IV. Hazardous Materials and Waste Management Plan
Goal—The goal of the Hazardous Materials and Waste Management Plan is to establish and maintain
procedures to safely control hazardous materials and wastes generated by the organization.
Scope—The scope of this plan includes the selecting, handling, storing, transporting, using and disposing
of hazardous materials from receipt or generation through use and/or disposal. This also takes into
consideration staff orientation, education and monitoring.
Hazard Communication Program
The Hazard Communication Standard (HCS), established by the Occupational Safety and Health
Administration (OSHA), requires that the hazards of all chemicals, produced or imported, be evaluated,
and that information concerning their hazards, if any, be transmitted to employees who may be exposed
to those chemicals under normal operating conditions or in foreseeable emergencies. This Hazard
Communication Program policy statement has been prepared to assist the clinic in complying with the
Hazard Communication Standard.
The Hazard Communication Program will provide all personnel with the means to understand the nature
of any chemical hazard to which they may be exposed during the course of their employment so that they
will be better able to protect themselves. The purpose of the program is to educate all personnel in the
proper use, storage and disposal of toxic substances and chemical agents to improve employee
protection from chemical hazards and thereby reduce illnesses and injuries caused by exposure to such
substances and agents.
The program includes:
1. Identifying and listing all hazardous chemicals present in the workplace;
2. Labeling all containers of hazardous chemicals in the workplace;
3. Obtaining and maintaining Material Safety Data Sheets;
4. Providing information about hazardous chemicals in the workplace;
5. Training employees regarding hazards of chemicals present in the workplace and the use of
appropriate protective measures
6. Reporting and investigating all hazardous materials or waste spills, exposures, and other incidents;
and
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Monitoring and disposing of hazardous gases and vapors.
Responsibilities
The Infection Control Officer or designee for this organization is responsible for the communication and
implementation of our program With all employees. The Infection Control Officer will compile a list of
all hazardous chemicals used in each clinic and will update that list if new chemicals are obtained. The
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chemical list will be placed in the Exposure Control Manual. The hazard determination will be based
on information contained in the Material Safety Data Sheet (MSDS) supplied by the manufacturer of
each chemical.
If a new chemical or material arrives without an accompanying MSDS, the Infection Control Officer will
immediately contact the manufacturer or the supplier and request the appropriate MSDS. If the Infection
Control Officer is unable to get the MSDS form the manufacturer or supplier, he/she will contact the
local OSHA office for assistance. If a MSDS is unavailable because the material is "not hazardous," the
supplier must provide a written statement to that effect and the statement will be filed with the other
MSDS sheets.
Identification and Listing of Hazardous Chemicals
All hazardous chemicals will be identified on this list in the same manner as those chemicals are
identified on the appropriate Material Safety Data Sheets. This list will be maintained in the clinic Policy
and Procedure Manual.
Material Safety Data Sheets (MSDS)
The clinic designee will maintain Material Safety Date Sheets for each product containing
hazardous chemicals known to be present in the workplace.
Each Material Safety Data Sheet will contain the following minimal information:
The name, address and telephone number of the chemical's manufacturer, importer or distributor
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Hazardous ingredients/identity of the chemical
Physical/chemical characteristics
Fire and explosive hazard data
Reactivity data
Health hazard data
Precautions for safe handling and use
Control measures.
Labels and Other Warnings
The Infection Control Officer will take all necessary and appropriate measures to ensure that all
hazardous chemicals present in the work area are labeled, tagged or marked as required under the
applicable regulations.
Labels and other warnings will include the identity of the product contained therein and appropriate
hazard warning(s). Labels and other warnings will be legible, in English, and be prominently displayed
on the container or readily available in the workplace throughout the work shift. Labels and other
warnings may be repeated in languages other than English in appropriate circumstances.
No employee will remove or deface existing labels or other warnings, unless the container is
immediately thereafter marked with the required label or other warning.
Employees will not be required to work with hazardous chemicals from unlabeled containers, except if
portable containers are used, and the user knows the contents of the containers that are intended for
immediate use.
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Information
The Infection Control Officer or designee will take all necessary and appropriate measures to ensure that
all employees are informed of hazardous chemicals in their work area at the time of their initial
assignment to that work area. Whenever a new hazard is introduced into their work area or significant
changes occur in the data provided, additional training will be conducted.
Non routine Tasks
Management and personnel anticipating non routine tasks will consult with the Infection Control
Officer/Employee Health Nurse before beginning these tasks. Any employee assigned to these tasks will
be informed of the chemical hazards associated with the performance of these tasks and will be informed
of the appropriate protective measures.
Hazard Communication Training
The Infection Control Officer or designee will take all necessary and appropriate measures to ensure that
all employees are trained in the proper use, storage, transportation and disposal of hazardous chemicals
in their work area at the time of their initial assignment in the work area and thereafter whenever a new
hazard is introduced into their work area.
Employees will be trained annually and be able to recall fundamental health and physical hazards
associated with the specific chemicals to which they are exposed in their job, All employees will be
given an opportunity for questions and answers during the training program. Employees should be able
to verbally recall hazardous chemicals they work with, where the chemicals are stored, the effect on the
body, detection, protection, disposal and other pertinent information. Written records of the training will
be maintained. The Infection Control Officer and/or consultants will provide training. Training may
include seminar presentations, videos, written materials, tests and demonstrations. Time will be allotted
for employee questions. Training will be provided by this organization, as required by OSHA, at the
following times and under the following conditions.
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During normal working hours and at no cost to the employee.
For all employees, full or part time, who have an actual or potential risk for contact with
hazardous chemicals.
When new hazardous materials and associated materials are received.
Whenever safe handling and emergency procedures are modified.
Annually as refresher training for all employees.
For all new employees within their probationary period.
For contract workers.
Employee training shall include the following:
1. The Hazardous Communication Standard provides a "right-to-know" law for employees.
2. Hazardous chemicals are used and stored in the clinic.
3. A Material Safety Data Sheet Manual is located in the clinic and contains information on each
particular chemical used in the clinic.
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4. Reading for comprehension of Material Safety Data Sheets is required, and a glossary of terms is
provided.
5. Employees may file complaints with the Department of Health and may not be discharged or
discriminated against in any manner for the exercise of any rights provided by this act. Employees
and citizens may make written requests to the Department of Health to require listing of small
quantities of certain highly hazardous chemicals.
6. Records for any employee with an actual occupational exposure will be kept. Records will be kept
confidential and will include the employee's name; social security number; hepatitis B vaccination
status and dates; results of examinations, medical testing and follow-up procedures; a copy of the
health care professional's written opinion; and a copy of information provided to the healthcare
professional rendering the opinion.
7. Prior to being assigned to tasks or job responsibilities requiring a potential exposure or occupational
hazard of exposure, employees must review the OSHA component during new employee orientation
and must successfully complete the Hazard Communication Training program.
Chemical/Mercury Spill Kits
This organization will maintain both a chemical and mercury spill kit at each clinical location, replacing
components as they are consumed. Employees will be trained on how to properly clean up spills,
whether of chemical or biological origin. In case of
a chemical spill the staff member will page "CODE GREEN... NAME OF Department.
(location of spill by giving zone)" over the system if possible or out loud for assistance. The staff
member will not leave the spill unattended. If the spill is in a patient care area, patients will be
evacuated immediately.
All employees must refer to the MSDS for proper cleanup procedures of a chemical spill. The spill kit
should be used for cleanup of ALL chemical spills and biohazardous spills of more than 15ml.
Mercury spill tits must be used to remove mercury. Mercury cannot enter the general waste stream.
PPEs (gowns, glove, masks, eyeshields) should be used when cleaning up the spill. If the spill involves
blood or other potentially infectious materials, then the spill bag or container must be placed in a
biohazardous waste container. (See also Infection Control).
Eyewash Stations
Each clinical site will have an eyewash station that is easily accessible to employees who are performing
those tasks, which may result in splashes of hazardous chemicals to the eye.
Eyewash stations will be inspected monthly to ensure that they are in good working order.
Handling of Disposable Waste
Disposable waste may be grossly contaminated with infectious materials and therefore should be
handled with care.
Contaminated disposable waste would include but is not limited to:
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-Any dressing used on phlebotomy sights
-Paper tissues containing sputum
-Wound dressings
-Any other item not mentioned above contaminated with blood or body fluids
-Disposable speculums
-Cotton tipped applicators
-Urine cups
-Culture paddles
Red bags are placed in trash containers in each room. All above items should be placed in red bags.
Wound Dressings are to be disposed of in a manner to confine and contain any blood/body fluids
that may be present.
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Small dressings can be enclosed in the disposable glove used to remove the dressing. Pull the glove
off inside out containing the dressing. The dressing and gloves can then be discarded into the red
bag lined trash container in each exam room.
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Larger dressings should be removed using gloved hands and placed into a red bag and then closed
and deposited into the Bio-Hazardous cardboard box stored in the specified area of each clinic.
Stericycle, Inc. Biomedical Waste, Enserv and BFI Services will pick up all red bag waste on a regular
basis and as needed when notified.
Disposal of Laboratory Specimens
Laboratory specimens of blood and urine shall be disposed of by flushing them into the public sewer
system in accordance with local sewage treatment or red bags.
Use of Personal Protective Equipment (PPE)
It is the policy of the clinic to protect employees from occupational exposure. Personal protective
equipment (PPE) is one means of protection from potentially infectious materials.
The purpose of the policy is to investigate instances when personal protective equipment is not used by
an employee on his/her own judgment. There may be instances when, under rare and extraordinary
circumstances it is the employee's professional judgment that the use of personal protective equipment
would prevent the delivery of health care or public safety services or would pose an increased hazard to
the safety of the worker or co worker.
Needle Recapping
1. Recapping is permitted on clean needles when needles are to be changed, or during the process of
drawing up medication
2. Contaminated needles should not be cut, bent or broken.
3. Contaminated needles are not to be recapped unless it is the only means for providing safe
transport to the needle disposal container. If it is necessary to recap a contaminated needle, the onehanded technique is to be used. Under no circumstances are needles to be recapped using a twohanded technique.
4. Recapping is only to be done by using a one-handed recapping method in a safe manner or by a
needle-to-syringe cork.
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Procedure
1. Needle/Syringe/Cap
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Place lid on a flat surface. Holding the syringe in one hand, slide the needle into the cap as far
as it will go.
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Using the opposite hand, carefully take the top of the cap between the forefinger and the thumb
and secure the lid onto the syringe.
2. Needle/Syringe/Cork
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Place cork on a flat surface standing upright.
Holding the syringe in one hand, place the needle in the center of the cork and insert carefully.
Keep your opposite hand away from the cork and needle.
Handling of Contaminated Needles and SharpsPolicy
Appropriate work practice controls will be followed in the handling and disposal of sharps in
accordance to OSHA'S Blood Borne Pathogens Standard. Waste will be disposed of in a safe, efficient,
environmentally sound and cost-effective manner.
Purpose
The purpose of outlining a procedure for the safe handling of contaminated sharps is to prevent needle
stick injuries and cuts. If such an injury should occur, the incident should be reported immediately and
protocol should be followed as outlined earlier in this manual.
Disposal of Sharps
1. All sharps are to be placed in appropriate receptacles for disposal.
2. The containers are to meet the requirements as outlined in the OSHA Blood Bourne Pathogen
Standard section that addresses the Regulations for Engineering Controls. These requirements are:
a) The container must be puncture resistant and leak-proof on the sides and bottom.
b) The container must be labeled or color-coded so that they can be readily identified by staff.
c) The container must be located as close as possible to the places where sharps are used and be
easily accessible.
d) If reusable containers are used, the container must be designed so that they can be emptied
without risk to the person emptying them.
3. Sharps containers are not to be filled over % full. The sharps container is to be closed tightly and
discarded in the area designated for disposal waste at each site when it reaches the % full level.
4. Stericycle, Inc., Biomedical Waste, Enserve or BFI Services will pick up all closed and bagged sharps
in the same manner in which they pick up red bag waste; on a regular basis and as needed when
notified.
5. Employees will be trained on these procedures during their orientation period.
Evaluation
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A summary of the Hazardous Waste Management Plan which evaluates the program's objectives,
scope, performance, and effectiveness will be prepared annually by the President/CEO for review
by the Board of Directors.
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