HACP-PE Study Guide & Practice Exam 2025

Healthcare Accreditation Certification Program (HACP) Examination Study Guide 2025

A Message from the HACP Examination Board Chair

  • Congratulations on seeking certification in healthcare accreditation.

  • The Healthcare Accreditation Certification Program (HACP) is developed and administered by the Center for Improvement in Healthcare Quality (CIHQ).

  • CIHQ helps healthcare organizations comply with standards and regulations to improve care quality.Commitment to professional competence in accreditation and regulation is acknowledged and appreciated.

Examination Content & Distribution of Questions

  • The HACP exam addresses key physical environment requirements for acute care hospitals.

  • The specific content and distribution of questions for the 2021 examination is as follows:

    • Security: 12 questions, 10%

    • Hazardous Materials & Waste: 16 questions, 13%

    • Emergency Power: 4 questions, 3%

    • Life Safety/Fire Safety: 42 questions, 35%

    • Healthcare Facilities Code: 28 questions, 23%

    • Utility and Medical Equipment: 4 questions, 3%

    • There's a need for experts to guide organizations in compliance activities due to federal regulations and external accreditation standards.

    • HACP focuses on the accreditation and certification arena, enabling professionals to demonstrate competency in this area.

    • Accreditation standards and CMS regulations form the foundation for delivering safe, quality patient care.


    • General Safety: 6 questions, 5%

    • Emergency Preparedness: 8 questions, 8%

  • A minimum score of 75% (90/120) is required to pass the examination.

  • The study guide's content is directly related to the scope of the HACP examination.

Tips for Taking the HACP Exam

  • Preview the exam to note easier questions and plan to skip harder ones, setting time limits.

  • Start with questions you can answer readily to gain credit for items you know well.

  • Recycle through the test, trying questions you couldn't do on the first attempt.

  • Set goals for time and pace yourself accordingly, saving time for review and revision.

  • Read the questions carefully, twice if necessary, avoiding jumping to conclusions.

  • Try to recall a concept from memory before looking at the options.

  • Alternatives may differ by only one or two words, so read the question stem with an alternative while covering up the others.

  • Use the hint of highly similar pairs -- the answer is often imbedded in one of two very similar pairs and the "most correct" answer is often the one that correctly uses terminology.

  • Be prepared to change your answer if you can determine a clear reason why your first response is incorrect.

  • Be wary of descriptive words which are overly exclusive or overly inclusive.

    • Absolute terms like always, never, completely, and only, are absolutes.

    • Relative words like often, usually, seem, and may are often more accurate.

  • If you must guess, look for some of these possibilities:

    • The style of an answer option is very different from all of the others.

    • The grammar of the question stem is not in agreement with the grammar of an alternative.

    • Some alternative is not in the area or topic of the question, but comes from some other part of the course.

Buildings

  • Hospitals must ensure the physical plant and overall environment is maintained to ensure patient safety.

  • Routine and preventive maintenance and testing are performed as necessary.

  • Maintenance schedules are established, and ongoing inspections are conducted to identify areas or equipment in need of repair.

  • Maintenance activities should be incorporated into the hospital’s QAPI plan.

  • Hospitals must be constructed and maintained to minimize risks for patients, employees, and visitors.

  • Important safety features are addressed in accordance with nationally recognized standards.

  • Accessibility

  • Age-related safety features

  • Security

  • Ligature risk

  • Weather-related exterior issues

Accessibility

  • Hospitals must meet State and Federal accessibility standards for all buildings.

  • These requirements apply to the interior and exterior of all buildings.

  • Americans with Disabilities Act (ADA)

    • The ADA is divided into five titles:

      • Employment

      • Public Services

      • Public Accommodations and Services Operated by Private Entities

      • Telecommunications

      • Miscellaneous

    • These titles define the rights of disabled individuals and the responsibilities of employers, government agencies, telecommunications companies, and privately-owned public facilities.

  • State building codes.

  • Local building codes.

Age-Related Safety Features

  • Hospitals must address safety hazards and risks related to age-related factors.

  • Healthcare provided to neonatal, pediatric, and geriatric patients must be in accordance with nationally recognized standards.

  • Age-related risks may include:

    • Security of inpatient and outpatient locations

    • Access to medications, cleaning supplies, and other hazardous materials

    • Furniture and other medical equipment

    • Increased chance of falls

  • The National Center for Missing and Exploited Children (NCMEC) provides guidelines on prevention of and response to infant abductions.

Security

  • Hospitals must demonstrate security features to minimize unauthorized access to and inappropriate departure from secured healthcare units.

  • This includes, but is not limited to, patients such as newborn, pediatric, behavioral health, those with diminished capacity and dementia/Alzheimer’s.

  • One of the primary nationally recognized standards would be the National Fire Protection Agency (NFPA) 101 Life Safety Code.

  • Doors within a required means of egress must not require a tool or key from the egress side, unless permitted by:

    • Locks complying with clinical needs of patients or specialized security measures.

    • Delayed-egress locks

    • Access-controlled egress doors

    • Elevator lobby exit access door locking

  • Door-locking arrangements are permitted where clinical needs of patients require specialized security measures or where patients pose a security threat, provided that staff can readily unlock doors at all times.

  • Provisions shall be made for the rapid removal of occupants by means of one of the following:

    • Remote control of locks

    • Keying of all locks to keys carried by staff at all times

    • Other such reliable means available to staff at all times

  • Only one locking device shall be permitted on each door.

  • More than one lock shall be permitted on each door, subject to approval of the authority having jurisdiction.

  • Psychiatric units, Alzheimer units, and dementia units are examples of areas with patients who might have clinical needs that justify door locking.

  • Forensic units and detention units are examples of areas with patients who might pose a security threat.

  • Door-locking arrangements are permitted where patient special needs require specialized protective measures for their safety, provided that all of the following are met:

  • Staff can readily unlock doors at all times in accordance with the following:

    • Provisions shall be made for the rapid removal of occupants by means of one of the following:

      • Remote control of locks

      • Keying of all locks to keys carried by staff at all times

      • Other such reliable means available to staff at all times

    • Only one locking device shall be permitted on each door.

    • More than one lock shall be permitted on each door, subject to approval of the authority having jurisdiction.

  • A total (complete) smoke detection system is provided throughout the locked space, or locked doors can be remotely unlocked at an approved, constantly attended location within the locked space.

    • Note: a total (complete) smoke detection system means that every corridor and every room have a smoke detector present.

  • The building is protected throughout by an approved, supervised automatic sprinkler system.

  • The locks are electrical locks that fail safely so as to release upon loss of power to the device.

  • The locks release by independent activation of each of the following:

    • Activation of the smoke detection system

    • Waterflow in the automatic sprinkler system

  • Pediatric units, maternity units, and emergency departments are examples of areas where patients might have special needs that justify door locking.

  • Delayed-egress locks are used as a security measure to delay the time it would take for someone to exit the space.

  • Approved, listed, delayed-egress locking systems are permitted to be installed on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system, provided that all of the following criteria are met:

    • The door leaves shall unlock in the direction of egress upon activation of one of the following:

      • Approved, supervised automatic sprinkler system

      • Not more than one heat detector of an approved, supervised automatic fire detection system

      • Not more than two smoke detectors of an approved, supervised automatic fire detection system

    • The door leaves shall unlock in the direction of egress upon loss of power controlling the lock or locking mechanism.

    • An irreversible process shall release the lock in the direction of egress within 15 seconds, or 30 seconds where approved by the authority having jurisdiction, upon application of a force to the release device under all of the following conditions:

  • The force shall not be required to exceed 15 lbf

  • The force shall not be required to be continuously applied for more than 3 seconds

  • The initiation of the release process shall activate an audible signal in the vicinity of the door opening

  • Once the lock has been released by the application of force to the releasing device, relocking shall be by manual means only

    • A readily visible, durable sign in letters not less than 1 inch high and not less than 1/8 inch in stroke width on a contrasting background that reads as follows, shall be located on the door leaf adjacent to the release device in the direction of egress: PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS

    • The egress side of doors equipped with delayed-egress locks shall be provided with emergency lighting.

  • Access-Controlled Egress doors are another way to secure a unit from entry into the space.

  • Hospitals permit door assemblies in the means of egress to be equipped with electrical lock hardware that prevents egress, provided that all of the following criteria are met:

    • A sensor shall be provided on the egress side, arranged to unlock the door leaf in the direction of egress upon detection of an approaching occupant.

    • Door leaves shall automatically unlock in the direction of egress upon loss of power to the sensor or to the part of the access control system that locks the door leaves.

    • Door locks shall be arranged to unlock in the direction of egress from a manual release device complying with all of the following criteria:

      • The manual release device shall be located on the egress side, 40 inches to 48 inches vertically above the floor, and within 60 inches of the secured door openings.

      • The manual release device shall be readily accessible and clearly identified by a sign that reads as follows: PUSH TO EXIT.

      • When operated, the manual release device shall result in direct interruption of power to the lock – independent of the locking system electronics, and the lock shall remain unlocked for not less than 30 seconds.

    • Activation of the building fire-protective signaling system, if provided, shall automatically unlock the door leaves in the direction of egress, and the door leaves shall remain unlocked until the fire-protective signaling system has been manually reset.

    • The activation of the manual fire alarm boxes that activate the building fire-protective signaling system shall not be required to unlock the door leaves.

    • Activation of the building automatic sprinkler or fire detection system, if provided, shall automatically unlock the door leaves in the direction of egress, and the door leaves shall remain unlocked until the fire-protective signaling system has been manually reset.

    • The egress side of the access-controlled egress doors, other than existing access-controlled egress doors, shall be provided with emergency lighting.

  • Access to non-clinical rooms identified as hazardous locations must be secured to prevent patient and visitor entry.

    • Examples include electrical rooms and heat, ventilation, air conditioning (HVAC) rooms.

Workplace Violence

  • Healthcare workers face a significant risk of job-related violence.

  • NIOSH defines workplace violence as “violent acts (including physical assaults and threats of assaults) directed toward persons at work or on duty.”

  • Risk factors include:

    • Working directly with people who have a history of violence

    • Drugs and alcohol

    • Relatives of patients

    • Facility arrangement that may block an employees’ vision or may interfere with their escape from a violent situation

    • Not enough or appropriate lighting in corridors, rooms, parking lots, etc.

    • Inappropriate means for emergency communication (or lack thereof)

    • Likelihood of weapons that might be brought into the facility

    • Neighborhoods with high crime rates

    • The organization does not have policies and procedures, including staff training on how to recognize, manage, and/or respond to a dangerous situation

    • Not have enough staff present

    • Lack of security

    • Long waits for patients and being overcrowded

  • An effective way to improve the overall safety and health program is to develop a workplace violence prevention program.

  • Management commitment and employee participation

  • Worksite analysis

  • Hazard prevention and control

  • Safety and health training

  • Recordkeeping and program evaluation

  • A violence prevention program focuses on developing processes and procedures appropriate for the workplace in question.

Weather-Related Exterior Issues

  • Hospitals are expected to address potential safety hazards specific to weather on both the exterior and the interior locations in accordance of nationally recognized standards.

  • Areas of risk include driveways, garages, entry points, walkways, etc.

Power Strips

  • Life Safety Code surveyors assess the use of power strips in healthcare facilities.

  • If line-operated medical equipment is used in a patient care room/area, inside the patient care vicinity:

  • UL power strips would have to be a permanent component of a rack, table, pedestal, or cart-mounted & tested medical equipment assembly.

  • Power strips providing power to medical equipment in a patient care room/area must be UL 1363A or UL 60601-1.

  • Power strips cannot be used for non-medical equipment

  • If line-operated medical equipment is used in a patient care room/area, outside of the patient care vicinity:

  • UL power strips could be used for medical & non-medical equipment with precautions.

  • Power strips providing power to medical equipment in a patient care room/area must be UL 1363A or UL 60601-1.

  • Power strips providing power to non-medical equipment in a patient care room/area must be UL 1363.

  • If line-operated medical equipment is not used in a patient care room/area, inside and outside the patient care vicinity:

  • UL power strips could be used with precautions.

  • Power strips providing power to non-medical equipment in a patient care room/area must be UL 1363.

  • In non-patient care areas/rooms, other UL strips could be used with the general precautions.

Hazardous Materials

  • Healthcare organizations use or generate numerous types of hazardous materials.

    • Some common products are sterilizing agents, compressed gases, disinfectants, chemotherapy, hazardous wastes, etc.

  • Organizations must identify hazardous materials that require special handling.

  • Risks must be minimized during use, and proper disposal methods must be ensured.

  • A written program for proper management and disposal of hazardous materials must be implemented.

  • Requirements are established by:

    • Occupational Safety and Health Administration (OSHA)

    • Department of Transportation (DOT)

    • Environmental Protection Agency (EPA)

    • Nuclear Regulatory Commission (NRC)

  • As part of the hazardous material program, organizations must:

  • Maintain an inventory of all hazardous materials used, stored, or generated.

  • Properly label all hazardous materials and waste.

  • Maintain hazardous waste manifests, permits, and licenses.

  • Monitor and document the correct disposal of hazardous gases and vapors.

  • Provide adequate space and proper equipment for handling and storage of hazardous materials.

OSHA Hazard Communication

  • Organizations with hazardous chemicals must implement a hazard communication program per OSHA's Hazard Communication Standard (HCS), 29 CFR 1910.1200.

  • The program must include labels on containers, safety data sheets (SDSs), and worker training.

  • Each organization must describe in a written program how it will meet the HCS requirements.

  • Six steps for effective hazard communication program:

    • Understanding the requirement

    • Implementation of the program

    • Container labeling

    • Maintaining Safety Data Sheets (SDSs)

    • Education for employees

    • Evaluation of the program

  • Organizations should obtain a copy of the Hazard Communication Standard and become familiar with the requirements.

  • Assign an individual responsible for the program.

  • The assigned individual will prepare a written plan and will express how the hazard communication will be addressed within the organization.

  • Prepare a written inventory list of all hazardous chemicals that are used within the workplace.

  • All containers are required to be labeled.

  • The labels are required to provide the following information:

  • Product identifier

  • Signal word

  • Pictogram

  • Hazard statement

  • Precautionary statement

  • Name, address, and phone of responsible party

  • Any additional information from manufacturer

  • The organization is required to ensure that containers in the workplace are labeled.

  • You can use the same label from the manufacturer or supplier, or you may label workplace containers with alternatives, such as third-party systems (e.g., National Fire Protection Association (NFPA) or Hazardous Materials Identification System (HMIS)) in addition to other required information.

  • At a minimum, a container used in the workplace must have the product identifier and general information concerning the hazards of the chemical.

  • Safety Data Sheets (SDSs) are detailed information on a type of hazardous chemical.

  • Organizations must maintain a copy of SDS for all known hazardous chemicals and make it accessible to employees when they are in their work areas during their work shifts.

  • Some will keep the SDS in a binder that is kept in a central location that all employees have access to.

  • Many organizations, especially that have a large number of chemicals used within the workplace, will choose to provide the SDSs electronically.

  • However, if the SDSs are supplied electronically, there must be an adequate back-up system in place in the event of a power outage, equipment failure, or other emergency involving the primary electronic system.

  • If you choose to use the electronic system, you must ensure that the staff are trained on how to access the SDS and how they can obtain a hard copy of the SDS.

  • The hard copy of the SDSs are required to be immediately available to medical personnel.

  • The standard requires that organizations provide training to their employees on the hazardous chemicals that are used in their respected work areas prior to their initial assignment and also when any new hazards are introduced into their work area.

  • The hazard communication standard does not require an organization to evaluate or reassess their plan, however it does require that it be current and relevant.

Emergency Shower and Eyewash Stations

  • OSHA regulation at 29 CFR 1910.151 states “where the eyes or body of any person may be exposed to injurious corrosive materials, suitable facilities for quick drenching or flushing of the eyes and body shall be provided within the work area for immediate emergency use.”

  • OSHA does not specify minimum operating requirements or installation setup requirements, instead referring to ANSI Standard Z358.1 (current edition is 2014).

  • ANSI Z358.1 also covers equipment performance and use requirements for personal wash units and drench hoses.

  • The ANSI standard also provides requirements for testing procedures, employee training, and maintenance of flushing equipment.

  • The ANSI standard states that all flushing equipment must be located in areas that are accessible within 10 seconds or approximately 55 feet.

  • The safety showers and eye wash stations must be located on the same level as the hazard and the path of travel shall be free from obstructions.

  • The safety showers and eye wash stations must be installed in a well-lit area and identified with a highly visible safety sign positioned so the sign shall be visible within the area served by the stations.

  • The units must be connected to a supply of flushing fluid to produce the required spray pattern for a minimum period of 15 minutes.

  • The units must be capable of delivering tepid flushing fluid (60−10060-100 degrees Fahrenheit).

  • The control valve of the unit shall remain open without the use of the operator’s hands until intentionally closed.

  • The valve shall be simple to operate and shall go from “off” to “on” in 1 second or less.

  • The valve shall be resistant to corrosion.

  • Employees who may be exposed to the hazardous materials shall be instructed in the location and proper use of emergency equipment.

  • Proper maintenance and weekly testing are necessary to ensure that emergency showers and eye wash stations are functioning safely and properly.

  • Weekly testing helps clear the supply lines of sediment and bacteria buildup that is caused by stagnant water.

  • The ANSI standard states that plumbed flushing equipment “shall be activated weekly for a period long enough to verify operation and ensure that flushing fluid is available.”

  • Bottle eyewash or other personal wash units are defined as supplemental equipment by the ANSI standard.

  • The standard states “supplemental equipment shall provide immediate flushing to support plumbed and self-contained emergency eye wash and shower equipment but shall not replace them.”

Department of Transportation Hazardous Material Regulations

  • The regulations from the Department of Transportation (DOT) can be found at 49 CFR Part 100-180.

  • The hazardous materials regulations are applicable to the transportation of hazardous materials in commerce and their offering to:

    • Interstate, intrastate, and foreign carriers by rail car, aircraft, motor vehicle, and vessel.

    • The representation that a hazardous material is present in a package, container, rail car, aircraft, motor vehicle or vessel.

    • The manufacture, fabrication, marking, maintenance, reconditioning, repairing or testing of a package or container which is represented, marked, certified or sold for use in the transportation of hazardous materials.

  • According to the DOT Hazardous Materials regulations, “no person may offer or accept a hazardous material for transportation in commerce unless that person is registered in conformance with the regulation and the hazardous material is properly classed, described, packaged, marked, labeled, and in condition for shipment as required or authorized…”.

  • Responsibilities for shippers (offeror) of hazardous materials:

    • Determine whether a material meets the definition of a hazardous material

    • Proper shipping name

    • Shipping Paper

    • Class/Division

    • Emergency Response information

    • Identification Number

    • Emergency Response telephone number

    • Hazard warning label

    • Certification

    • Packaging

    • Placarding

    • Marking

    • Security Plan

    • Employee training

    • Incident Reporting

  • Identification of a hazardous material is the first step, and frequently the most difficult. Of all the shipper’s responsibilities, the requirement to properly classify a hazardous material is very important.

  • It is from the proper identification of the hazardous materials that the other requirements are based on. A list of all material regulated by the DOT is location in 49 CFR 172.101.

  • A hazardous material is a material that is posing an unreasonable threat to the public and the environment includes:

    • Hazardous substances

    • Hazardous wastes

    • Marine pollutants

    • Elevated temperature material

    • Materials identified in 172.101

    • Materials meeting the definitions contained in Part 173.

  • Hazardous materials that are regulated by the U.S. Department of transportation include:

    • Class 1 - Explosives

    • Class 2 – Gases

    • Class 3 – Flammable Liquid

    • Class 4 – Flammable Solids

    • Class 5 – Oxidizing Substances: Organic Peroxides

    • Class 6 – Poisonous (Toxic) and Infectious Substances

    • Class 7 – Radioactive Material

    • Class 8 – Corrosives

    • Class 9 – Miscellaneous Dangerous Goods

  • In addition to the hazardous material table, emergency response requirements, training, and security plan, the DOT has requirements around communications.

    • Communications can be either shipping papers, marking, labeling, or placarding.

  • Shipping papers are any document whose purpose is to communicate a hazard and conforms to the DOT requirements.

  • The basic information that is required on a shipping paper includes the proper shipping name, hazard class, identification number, and packaging group.

  • There must also be an emergency response telephone number included on the shipping paper.

  • While the DOT does not dictate who signs the certification on the shipping papers, that individual should be the person that has the most knowledge of the shipment.

  • Public law requires that an organization retain shipping papers for 1 year.

  • When it comes to marking there must be at least a proper shipping name and identification number of the hazardous materials contained in the package.

  • Each person who offers for transportation or transports a hazardous material shall ensure the package is properly labeled.

  • Training is required for anyone who is considered to be a hazmat employee.

  • Any person who performs a function subject to the hazardous material regulations must be trained, including a secretary who is signing the shipping papers.

  • The training that is required for hazardous material employees includes the following:

    • General awareness/familiarization

    • Function-specific

    • Safety

    • Security awareness

    • In-depth security training, if a security plan is required

    • Driver training (for each hazardous material employee who will operate a motor vehicle)

  • Initial training of new hazardous material employees, or an employee who changes job functions, must be completed within 90 days of employment or change in job function.

  • Recurring training is required at least once every three years.

  • Training records must be kept by the hazardous material employer for each hazardous material employee.

Waste Management

  • Healthcare facilities generate hazardous waste.

  • Hazardous waste is defined by the Resource Conservation and Recovery Act (RCRA) as a solid waste, or combination of solid wastes, which because of its quantity, concentration, or physical, chemical or infectious characteristics may:

    • Cause or significantly contribute to an increase in mortality or an increase in serious irreversible, or incapacitating reversible, illness.

    • Pose a substantial present or potential hazard to human health or the environment when improperly treated, stored, transported, or disposed of, or otherwise managed.

  • Medical wastes found in healthcare facilities include excreta, blood, secretions, etc., and solid wastes such as linens and paper or plastic materials.

  • Organizations need to develop hazardous waste management procedures that will address the generation, use, storage, transportation, and disposal of all hazardous or potentially hazardous materials.

  • Hazardous wastes are certain materials that have been generated as wastes from processes carried out at the organization.

  • As a generator of hazardous wastes, organizations will have to look at various processes around topics such as:

    • How long can my waste be stored on site?

    • What are the storage requirements?

    • What kind of records do I have to maintain?

  • Ways to determine if your waste is classified as a hazardous waste that is regulated:

    • Is it a listed waste?

    • Is it a characteristic waste?

      • Ignitability

      • Corrosivity

      • Reactivity

      • Toxicity

  • Once it is identified as to what type of hazardous waste the organization generates, the next step is to collect data on how much is generated.

Pharmaceutical Waste

  • It is very important for healthcare facilities to have appropriate pharmaceuticals available for the treatment of their patients.

  • The first thing a healthcare facility must do is to determine if any pharmaceutical waste must be treated as a hazardous waste under RCRA by answering the following questions about the waste:

    • Is it listed on RCRA?

      • P-List

      • U-List

      • D-List

    • Is it a characteristic waste due to?

      • Toxicity

      • Ignitability

      • Corrosivity

      • Reactivity

  • When determining if it is listed, RCRA has created tables with a list of P, U, and D lists which can most commonly be found in a healthcare facility.

  • If a pharmaceutical that is listed or characteristic and is returned to the vendor, it is not considered to be a waste. This process is called “reverse distribution.”

Hazardous Materials Spills and Releases

  • There is always a potential that a healthcare facility may have an accidental spill or release of a hazardous material or waste.

  • We look to the Hazardous Waste Operations and Emergency Response (HAZWOPER) standard when it comes to what regulations govern organizations that may experience this.

  • When it comes to spill control the HAZWOPER standard addresses certain requirements.

  • Making available DOT specific salvage drums or containers and suitable quantities of proper absorbent in areas where spill, leaks, or ruptures may occur.

  • Development of a spill containment program

  • Training responders to OSHA regulations

Environmental Protection Agency (EPA)

  • The EPA was created in 1970 and is responsible for the majority of federal programs intended to protect human health and the environment.

  • The EPA's authority to regulates are based on laws such as:

  • Resource Conservation and Recovery Act (RCRA)

  • Clean Air Act (CAA)

  • Clean Water Act (CWA)

  • Emergency Planning and Community Right-to-Know Act (EPCRA)

  • Toxic Substances Control Act (TSCA)

  • Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA)

Resource Conservation and Recovery Act (RCRA)

  • RCRA provides a “cradle-to-grave” control of solid and hazardous waste by establishing management requirements on generators and transporters of hazardous waste.

  • Organizations will have inspectors come to the facility to conduct a site visit to verify that the hospital has identified all of their hazardous waste.

  • Types of generators:

    • Very small quantity generators (VSQGs) – generates less than 220 pounds per month

    • Small quantity generator (SQGs) – generates between 220 and 2,200 pounds per month

    • Large quantity generator (LQGs) – generates more than 2,200 pounds per month

  • Common findings from hospital inspections are:

    • Either no or infrequent weekly inspections of hazardous waste storage and/or satellite accumulation areas

    • Either no or improper labeling of hazardous waste containers

    • Open containers of hazardous waste

    • Either no or incorrect hazardous waste manifests

    • Improper disposal of hazardous materials

    • Lack of hazardous waste training of employees

    • Lack of a contingency plan

    • Spill control equipment not readily accessible

    • Failure to make hazardous waste determinations

Clean Air Act (CAA)

  • The CAA is the comprehensive Federal law that regulates air emissions from area, stationary, and mobile sources.

  • For healthcare facilities the primary areas of interest are around the following:

    • Air conditioning and refrigeration

    • Boilers

    • Medical Waste Incinerators

    • Asbestos

    • Ethylene oxide (ETO) sterilizers

    • Generators

  • The healthcare facility should have available any air permits that were issued to them by the EPA or their state agencies.

  • The most common issues that are related to the CAA are the following:

    • Failure to use properly trained and accredited asbestos personnel.

    • Failure to notify EPA of asbestos removal projects and keep required documentation/recordkeeping.

    • Failure to properly dispose of asbestos debris.

    • Failure to close lids on parts washers when not in use.

    • Failure to use certified CFC technicians.

    • Failure to maintain CFC leak rate repair records for large air conditioning and refrigeration units.

    • Failure to include ETO sterilizer, spray paint booth, and parts degreaser in air permit.

Clean Water Act (CWA)

  • The CWA establishes the basic structure for regulating discharges of pollutants into the water of the United States and regulating quality standards for surface waters.

  • Healthcare facilities are affected by the CWA in three particular areas:

    • Wastewater

      • Lavatories, sinks, and showers,

      • Labs

      • Washing machines and dish washers

      • Boilers

      • Maintenance Shops

    • Storm water

    • Oil storage tanks.

Emergency Planning and Community Right-to-Know Act (EPCRA)

  • The EPCRA was applied to a broader law known as the Superfund Amendments and Reauthorization Act (SARA).

  • EPCRA was designed to promote emergency planning and preparedness at both the state and local level.

  • It provides citizens, local governments, and local response authorities with information regarding the potential hazards in their community.

  • If a healthcare facility has a chemical that is listed on the extremely hazardous substance list that is at or above the planning threshold quantity must do the following:

    • Notify the State Emergency Response Commission (SERC) and Local Emergency Planning Committee (LEPC) within 60 days of receiving the shipment on site.

    • Designate a representative who will participate in the emergency planning process with the LEPC.

    • Provide requested information to enable the LEPC to develop and implement the emergency plan.

  • If the healthcare facility should have a reportable release into the environment of a hazardous substance, they must provide the following information:

  • An emergency notification

  • A written follow-up notice to the LEPC and SERC for any area likely to have been affected.

  • The healthcare facility must submit copies of the hazardous chemical SDS or a list of SDS chemicals to the LEPC, SERC, and local fire department.

The Toxic Substances Control Act (TSCA)

  • The Toxic Substances Control Act (TSCA) was enacted in 1976 to give the EPA the authority to control unreasonable risks associated with manufacturing and use of industrial chemicals.

  • Healthcare facilities may be affected by TSCA through one of the following circumstances:

    • Lead hazard reduction regulations

    • Polychlorinated biphenyls (PCB) hazard reduction regulations, or asbestos hazard reduction regulations.

Hexavalent Chromium Compound

  • Hexavalent chromium compound has historically been used for water treatment in industrial cooling towers.

  • These compounds would also be subject to the TSCA regulations.

The Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA)

  • The Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA) provides the EPA with the authority to oversee the registration, distribution, sale and use of pesticides.

Emergency Power

  • Healthcare organizations are required to have emergency power available.

  • CMS states that at a minimum there should be emergency power and lighting in operating rooms, recovery rooms, intensive care units, emergency rooms, and stair