2015 CDPH Medical Waste UCLA Inspections

2015 California Department of Public Health Medical Waste Inspection planning.

Thanks for your cooperation!

The California Department of Public Health (CDPH) completed their annual inspection of all UCLA campus laboratories and clinic locations that generate medical waste and all accumulation sites on October 26-27, 2015. 

As usual, the inspectors were very thorough, spending two days inspecting our facilities and records. The CDPH inspectors were generally pleased to find how well informed the UCLA staff and faculty were during their inspections and they commended UCLA on our continued improvements in our Medical Waste Program.  EH&S Biosafety would like to thank everyone for your careful preparation for, and cooperation during the CDPH inspection process.

CDPH Final Report, 2015

No medical waste violations were noted by CDPH in 2015 for:

Arthur Ashe Student Health  Life Science Rehabilitation  Young Hall
Brain Research Institute (A-C)  Marion Davies Children Ctr Semel (NPI)
Doris Stein Eye Institute Neuroscience Research Bldg. Slichter Hall
Engineering IV Public Health Terasaki Life Science Bldg.
Hillblom Islet Ctr. Reed Neurological Research Ctr. Warren Hall

2015 UCLA Violations, Ranked

In rank order based on its frequency, the UCLA violation categories are shown below.  
 
Rank Description
1

Overfilled Sharps Containers

2 Overfilled Medical Waste Containers/Waste protruding from waste container
2 Medical Waste container missing proper labels.
4 Items on top of medical waste/sharps containers preventing access
4 Medical Waste disposed into unlined secondary containers
6 Secondary Medical Waste container without proper tight-fitting lid
6 Re-use of Biohazard Bag liners
8 Unsanitary/soiled medical waste secondary container
8 Pharmaceutical wastes mis-disposed in Biohazard sharps container
10 Improper Secondary Containers (e.g., cardboard, beaker)
Sharps container line with a red biohazard bag
Biohazardous pipette tips on floor next to Biohazard waste container
Container labeled "Biohazard waste" which was not used for medical waste
Biohazard bag top edge taped to the inside of the secondary container
Staff indicated Biohazard bags are hand-carried to acumulation site
Biohazard bags used for a purpose other than containment of medical wastes

CDPH asked that corrective action plans be submitted for each violation, which included:  

  1. How the issue was corrected, and
  2. Monitoring plans to ensure these violations do not re-occur or continue.  

As of January 25, 2016, all users in which violations were noted have been contacted by Biosafety and each lab's corrective action plan has been submitted to CDPH for review.  

Tools to Review your Labs:

Please use the following tools developed by the EH&S Biosafety Program to help ensure your lab is in continued compliance with the 2015 California Medical Waste Act:
  1. Medical Waste Checklist to make sure your areas are prepared. 
  2. Medical Waste Fact Sheet with photographs to compare proper practices for your review.  
  3. 2015 Medical Waste Pre-Inspection Top 10 Findings.

Reminder:  2015 Regulatory Changes

In January 2015, California Medical Waste Act was amended.  Also, CDPH 2014 inspections provided new information.  The regulations were amended yet again on September 28, 2015.  Please review the following four changes and implement these in your labs. 

1. All OUTER biohazard bags in the vendor barrel must be certified and marked by the manufacturer as meeting the following American Society for Testing and Materials (ASTM) standards: 

 

ASTM D1922 Tear Resistance 

ASTM D1709 Dart Resistance

ASTM Marked Biohazard Bag
Note: CDPH has indicated that they will allow users to finish their current supply of bags, but re-supply orders orders should ensure replacement bags bear the new ASTM markings.  Options for compliant medical waste bags can be viewed here.  
Note: As of September 28. 2015:  Biohazard Bags in which you collect waste which are then placed into another bag that meets the above standard before placement in the vendor barrel only need to be certified to meet the ASTM D1709 Dart Resistance standard.  

2. All pharmaceutical waste containers must be labeled with the words “HIGH HEAT" or "INCINERATION ONLY”.  

Pharma-corrected

Note: these instructions reflect the changes made in the September 28, 2015 amendment of the Medical Waste Act.  Most purchased pharmaceutical containers already bear "INCINERATION ONLY" labels.  Please ensure these are affixed on the lid and all sides to be visible from any lateral direction.   

3. You are permitted use additional colors of bags than red to help segregate and contain wastes (provided they comply with the other marking requirements for medical waste bags) as follows:

Trace Chemotherapy WasteYellow bagsTraceChemBag
Pathology Waste White bags not yet available 
Note: you may still with to use red biohazard bags for trace chemo and pathology wastes.  This is only another option.  

4. Gooseneck tie or Overhand Knot bags within your laboratory/clinic prior to transport to accumulation sites:

  1. While wearing gloves, gather the 4 top edges of the red bag from the sides of the container.
  2. Twist the top of the bag several to seal the contents by creating a neck.
  3. Secure the neck closed with a strong, hand-tied single overhand know OR tie with a goosenck tie by folding the neck over on itself, twisting again, then securing the neck with a zip or twist tie, or non-porous tape. 

OverhandKnot      gooseneck2