DEPARTMENT: Design and Construction
- Facility Management and Engineering
Services Department
PAGE: 1 of 3
EFFECTIVE DATE: November 1, 2005
POLICY DESCRIPTION: Environmental –
Hazardous Waste Management
REPLACES POLICY DATED: 1/12/99, 7/21/99
PROCEDURE NUMBER: DC.010
SCOPE: All Company-affiliated subsidiaries including, but not limited to hospitals, ambulatory
surgery centers, outpatient imaging centers, physician practices, Corporate Departments, Groups, and
Divisions, and on-site subcontractors.
PURPOSE: To require each facility to handle and dispose of hazardous waste in accordance with
applicable Environmental Protection Agency (EPA) regulations.
POLICY:
1.
This procedure addresses federal regulatory requirements. State laws or regulations may
impose additional requirements. Each facility should consult with HCA Facility Management
and Engineering Services Department and the facility’s Operations Counsel to identify and
comply with any additional requirements.
2.
If a facility generates hazardous waste, the facility must determine its generator status. If
necessary, the facility must register with EPA as a generator and comply with generator
requirements. A list of hazardous waste commonly generated from a health care operation is
available on Atlas at:
http://atlas2.medcity.net/content/ethics/policies/DC_Design_and_Constructions/DC_Desig
n%2520and%2520Construction%2520Attachments/DC010List_of_Typical_Hazardoug_Was
tes%2520.doc.
3.
A site specific hazardous waste separation, recycling, and waste minimization program must be
developed to minimize the hazardous waste generation.
4.
Hazardous waste generated by non-HCA sources must not be accepted.
5.
A facility must use an EPA/Department of Transportation (DOT) certified hazardous waste
transporter to remove the waste and dispose of it at an EPA registered treatment or disposal site.
The hazardous waste disposal contract must be reviewed by the HCA Legal Department. Avoid
those facilities with poor operating records, too many violations, or listed as uncontrolled site.
PROCEDURE:
Registration and Analytical Testing
1. A facility must determine if it generates hazardous waste.
2. Also, the facility must determine how much hazardous waste will be generated so that the facility
can determine if it is a conditionally exempt generator, a limited quantity generator, or a generator
before it registers with EPA. A limited quantity generator is not required to annually report to
State/EPA.
10/2005
DEPARTMENT: Design and Construction
- Facility Management and Engineering
Services Department
PAGE: 2 of 3
EFFECTIVE DATE: November 1, 2005
POLICY DESCRIPTION: Environmental –
Hazardous Waste Management
REPLACES POLICY DATED: 1/12/99, 7/21/99
PROCEDURE NUMBER: DC.010
3. If a facility needs assistance, contact the HCA Facility Management and Engineering Services
Department Manager.
4. An EPA certified hazardous waste disposal facility requires a waste profile before the hazardous
waste can be accepted for disposal. If a facility generates a new type of hazardous waste, either from
specific projects or routine health care operations, the characteristics of the waste must be
determined by sampling and analysis. A facility should ask for a copy of the analytical test results
and keep it on file.
Handling
1. Never mix hazardous and non-hazardous wastes. Hazardous waste must not be disposed of with
regular trash.
2. Each hazardous waste stream must be segregated according to the nature of the hazard.
3. Containers of hazardous waste must be kept closed.
4. Hazardous waste containers must be properly labeled and tagged with appropriate warnings.
5. Secondary containment should be provided for all hazardous waste storage/holding.
6. Do not store filled containers of hazardous waste more than 180 days. If the facility is a large
quantity generator, the maximum storage time is 90 days.
7. Weekly visual inspection of hazardous waste storage is required.
Handling Antineoplastic Waste
1. Chemotherapy containers holding any amount of free liquid must be managed as hazardous waste.
Place container (e.g., vials, syringes, IV bags) into the bulk hazardous waste container for proper
disposal.
2. Gowns, goggles, gloves or other materials such as those used for spill clean up (rags, wipes, towels,
pads, etc.) which are contaminated with antineoplastic agents must be managed as hazardous waste.
Place these items into the bulk hazardous waste container for proper disposal.
3. Needles used with antineoplastics must be placed in a designated chemo sharps container for
incineration as regulated medical waste.
4. Completely empty vials, syringes, IV bags, gowns, goggles, gloves, tubing, and wipes that have no
visible liquid antineoplastic agent are considered trace-contaminated chemotherapy waste. These
should be placed in separate (often yellow) regulated medical waste containers for
incineration/disposal.
10/2005
DEPARTMENT: Design and Construction
- Facility Management and Engineering
Services Department
PAGE: 3 of 3
EFFECTIVE DATE: November 1, 2005
POLICY DESCRIPTION: Environmental –
Hazardous Waste Management
REPLACES POLICY DATED: 1/12/99, 7/21/99
PROCEDURE NUMBER: DC.010
Transportation
1. Any hazardous waste must be packaged in a DOT approved container with proper label and warning.
2. It is not acceptable for facility personnel to transport hazardous wastes.
3. Each facility should verify the registration (DOT and State Environmental Agency) of the hazardous
waste transporter, and have the transporter sign the manifest for each removal.
4. Each shipment of hazardous waste must be accompanied by a properly executed EPA hazardous
waste manifest and applicable land ban notification forms. A facility should keep a copy of
manifest.
Disposal
1. The facility must dispose of hazardous waste at an EPA registered treatment or disposal site. The
facility should verify that the disposal site is properly operated in accordance with all applicable state
and federal requirements by performing an audit or surveillance.
2. After a shipment of hazardous waste is removed, the manifest, signed by the transporter and the
ultimate disposal facility, should be returned to the facility within 30 days. This manifest should be
kept forever. If a complete hazardous waste manifest has not been returned to the facility within 45
days, the facility is required to contact the disposal facility, write an “exception report” with
explanation, and attach the file copy of the manifest.
RECORDKEEPING:
A complete records file should include:
 Original EPA (or state) notification form for hazardous waste generator registration and all
subsequent amendments;
 A copy of the permit from each hazardous waste transporter and disposal facility which provides
services for the property;
 Any annual reports to EPA;
 A list of wastes for off-site hauling (waste profile);
 Waste pickup logs;
 All manifests, receipts, certificates of disposal/destruction,or equivalent documents (never
destroy these records);
 Weekly inspection (by facility personnel) logs;
 Personnel training records; and
 Agency visit/inspection records.
REFERENCES:
Federal Regulations 40 CFR 261-266
Federal Regulation CFR 1910.1030, OSHA Bloodborne Pathogens
10/2005