicable regulations: OSHA, EPA, DOT, NRC, DOE, state regulations, and local bylaws.

In order to reduce risk, hospitals should consider getting a third party inspection, or audit, to assist on both compliance with applicable hazardous materials and hazardous waste regulations, and conformance to the Joint Commission Environment of Care standard. If you would like to find out more, please contact CAPACCIO’s William Potochniak, PE, at wpotochniak@capaccio.com or Jill Vernes, CHMM, TURP, at jvernes@capaccio.com.

Have You Reviewed Your Risk Management Plan/Process Safety Management Program Lately? Reply

In accordance with US Environmental Protection Agency (EPA) regulations at 40 CFR 68.79, facilities required to maintain Risk Management Plans (RMP) must audit their programs at least once every three years. Similarly, in accordance with Occupational Safety and Health Administration (OSHA) regulations at 29 CFR 1910.119(o), facilities required to maintain Process Safety Management (PSM) programs must also conduct program audits every three years.

Some important points:
• Audits must be completed by a team, with at least one team member who is knowledgeable
about the process
• All findings must be documented
• All actions to address audit findings must be documented
• The audit must contain a certification that the audit evaluated the program

Some common audit findings include:
• Inadequate development of one or more program elements
• Inadequate documentation of program activities (particularly mechanical integrity programs)
• Hazard assessments are not adequate or not available, or no documentation of follow-up
activities exists
• Operating procedures not certified annually
• Management of change program not implemented
• Contractor safety program not implemented

EPA and OSHA are routinely conducting audits – be ready. CAPACCIO has experience developing and auditing RMP and PSM programs for a variety of different industries. If you would like to find out more, please contact Chris Walton, PE, BCEE, at (508) 970-0033 ext. 139 or at cwalton@capaccio.com.

Addition of Nonylphenol Category; Community Right-To-Know Toxic Chemical Release Reporting: Final Rule Reply

Following is an update from the EPA Superfund, TRI, EPCRA, RMP & Oil Information Center:

On September 30, 2014, the Environmental Protection Agency (EPA) published a rule to finalize the addition of a nonylphenol category to the list of toxic chemicals subject to TRI reporting under EPCRA Section 313 (79 FR 58686). EPA has determined that this category meets the EPCRA Section 313(d)(2)(C) toxicity criterion based on available ecological toxicity data. EPA listed the nonylphenol category as a delimited category defined by a list of chemical names and Chemical Abstract Service Registry Numbers (CASRNs) rather than by a chemical structure. This final rule is effective on September 30, 2014, and shall apply for the reporting year beginning January 1, 2015 (reports due July 1, 2016).

Additional information, including the final rule, is available at the following URL:

http://www2.epa.gov/toxics-release-inventory-tri-program/addition-nonylphenol-category-final-rule

For questions about this final rule or the TRI regulations in general, please contact EPA’s Superfund, TRI, EPCRA, RMP & Oil Information Center at:

(800) 424-9346 — Toll Free
(703) 412-9810 — Metropolitan DC area and international calls

To speak with an Information Specialist, please call between 10:00 AM and 5:00 PM, Monday through Friday, eastern time.

To speak with a specialist at CAPACCIO, please call Travis Wheeler at 508.970.0033 ext. 115 or twheeler@capaccio.com or Jill Vernes at 608,970.0033 ext. 136 or jvernes@capaccio.com.

Draft Storm Sewer General Permit for 200+ Small Massachusetts Municipalities Reply

News Release
U.S. Environmental Protection Agency
New England Regional Office
September 30, 2014

Contact: David Deegan, (617) 918-1017
Re: Draft Storm Sewer General Permit for 200+ Small Massachusetts Municipalities Will Help Clean Water Protection

BOSTON – EPA is releasing for public comment draft general permit for small “Municipal Separate Storm Sewer Systems” (MS4) located in Mass. The new permits, when finalized, will update efforts in up to 260 municipalities, better protecting rivers, streams, ponds, lakes and wetlands across Massachusetts.

EPA previously released draft general permits for small MS4s in North Coastal Watersheds in 2010 and in the Interstate, Merrimack and South Coastal Watersheds in 2011. In response to many of the public comments submitted previously, and the availability of new technical and census information, EPA has revised the two general permits into one document and is now releasing the revised draft general permits for public input. EPA has also made changes to the newly proposed draft permit in response to public comments seeking more clarity, guidance and flexibility in meeting permit requirements.

The draft general permit, a detailed fact sheet, and information on public meetings and public hearing can be found at: http://www.epa.gov/region1/npdes/stormwater/MS4_MA.html

To read EPA’s full press release, please visit: http://yosemite.epa.gov/opa/admpress.nsf/d0cf6618525a9efb85257359003fb69d/e34e1b71021cf54885257d63005ba5b4!opendocument