A healthcare facility's environment is part of patient care. Water systems, pharmaceutical waste, sharps, chemicals and floors can all injure patients, staff or the public, and each has its own set of rules. Environmental problems also tend to fall between insurance policies, because standard liability and property forms limit pollution, bacteria and fungi exposures. This guide covers the main environmental hazards in clinics, surgery centers, long-term care and hospitals, the federal and Washington requirements that apply, and how to check that your coverage matches.

Aug 21, 2019EPA ban on sewering hazardous waste pharmaceuticals took effect
All sizesHealthcare facilities covered by the sewer ban
AnnuallyReview of the bloodborne pathogens exposure control plan

Pharmaceutical waste: no drain disposal

EPA's rule for hazardous waste pharmaceuticals bans healthcare facilities and reverse distributors of all sizes from disposing of hazardous waste pharmaceuticals down a sink, toilet or drain. The ban took effect on August 21, 2019, and applies in all states, territories and Indian country. EPA defines "healthcare facility" broadly: hospitals, clinics, physicians' offices, dental and optical providers, veterinary clinics, long-term care facilities and pharmacies are all included.

The ban covers pharmaceuticals that are RCRA hazardous waste, meaning they exhibit a hazardous characteristic or appear on EPA's P or U lists, and it applies to controlled substances that are also hazardous waste. The FDA "flush list" is household guidance and does not apply to healthcare facilities. EPA strongly discourages sewering any pharmaceutical, with very few exceptions.

In Washington, the Department of Ecology updated its dangerous waste rules (chapter 173-303 WAC) effective October 31, 2020. Ecology describes the update as giving hospitals, clinics and pharmacies a single set of rules for designating and disposing of unused drugs, and confirms that health care facilities, including small quantity generators, can no longer put dangerous waste pharmaceuticals down the drain.

  • Identify which drugs on your formulary designate as hazardous or dangerous waste, and label collection containers accordingly.
  • Train nursing and pharmacy staff on which container each waste goes in. Wasting at the bedside is where drain disposal happens.
  • Use a qualified waste vendor and keep manifests and pickup records.
  • Coordinate controlled substance wasting with both DEA and hazardous waste requirements.

Water management and Legionella

Building water systems can grow Legionella and other waterborne pathogens, and patients with weakened immune systems are especially vulnerable. CMS memo QSO-17-30 (issued June 2, 2017 and revised in 2018) expects Medicare-certified hospitals, critical access hospitals and long-term care facilities to have water management plans and documentation that, at a minimum:

  • include a facility risk assessment identifying where Legionella and other opportunistic waterborne pathogens could grow and spread;
  • implement a water management program that considers the ASHRAE industry standard and the CDC water management toolkit;
  • specify testing protocols and acceptable ranges for control measures, and document results and corrective actions when control limits are not met; and
  • maintain compliance with other federal, state and local requirements.

CMS does not require water cultures for Legionella, leaving testing protocols to the provider. The CDC states that CMS requires healthcare facilities to develop and adhere to ASHRAE-compliant water management programs. Clinics and surgery centers outside the memo's scope can still use the CDC toolkit as a practical framework, particularly after construction, low-occupancy periods or water outages. Our water damage prevention and mold prevention articles cover the property side of water risk.

Sharps and bloodborne pathogens

The Needlestick Safety and Prevention Act revisions to OSHA's bloodborne pathogens standard, effective April 18, 2001, remain the foundation of sharps safety:

  • Review and update the exposure control plan at least annually to reflect new technology, and document which safer devices were considered, how they were evaluated and why they were chosen.
  • Ask non-managerial employees who provide direct patient care for input on selecting engineering controls and safer devices, and record how you did it.
  • Employers who must keep injury and illness records and have employees with occupational exposure must also keep a sharps injury log recording, at minimum, the device type and brand, where the incident happened and a description.
  • Train exposed employees at initial assignment and at least annually after that.

Sharps containers that are overfilled, missing or placed out of reach are a frequent finding. Place them at the point of use and assign responsibility for changing them.

Chemicals, disinfectants and medical gases

Healthcare facilities use disinfectants, sterilants, laboratory reagents, hazardous drugs and compressed gases. Each needs an accurate inventory, current safety data sheets, correct labeling of secondary containers, appropriate ventilation and staff training under OSHA's hazard communication standard. Our hazard communication guide covers labels, SDS and training in detail. Store oxidizing gases away from flammables, secure cylinders upright, and keep spill kits where chemicals are used.

Slips, patient handling and the physical environment

OSHA lists patient handling, needlesticks, slips, trips and falls, and violence from agitated patients or visitors among the main hazards for hospital workers. Many of the same conditions injure patients and visitors: wet floors near sinks and entrances, cords in exam rooms, poor lighting in parking areas and cluttered corridors. Our slip, trip and fall prevention guide applies directly to lobbies and treatment areas, and the medical equipment safety article covers equipment maintenance and inspection. Pair a written floor-care schedule with incident reporting so that hazards are fixed, not just noticed.

Environment of care inspection checklist

  • Pharmaceutical waste containers labeled, segregated and picked up on schedule.
  • Water management plan current, with test results and corrective actions logged.
  • Exposure control plan reviewed within the last 12 months, with safer-device evaluation documented.
  • Sharps containers at point of use and below the fill line.
  • Chemical inventory and SDS current; secondary containers labeled.
  • Gas cylinders secured and stored by compatibility.
  • Floors, cords, lighting and exits checked on a set route and frequency.
  • Biomedical waste stored securely and handled by a qualified hauler.

How insurance responds, and where gaps appear

Environmental incidents can involve several policies at once, and forms vary by carrier. Three patterns come up repeatedly:

  • Pollution exclusions. Most commercial general liability and property policies exclude or sharply limit pollution. A spill, a release from a waste storage area or contamination at a disposal site may need a separate premises pollution or environmental liability policy.
  • Bacteria and fungi limits. Many liability and property forms exclude or sublimit mold, fungi and bacteria. A Legionella claim can be argued under several policies; whether professional liability, general liability or a pollution policy responds depends on the wording. Review these exclusions before a claim, not after.
  • Infections and exposures. Patient infection claims usually fall under healthcare professional liability. Staff needlestick injuries and chemical exposures fall under workers' compensation. Building and equipment damage from water falls under commercial property, subject to its water and mold provisions.

Also ask your waste vendors for certificates of insurance that include pollution coverage for transportation and disposal, and confirm that your contracts with them address indemnity.

When to call a broker

Talk with us when you open or remodel a facility, add services such as compounding, infusion or surgery, change waste vendors, or receive an environmental or survey finding. We can review whether your liability and property forms leave a pollution or bacteria gap and compare environmental coverage options across the market.

This article is general information, not legal or regulatory advice. Confirm waste designation and facility requirements with your environmental consultant and regulators.

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