I            PURPOSE

 The purpose of the Hazardous Materials and Waste Plan is to provide a programmatic framework to reduce the risk to New York State Psychiatric Institute.  The plan includes processes that are designed to evaluate risks that may adversely affect the life or health of patients, staff, and visitors.

 

Mission: New York State Psychiatric Institute is committed to providing a safe, secure, and therapeutic environment at its main facility and off-facility program sites for all patients, staff and visitors.  The hazardous materials and waste program is designed to support safe, effective patient care by providing reliable information that allows facility management and staff to make better hazardous materials decisions and to evaluate key issues and opportunities for improvement of hazardous materials performance

 

Consistent with this mission, New York State Psychiatric Institute has established and provides ongoing support for the hazardous materials and waste management program.

 

II            SCOPE

 

The facility has an Environment of Care Committee (EOCC) consisting of a cross representation of the facility’s staff.  The monitors training and competence of staff and assesses conditions of physical plant, grounds, and equipment through building inspections, environmental rounds, hazardous materials inspections, and various performance improvement initiatives.  Through review of reliable information, management is able to make the best decisions regarding hazardous materials concerns and to evaluate hazardous materials performance related to key issues with opportunities for improvement.  The EOCC monitors and evaluates all hazardous materials and waste areas.  It takes action and makes recommendations to the facility leadership, including the facility Director, who is a member of the Governing Body.  The EOCC may issue assignments to committee members and non-committee staff for follow-up actions / improvements and completion of reports. To facilitate these functions, the EOCC has formed a Laboratory Safety Sub-Committee. The staff of the Sub-Committee meets regularly to review specific HazMat issues, and take initiatives related to chemicals, bio-hazards, and associated safety concerns. Membership of the Sub-Committee includes research scientists, the Director of Infection Control, the Chief Safety and Security Officer, the Head of Housekeeping, the Chief Engineer, and others.

The Sub-Committee reports to the EOCC regularly; including a detailed annual report.

 

 

III            FUNDAMENTALS

 

A.   The scope of the hazardous materials and waste management program is determined by the materials in use and the waste generated at or by the facility, by contractors, and others.

 

B.    Hazards associated with materials and waste are defined by law (PESHA) or regulation and are identified in material safety data sheets (MSDS) or similar documents provided by suppliers and manufacturers. Specific MSDS information is available through the EOC Website.

 

C.        Hazards are managed by involving all appropriate staff in the design and implementation of all parts of the plan.

 

D.       Protection from hazards requires all staff, who use or are exposed to hazardous materials, to become educated to the nature of the hazards and to use equipment and procedures for safe use and handling when working with or around hazardous materials and waste.

 

E.        Proper chemical storage is strictly observed to minimize and prevent unnecessary exposure or accidents.

 

F.     Rapid, effective response is required if a spill, release or exposure to a hazardous materials and waste occurs.

 

G.     Segregation of hazardous waste at the point of generation is an effective means of controlling the potential for exposures or spills during collection, transport, storage, and disposal.

 

H.     Special monitoring processes and systems are initiated as required to manage certain gases, vapors, and other environment issues, as they are often undetectable to human senses. (This includes a regular monitoring of all outgoing wastes for possible radiation wastes.)

 

 

IV    GOALS

 

A.        Comply with accepted standards of hazardous materials and waste regulations

 

B.        Provide a safe, secure, and therapeutic environment for patients, staff, and visitors.

 

    C.    Integrate hazardous materials practices into daily operations.

 

  D.   Identify opportunities to improve performance.

 

 

 

 

 

 

 

V.        ORGANIZATION AND RESPONSIBILITY

 

A.   Through the Minutes and Repots of the EOCC, the Director receives regular reports on activities of the hazardous materials and waste program. The Director reviews reports and, as appropriate, communicates safety related concerns about identified issues and regulatory compliance.

 

B.    The Director reviews reports and, as necessary, communicates concerns about key issues and regulatory compliance to appropriate departments, services, and staff.  The administration collaborates with appropriate departments, services, and staff to establish operating and capital budgets for the safety program.

 

C.    The Environment of Care Committee Chairperson has responsibility for identification of hazardous materials deficiencies, development of plans for improvement, accident and injury prevention and investigation, the Information, Collection, and Evaluation System (ICES), and emergency response.  Training of staff and volunteers is facilitated by the Education and Training Department.

 

D.    The EOCC coordinates processes within the Environment of Care Standards.  Membership on the EOCC is by appointment from the facility Director and includes representatives from administration, clinical services, and support services.  The EOCC meets as often as is necessary on a regular basis (usually each month except for August) to receive reports and to conduct reviews of safety issues.   Additional meetings may be scheduled at the request of the EOCC Chairperson.

 

E.    The Director authorizes key staff to take immediate and appropriate action in the event of an emergency.  An emergency is a situation that poses a threat to life, personal injury, or damage to property.

 

F.   Department, program and site managers are responsible for orienting new staff members to the department/programs and to job specific hazardous materials procedures.  Specific training needs and expertise can be requested by the department/program/site managers in concert with the Education and Training Department.

 

G.   Individual staff members are responsible for learning and following job and task specific procedures for hazardous materials operations.  Individual staff members are also responsible for learning and using reporting procedures.

 

 

 

 

 

VI            PROCESSES OF THE HAZARDOUS MATERIALS & WASTE MANAGEMENT PROGRAM

 

A.            Selection

 

Each department, program, and site manager is responsible, prior to purchase, for obtaining and evaluating the MSDS for hazards.  Evaluation should be based upon associated hazards, engineering and safety controls, requirements for additional training, the need for personal protective equipment (PPE), and the need for the substance.  Whenever possible, the less hazardous substances suitable for use will be purchased.  Each department, program, and site manager who uses or handles hazardous materials is responsible for the product from the time it enters the department, program, or site until the product is disposed of as waste. 

 

The Business Officer / RTK Officer controls the purchase of all hazardous materials through their approval.

 

B.                    Inventory

 

The LSSC maintains a database of hazardous materials inventories, as required, including hazard classifications and the total quantities, where applicable for the facility.

 

Inventories are updated as required.  Hazardous materials in the inventory are reported to the local emergency planning office and the NYS Department of Environmental Conservation as required by the Community Right to Know Act.

 

C.                    Waste Handling

 

Housekeeping is responsible for managing the program of hazardous waste.   The EOCC develops policies and procedures for handling hazardous and regulated waste.  Department, program, and site managers are responsible for ensuring that these policies and procedures are followed.  Hazardous waste handled by New York State Psychiatric Institute includes    chemical, radioactive, medical/infectious, and special waste.

 

The manager of each department, program, and site that generates waste is responsible for identifying the waste that requires regulated disposal.  Department, program, and site managers review MSDS and/or confer with Housekeeping) to determine proper segregation and disposal methods for all hazardous and regulated waste. Disposal methods must be in compliance with facility policy, and all federal, state and local regulations.

 

The Housekeeping, and Infection Control oversee the collection, handling and disposal of all regulated medical waste.  Waste is segregated at the point of origin in appropriately marked containers.  The Housekeeping department is responsible for collection of regulated medical waste from the point of generation, including clinics and off sites, to the staging area for packing and disposal.  Regulated medical waste is disposed of appropriately.  The facility maintains locations where waste is held until transported by licensed contractor for disposal.

 

The Plant Superintendant  manages material containing asbestos.  This department arranges for sampling, testing, the abatement process, and overseeing each project.  Included is the coordination of final air testing, material disposal, and tracking. 

 

The Housekeeping and Engineering Departments) oversee the collection, handling, and disposal of all special category waste.  Special category waste includes universal waste such as, spent mercury lamps, florescent lamps, ballasts containing PCBs, batteries, tires, heavy metal waste products, and any other regulated waste not specifically identified in any of the other waste categories.  Generally these items are collected and stored for recycling or disposal through outside vendors.

 

D.                    Gas Monitoring

 

Areas identified for potential exposure to hazardous gases, volatile materials, or other identified hazards are monitored and controlled according to facility policy, procedure, and regulatory requirements.  The polices and procedures are approved by the EOCC. There are no piped medical gases used at NYSPI.

 

 

 

 

 

 

 

 

E.   Space Management

 

The Engineering Dept., Chief of Safety and Security, Infection Control Nurse, and Chair of the EOCC are jointly responsible for managing the program for providing appropriate space and equipment for handling and storing hazardous materials and waste. The space for handling and storage of hazardous materials and waste is also monitored as part of the hazard surveillance program.  The space is also evaluated by each department, program, and site manager on an as needed basis.

 

 

F.        Reporting and Investigating

 

The hazardous materials and waste program uses a variety of reporting methods to document activities.  The Chief of Safety and Security, and Housekeeping Director share responsibilities for managing, reporting and investigating.  

 

Reports of staff, patient and visitor incidents/accidents are made using the appropriate report forms.   This information is reviewed by appropriate committees: Incident Review, EOCC, Risk Management, Infection Control. This information is reviewed by the EOCC through the ICES.

 

Reports of significant property damage are directed to the Chief of Safety and Security.

 

One of the goals of the reporting process is for the responsible manager to receive facility incident reports as soon as practical after an occurrence. This goal is intended to allow appropriate and timely reporting and follow-up activities as needed.

 

 

G.   Orientation and Education

 

The facility Education and Training Department has overall responsibility for organizing the orientation and education program for each of the seven functions associated with Management of the Environment of Care. Department, program, and site managers are responsible for assuring the hazardous materials and waste management program orientation and education is implemented.

 

Every new staff member participates in a general orientation program that includes information related to the hazardous materials and waste management program. 

 

The facility Education and Training Department is responsible for conducting the general orientation program with current information on general hazardous materials and waste processes to new staff members as soon as possible but within 30 days of employment.  The Education and Training Department records attendance for each new staff member who completes the general orientation program.  Attendance records are maintained in the Education and Training Department.

 

Staff members also receive department-specific orientation to the department to which they are assigned.  Each department, program, and site manager is responsible for providing their new staff members with department-specific orientation to the hazardous materials and waste management program.  The goal of the department orientation program is to provide new staff members with current hazardous materials and waste management information including area or job specific hazardous materials issues and hazards specific to the department.

 

All staff members of the facility must participate in mandatory continuing education at least once each year, which includes information specific to the hazardous materials and waste management program. This requirement may be satisfied through completion of a self-learning packet or attendance at a regularly scheduled facility-wide continuing education program.  The Education and Training Department maintains records of all completed training. 

 

Various Departments collaborate with the Education and Training Department and individual department managers, as appropriate, for developing content and supporting material for general and department, program, site specific orientation and for continuing education programs.  The content and supporting materials utilized in general and department, program, site specific orientation and continuing education programs are reviewed and revised as necessary.

 

The Education and Training Department reports information on orientation and continuing education data during the reporting period to the EOCC

 

 

H.     Performance Improvement Monitoring

 

The EOCC Chairperson through the EOCC has overall responsibility for coordinating the ongoing performance monitoring and the performance improvement monitoring for each of the seven functions associated with Management of the Environment of Care.  The EOCC Chairperson is responsible for all monitoring associated with the hazardous materials and waste management program. 

 

The intent of establishing performance monitoring is to improve the hazardous materials and waste management program through objective measures of demonstrated performance.  Performance improvement is an important aspect of the Hazardous Materials and Waste Management Plan.  Ongoing performance monitoring serves as an indicator of continued effectiveness of the hazardous materials and waste management program and is a mechanism to identify performance improvement opportunities.

 

J.   Emergency Procedures

 

The Chief of Safety and Security and Chair of the EOCC have overall responsibility for coordinating activities related to establishing and maintaining emergency procedures for the hazardous materials and waste program.  The manager of each department, program and site designated as a hazardous materials area is responsible for coordinating the activities with regard to establishing and maintaining emergency procedures.  Each manager is responsible for developing emergency hazardous materials procedures in conjunction with the needs of their patients and with the needs of other departments, programs and sites, especially clinical areas that may be negatively impacted by a failure to follow normal hazardous materials procedures.

 

The Chief of Safety and Security and the EOCC each have responsibility for reviewing emergency hazardous materials procedures related to the operations of hazardous materials areas.

 

 

Emergency hazardous materials procedures contain specific information related to actions to be taken in the event of a hazardous materials incident with provisions for handling the media and providing additional personnel to control traffic during emergencies.

 

Each manager is required to structure their department, program, and site hazardous materials procedures to ensure that procedures provide personnel with essential information needed during and emergency.

 

Each manager is responsible for maintaining copies of departmental, program, or site emergency procedures in a location accessible to their staff for reference during an emergency. Managers are responsible for providing their staff with orientation to emergency procedures that relate to their jobs.  Additional department level training is provided on an annual basis as part of the continuing education program and when emergency procedures are revised.

 

Managers are responsible for maintaining the emergency procedures. Each manager is responsible for reviewing emergency hazardous materials procedures and updating as necessary. The Chief of Safety and Security and the Chair of the EOCC are responsible for coordinating the review program for emergency procedures and for communicating information related to the findings of the review to the EOCC.

 

 

K.   Annual Evaluation

 

The EOCC Chairperson has overall responsibility for coordinating the annual evaluation of each of the seven functions associated with Management of the Environment of Care.  The EOCC Chairperson, the LSSC, the Head of Housekeeping and the Chief of Safety and Security are responsible for completing the annual evaluation of the hazardous materials and waste management program.  An evaluation of Hazardous Materials and Waste Management Plan objectives, scope, performance, and effectiveness is included in each annual evaluation.