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Healthcare Environmental Compliance Pitfalls

Healthcare Environmental Compliance Pitfalls. December 6, 2007. Healthcare Compliance?. In the business to promote health Hospitals already fall under several regulatory standards Environmental compliance refers to: Hazardous waste or RCRA Air quality or air permits requirements

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Healthcare Environmental Compliance Pitfalls

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  1. Healthcare Environmental Compliance Pitfalls December 6, 2007

  2. Healthcare Compliance? • In the business to promote health • Hospitals already fall under several regulatory standards • Environmental compliance refers to: • Hazardous waste or RCRA • Air quality or air permits requirements • Waste water discharges

  3. Healthcare compliance • Regional assistance programs try to educate and help facilities identify compliance gaps and pollution prevention opportunities. • East coast EPA compliance initiative in 2006 • Compliance pitfalls identified on east coast, probably mirror the compliance gaps we have in Midwest

  4. Healthcare compliance • Our region, Region 7, has begun inspecting hospitals • State tables in vendor area • 2006 Region 2 (east coast) audit finding

  5. Results EPA Region II:Compliance Monitoring & Incentives Programs Adapted from Region 2 August 2006

  6. Healthcare Violations – All R2 Adapted from Region 2 August 2006 presentation

  7. Healthcare CAA Violations – All R2 Adapted from Region 2 August 2006 presentation

  8. Air Compliance Issues • 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 properly handle CFCs and records. • Failure to include ETO sterilizer, spray paint booth, and parts degreaser in air permit.

  9. Healthcare CWA Violations – All R2 Adapted from Region 2 August 2006 presentation

  10. Water Compliance Issues • No permit for wastewater discharges • Not complying with permit conditions • No/inadequate secondary containment of storage tanks/containers • No SPCC plan • Floor drains

  11. Healthcare RCRA Violations – All R2 Adapted from Region 2 August 2006 presentation

  12. What to Expect When EPA Shows UP RoutineRCRA Inspections, Common Violations, and Enforcement Follow-up Dedriel Newsome - RCRA Inspector Environmental Field Compliance Branch, USEPA WK # (913) 551-7049 or (e-mail) – Newsome.Dedriel@EPA.gov

  13. Goals of Enforcement • Environmental Protection • Correction of Violations - Return to compliance • Deterrence • Fairness - level playing field

  14. Purpose of RCRA Inspection • Determine generator status • Determine if the facility is in compliance with the applicable RCRA regulations based on their generator status

  15. RCRA Inspection • Conduct desktop file review • Conduct drive-by surveillance of facility • Initial facility entry • Conduct initial interview (general facility information)

  16. RCRA Inspection • Collect facility process information • Collect facility waste stream information • Conduct visual inspection – hazardous waste storage areas and satellite accumulation areas • Conduct records review • Conduct exit briefing

  17. Typical Hospital Wastes / Areas Visually Inspected • Clinical Labs (spent solvents - distillation) • Research Labs (spent solvents, corrosives, off-spec chemicals, unwanted chemicals) • Facilities - Maintenance, Painting, Grounds, etc. (spent solvents, waste paints, used oil, parts washer solvents, rags, waste pesticides, batteries, mercury wastes, fluorescent lamps, aerosols) • Pharmacies (off-spec drugs, investigatives) • Operating Room (breathing machine spent media)

  18. Typical Hospital Wastes / Areas Visually Inspected • Housekeeping (Autoclave indicator tape) • Printing (spent solvents, waste inks) • Biomedical (batteries, soldering wastes) • IT (batteries, soldering wastes, solvent rags) • Radiology (lead aprons, film developing wastes) • Chemical Storage Areas (Off-spec and unwanted chemicals)

  19. Common Violations Hazardous Waste Determinations • What we find… • Mischaracterized or uncharacterized wastes; or • Materials that are unused and pending disposal not characterized • Changes in processes!!!

  20. Common Violations Satellite Accumulation Container Management • What we find… • Unlabeled satellite containers (In MO, also undated satellite containers and >1yr in area; in KS not having the words “Hazardous Waste”) • Open satellite containers • Containers not at or near the point of generation and under the control of the operator • Containers not moved in 3 days of filling (In KS and MO, one container per waste stream)

  21. Common Violations Storage Container Management • What we find… • Unmarked/unlabeled storage containers • Undated storage containers • Open storage containers • Incompatibles stored without proper separation

  22. Common Violations Illegal Treatment, Storage, and Disposal Offering Hazardous Waste Without a Permit • What we find… • Evaporation of hazardous wastes • Disposal of hazardous waste with non-hazardous waste (i.e. general trash or biomedical waste)

  23. Following the RCRA Inspection • Following RCRA Inspection, what should the facility do? • Achieve compliance with RCRA ASAP!!!!!!! • Provide a response to EPA for the Notice of Violation (NOV) • Response is required even if compliance not achieved! • Follow-up response should be provided when compliance is achieved

  24. Following the RCRA Inspection (cont.) • EPA RCRA Inspection Report • Provided to a compliance officer for review to determine enforcement response • Typically provided to the facility after it is completed

  25. Estimated Hospital RCRA Inspections and Completed Enforcement Actions in the Past 5 Years • EPA conducted about 30 inspections • States conducted about 26 inspections • EPA Informal Orders – 28 completed • EPA Formal Orders – 4 completed • State Informal Orders – 11 completed • State Formal Orders – 1 completed (These numbers do not include pending orders)

  26. Informal Enforcement • Notice of Violation (NOV) • Issued by inspector following inspection or • Sent via letter • Letter of Warning • Sent via letter and/or • May include information request (Section 3007)

  27. Formal Civil Enforcement • RCRA Section 3008(a) Order • Includes penalty • May include compliance measures • May include sampling • RCRA Section 3008(h) • RCRA Corrective Action Order • Usually includes sampling and monitoring • Does not include penalty • RCRA Section 3013 Order • Hazardous waste may present a “substantial” hazard to human health or the environment • Includes monitoring, analysis, and testing • Does not include penalty

  28. Formal Civil Enforcement (cont.) • RCRA Section 7003 Order • Solid waste and/or hazardous waste may present a “imminent and substantial” hazard to human health or the environment • Usually “fast track” response • Does not include penalty • Referral to Department of Justice (DOJ) • Referred if negotiations have stalled • Referred if facility not complying with Order • May be referred if multiple facilities are included in the enforcement proceedings

  29. Criminal Enforcement • Inspection information may be turned over to criminal investigation team if violations appear to be “intentional” • Criminal and Civil Enforcement may proceed at the same time • Violator may go to prison

  30. COMPLIANCE ASSISTANCESTATE WEB PAGES • Kansas Department of Health and Environment (KDHE) • http://www.kdhe.state.ks.us/environment/index.html • Missouri Department of Natural Resources (MDNR) • http://www.dnr.mo.gov/ • Nebraska Department of Environmental Quality (NDEQ) • http://www.deq.state.ne.us • Iowa Department of Natural Resources (IDNR) • http://www.iowadnr.com/

  31. COMPLIANCE ASSISTANCEEPA WEB PAGES • EPA HQ Web Page www.epa.gov • EPA Region 7 Web Page www.epa.gov/region07/ • EPA Region 7 RCRA Web Page www.epa.gov/region7/waste/index.htm

  32. What Can My FacilityDo Prior to the RCRA Inspection?

  33. What Can My Facility Do Prior to the RCRA Inspection? • Obtain the federal and state regulations and become familiar with them • Keep your facility in compliance – Characterize all waste streams!!!! • Schedule and maintain employee training • Contact EPA or State with questions • Access and use various “tools” from State and EPA websites

  34. What Can My Facility Do Prior to the RCRA Inspection? • Conduct a self-audit and disclose the violations found to the EPA • EPA’s Self-Audit Policy (a.k.a. Self-Disclosure) • See: http://www.epa.gov/compliance/incentives/auditing/auditpolicy.html • Contact Becky Dolph, EPA R7 CNSL at 913-551-7281 or at dolph.becky@epa.gov

  35. Questions

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