As the facilities manager of a medical practice, clinic or other type of healthcare facility, you’ve got a lot on your plate. While keeping the staff trained on OSHA requirements, DOT compliance, RCRA regulations, etc., can be a burden, it simply cannot be postponed or neglected.
Large medical facilities often have an in-house compliance manager responsible for implementing and monitoring many of these requirements. In smaller facilities, this often receives less attention or simply falls through the cracks entirely. Then, an inspection occurs, violations are discovered, and you’re forced to respond quickly, with risk to your organization’s reputation. That’s not a good place to be.
Who Needs Compliance Training? Anyone in the organization who has a reasonable chance of being exposed to hazardous waste and/or sharps must be trained -- not just those involved in waste disposal. New hires require training when they join the team, and everyone must go through refresher courses periodically.
Of course, all of this has to happen while you’re managing hundreds of other tasks, big and small. To help you to stay on top of it all we compiled this checklist. It’s a reminder of the training requirements for OSHA, DOT, RCRA and HIPPA compliance, all in one place. We also provide links to the relevant standards for easy reference. (Manager Tip: copy & paste the link to this article into a recurring workplace calendar reminder that prompts you to schedule training on a regular basis).
OSHA – Occupational Safety and Health Administration
- OSHA's Bloodborne Pathogens (BBP) standard is specified in (29 CFR 1910.1030) and includes the Needlestick Safety and Prevention Act.
- The focus is on dealing with sharps and potentially infectious substances.
- Training is required for all employees who may be exposed to bloodborne pathogens (BBPs) as a result of their job responsibilities.
- All new employees who may be exposed to BBPs or sharps must be trained. Annual refresher training is required for staffers who have a reasonable chance of exposure.
- Training should cover how to avoid injury from, and mitigate the risk of needle sticks and BBP exposure. Records of training must be kept for three years.
- States and territories must adopt a BBP standard that is at least as effective as the Federal OSHA standard. Your state could have more strict requirements.
DOT – Department of Transportation
- The DOT mandates training for employees involved with segregating, packaging and labeling medical waste for shipping.
- DOT requirements are designed to protect employees, the public and the environment from hazardous waste – all very important goals.
- Training should occur before an employee starts his/her job, but no later than 90 days after the hire date, and every three years thereafter.
- The training must include general awareness training and it must also be functionally specific.
- Fines for non-compliance can be thousands of dollars.
RCRA (Resource Conservation and Recovery Act)
- The EPA regulates the storage, management, and disposal of hazardous waste in the U.S. However, it has not had direct authority over medical waste since the Medical Waste Tracking Act (MWTA) of 1988 expired in 1991.
- Requirements for handling medical waste and employee training is primarily regulated by state environmental and health departments. State requirements must be at least as strict as EPA RCRA hazardous waste generator regulations.
- Regulations are most stringent for Large Quantity Generators of hazardous waste, whose employees must be trained within six months of starting a new assignment, and must work under supervision until the training is completed. Annual training for all is required, and records of the training must be kept.
- The relevant part of the Code of Federal Regulations (copy & paste into your favorite search engine) is 40 CFR 262.17(a)(7)(ii).
HIPPA (Health Insurance Portability And Accountability Act)
Although HIPPA regulations do not specifically focus on medical waste, they do require training for employees of medical facilities, so we’ve included it in this checklist.
- HIPAA training is mandatory under the HIPAA Privacy Rule (45 CFR §164.530) the HIPAA Security Rule (45 CFR §164.308).
- While requirements differ by the type of entity, facilities should “implement a security awareness and training program for all members of the workforce” and training should be provided “as necessary and appropriate”.
- Although this may sound vague, it cannot be ignored. If a breach of Protected Health Information (PHI) occurred and an investigation found that no training had been provided, your facility should expect a hefty fine from the HHS ́ Office for Civil Rights.
- Bottom line: A risk assessment should define the function of each individual who may have contact with PHI (or ePHI) to structure an appropriate HIPPA security awareness and training program.
Employee Training Documentation In addition to understanding the training requirements that apply to your facility, it is also essential to have written verification that training occurred.
- Include the date of training, name and qualifications of trainer, subject of training, and printed name, job title, and signature of the employee.
- Keep these records for at least three years after the training occurs, even if an employee no longer works at the facility.
- Note that each state can impose additional training requirements. Some require both new-hire and annual refresher training. Monitor your state’s requirements, make sure you have the appropriate training in place, and document that training.
Your Next Steps
We hope this checklist helps you to protect your facility, employees and patients, avoid fines and other penalties for non-compliance, and be ready for a Joint Commission inspection before it happens.
United offers both web-based and in-person training options that are designed uniquely to fit your needs. Inquire today about how we can help. For more details on what our programs cover, you may download our training brochure here.
Want to connect with a compliance training expert? Simply inquire about which compliance program is best for you.