Lessons Learned Region II Audit Disclosure Data

1
Lessons Learned Region II Audit Disclosure Data

• Janet Bowen, EPA Region I
• 617-918-1795, Bowen.Janet_at_epa.gov
• www.epa.gov/region1/healthcare
• January 25, 2007

2
Region I Approach

• Mercury Challenge Program (1999-2001)
• Rolled 47 Regional partners into H2E
• Regional Hospital email group
• Regional Partners
• Pledged to reduce mercury and solid waste
• 164 partners in New England

3
Region 1 Approach (Cont.)

• Increased Compliance Assistance
• - Compliance workshop 2001
• - SPCC Conference 2002
• - Compliance workshop May 20, 2004

4
Region 1 Approach (Cont.) Increase Enforcement
Presence in Healthcare

• EPA sent letter to hospital CEOs (April 2004)
• - Increase enforcement presence
• - Information about EPA Audit policy
• - Information about Region II
• enforcement cases

5
Follow-Up Training

• RCRA half day trainings
• One in each state
• June 2004- December 2004
• EPCRA Workshops
• ME Hospital Association (3/05)
• NH Hospital Association (6/05)
• MA Hospital Association (1/07)
• General EPCRA trainings being offered in
  every state

6
EPAs Audit Policy

• National Audit policy
• www.epa.gov/compliance/incentives/auditing/auditpo
  licy.html
• Regional Contact
• Joel Blumstein
• 617-918-1771
• Blumstein.Joel_at_epa.gov

7
Audit Disclosure UpdateNew England

• Six signed hospital agreements
• Yale-New Haven Hospital
• St. Francis Hospital and Medical Center
• Central Connecticut Health Alliance
• Bridgeport Hospital
• Caritas Christi Health System
• Dana-Faber

8
Audit Disclosures UpdateNew England

• 29 Audit disclosures received to date
• Three additional disclosures expected May 2007
  pursuant to MOU

9
EPA Audit Policy Press Releases New England

• September 23, 2005 Dana-Fabar
• http//www.epa.gov/region1/pr/2005/sep/dd050908.ht
  ml
• May 25, 2005 Caritas Christi Health Care
• http//www.epa.gov/region1/pr/2005/may/sraw050501.
  html
• April 6, 2005 Saint Francis Hospital and Medical
  Center
• http//www.epa.gov/ne/pr/2005/apr/sr050401.html
• February 14, 2005 Portsmouth Regional Hospital
• http//www.epa.gov/region1/pr/2005/feb/sr050203.ht
  ml

10
Region I Enforcement

• Veterans Administration Hospital
• - Located in White River Junction, VT
• - Proposed fine of 372,254
• Press release August 5, 2005
• http//www.epa.gov/region1/pr/2005/aug/dd050806.ht
  ml
• Press Release January 2007
• VA Developing Comprehensive Waste Tracking System

11
Recent Region 1 Enforcement(Cont.)

• Violations
• Failure to conduct waste determination
• Failure to have fire suppression equipment
• Failure to label
• Failure to close containers
• Failure to date containers
• Unauthorized treatment and disposal
• Failure to minimize potential for release
• Universal Waste dating
• Failure to separate incompatibles

12
Region I EnforcementCont.

• Two New England Hospitals (NH, ME)
• - Sign Expedited Agreement
• - Pay 3,000
• - For Oil Spill Prevention Laws
• Press Release October 28, 2005
• http//www.epa.gov/region1/pr/2005/oct/dd051003.ht
  ml

13
Approach EPA Region II

• Region 2 combined the following strategies to
  address compliance issues in these sectors
• Compliance assistance
• Compliance incentives (voluntary
  audit/disclosure)
• Compliance monitoring
• Enforcement
• Pollution prevention
• Environmental management systems (EMS)

14
Results EPA Region IICompliance Monitoring
Incentives Programs
15
Healthcare Violations All R2
16
Top 10 Violations (From 146 Voluntary
Disclosures)
17
Top 10 Violations Cont.
18
Maximum Number Of Violations (From 156 Voluntary
Disclosures)
19
Number Of Facilities With Violations From 156
Voluntary Disclosures
20
Root Causes Of Noncompliance

• Systemic violations appear to stem from
• Inadequate resources for people, equipment and
  training to carry out environmental activities
• Limited or no environmental compliance
  accountability for individual departments,
  laboratories, and staff
• Limited authority vested in environmental
  compliance officials

21
Root Causes Of Noncompliance

• No clear environmental compliance
  chain-of-command
• Scattered, incomplete, and missing environmental
  compliance documentation
• Incomplete institutional knowledge regarding
  environmental regulatory requirements and
• Broad use of hazardous materials when effective
  substitutes exist

22
(No Transcript)
23
(No Transcript)
24
(No Transcript)
25
(No Transcript)
26
(No Transcript)
27
(No Transcript)
28
(No Transcript)
29
(No Transcript)
30
(No Transcript)
31
(No Transcript)
32
(No Transcript)
33
(No Transcript)
34
(No Transcript)
35
(No Transcript)
36
(No Transcript)
37
(No Transcript)
38
(No Transcript)
39
(No Transcript)
40
(No Transcript)
41
(No Transcript)
42
(No Transcript)
43
(No Transcript)
44
(No Transcript)
45
(No Transcript)
46
(No Transcript)
47
(No Transcript)
48
(No Transcript)
49
(No Transcript)
50
(No Transcript)
51
Healthcare RCRA Violations All R2
52
Hazardous Waste (HW) Issues

• Lack of HW management training of employees
• Treating HW without a permit
• Lack of RCRA contingency plan
• Spill control equipment not readily accessible
• Failure to make HW determinations

53
Hazardous Waste (HW) Issues

• Failure to ensure that HW meets Land Disposal
  Restrictions
• Failure to upgrade/close underground storage
  tanks (USTs) by 12/22/98
• Malfunctioning leak detection systems on USTs

54
Common Hazardous Waste Violations

• Laboratories
• Dental clinics
• X-rays units
• Nuclear medicine areas
• Pharmacy
• Maintenance areas
• Physical therapy
• Underground storage tanks

• Laundry
• Morgue
• Operating rooms
• Nursing units
• Hazardous waste storage areas
• Medical technology unit
• Construction areas
• Satellite accumulation points

55
Hazardous Waste Environmental Compliance Audit
Protocols

• Hazardous Waste Generators
• Used Oil and Universal Waste Generators
• Underground Storage Tanks
• Hazardous Waste Treatment, Storage, and Disposal
  Facilities
• Facilities Regulated under Subtitle D of RCRA
• www.epa.gov/compliance/incentives/auditing/protoco
  l.html

56
Hazardous Waste Environmental Assistance Resources

• Hazardous Waste General Resources
• http//www.hercenter.org/hazmat/hazardouswast
  e.cfm
• Hazardous Waste Generator Regulations, User
  Friendly Guide (web-based)
• http//www.epa.gov/epaoswer/osw/gen_trans/too
  l.pd
• State Hazardous Waste Resource Locator
• http//www.hercenter.org/hz.cfm
• EPAs Office of Underground Storage
  Tankshttp//www.epa.gov/swerust1/index.htm

57
Hazardous Waste Environmental Assistance
Resources (Cont.)

• Hazardous Identification
• http//www.hercenter.org/hazmat/hazdeterm.cfm
• http//www.fedcenter.gov/resources/facilitytour/ha
  zardous/whatis/flowchart/
• Universal Waste General Resources
• http//www.epa.gov/epaoswer/hazwaste/id/univwast/i
  ndex.htm
• http//www.hercenter.org/hazmat/druniversal.cfm

58
Healthcare CAA Violations All R2
59
Air Compliance Issues

• Failure to use properly trained and accredited
  asbestos personnel.
• Failure to notify EPA of asbestos removal
  projects and keep required documentation/recordkee
  ping.
• 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.

60
Air (40 CFR 50-99)

• Clean Air Act General Resources
• http//www.hercenter.org/regsandstandards/caa.
  cfm
• Air Conditioning/Refrigeration
• http//www.epa.gov/ozone/title6/608/
• Asbestos
• http//www.epa.gov/asbestos
• Boilers/Emergency Generators
• Medical Waste Incinerators
• http//www.epa.gov/ttn/atw/129/hmiwi/rihmiwi.html
  
• Other (e.g., degreasers, ETO sterilizers, spray
  booths)

61
Healthcare CWA Violations All R2
62
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

63
Water Regulations (40 CFR Parts 100-136, 403, 460)

• Clean Water Act general resources
• http//www.hercenter.org/regsandstandards/cwa
  .cfm
• Wastewater DischargesNPDES http//www.epa.gov/np
  desPretreatment http//cfpub.epa.gov/npdes/home.
  cfm?program_id3
• UIC http//www.epa.gov/ogwdw/uic.html
• Stormwater Dischargeshttp//cfpub.epa.gov/npdes/h
  ome.cfm?program_id6
• Oil above ground and underground tanks - (new
  inspector guide online)
• http//www.epa.gov/oilspill/index.htm
• Other (e.g. filtration plants)

64
Healthcare EPCRA Violations All R2
65
EPCRA General Resources

• HERC site
• http//www.hercenter.org/regsandstandards/epcra.cf
  m
• Overview EPA site
• http//yosemite.epa.gov/oswer/CeppoWeb.nsf/content
  /epcraOverview.htm
• Tier II Submit
• http//dintra02.rtp.epa.gov/host/oswer/CeppoAdmin.
  nsf/content/tier2.htm
• Compliance Audit Protocol - EPCRA
• http//www.epa.gov/compliance/resources/policies/i
  ncentives/auditing/apcol-epcra.pdf

66
Healthcare TSCA Violations All R2
67
Other Requirements

• Pesticides (40 CFR 150-189)http//www.epa.gov/pes
  ticides/
• PCBs (40 CFR Part 761)http//www.epa.gov/opptintr
  /pcb/
• www.epa.gov/compliance/incentives/auditing/protoco
  l.html
• Lead Paint Region I fact sheet for Colleges
• http//www.epa.gov/region1/assistance/univ/pdfs/l
  ead-based-paint7-03.pdf

68
National Tools

• Profile of the Healthcare Industry (2/05)
  Document Number 310R05002
• - plain language environmental profile
• http//www.epa.gov/compliance/resources/publicatio
  ns/assistance/sectors/notebooks/health.html
• Compliance Assistance Center Healthcare
• - on-line compliance assistance
• - Website www.hercenter.org

69
National Tools Cont.

• Managing Pharmaceutical Waste A 10-Step
  Blueprint for Health Care Facilities in the
  United States, April 2006
• http//www.h2e-online.org/docs/h2epharmablueprint4
  1506.pdf
• Environmental Compliance and Improvement Guide
  To improve compliance with JCAHO Environmental of
  Care Standard
• http//www.h2e-online.org/regsandstandards/jcahoin
  tro.html

70
National Tools Cont.

• Healthcare Guide to Pollution Prevention
  Implementation through Environmental Management
  Systems, second edition
• Revised draft second edition May 2005
• Available
• Kentucky Pollution Prevention Center
• URL www.kppc.org, under Publications, Print
  Materials, Healthcare Guide

71
Resources H2E 10 Step Guides

• Integrated Pest Management Program
• http//www.h2e-online.org/docs/h2e10stepipm.p
  df
• Green Cleaning
• http//www.h2e-online.org/docs/h2e10stepgreen
  clean-r5.pdf
• Reducing Mercury
• http//www.h2e-online.org/hazmat/mercguide.ht
  ml
• Fluorescent Light Bulb Recycling
• http//www.h2e-online.org/docs/h2e10stepfluor
  escent121802.pdf
• Electronics
• http//www.h2e-online.org/docs/h2eelectronics
  40504.pdf
• Environmentally Preferable Purchasing
• http//www.h2e-online.org/wastereduction/epp/
  10steps.html