Top 10 final

Top Ten Environmental Compliance Pitfalls: 

Top Ten Environmental Compliance Pitfalls December 7, 2006

Healthcare Compliance?: 

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

Healthcare compliance: 

Healthcare compliance Kansas H2E and regional H2E program helps with compliance and pollution prevention (workshop with KHEA) East coast EPA compliance initiative Compliance pitfalls identified on east coast, probably mirror the compliance gaps we have in Midwest

Healthcare compliance: 

Healthcare compliance Janet Bowen will present on east coast findings Our region, Region 7, has begun inspecting hospitals State tables in vendor area Learn from our east coast finding

Top Ten Compliance Pitfalls based on Region II Audit Disclosure Data: 

Top Ten Compliance Pitfalls based on Region II Audit Disclosure Data Janet Bowen, EPA Region I 617-918-1795, Bowen.Janet@epa.gov www.epa.gov/region1/healthcare December 7, 2006

EPA - Regions: 

EPA - Regions

EPA Region I Approach: 

EPA Region I Approach Mercury Challenge Program (1999-2001) Increased Compliance Assistance (2001-2004) Letter to hospital CEOs (2004) - Increase enforcement presence - Promote audit disclosure policy Audit Disclosures to date - 6 agreements representing 14 large hospitals - over 30 disclosures received to date

Approach – EPA Region II: 

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)

Results EPA Region II:Compliance Monitoring & Incentives Programs : 

Results EPA Region II: Compliance Monitoring & Incentives Programs

Healthcare Violations – All R2: 

Healthcare Violations – All R2

Top 10 Violations (From 146 Voluntary Disclosures): 

Top 10 Violations (From 146 Voluntary Disclosures)

Top 10 Violations –Cont. : 

Top 10 Violations –Cont.

Maximum Number Of Violations (From 156 Voluntary Disclosures): 

Maximum Number Of Violations (From 156 Voluntary Disclosures)

Number Of Facilities With Violations From 156 Voluntary Disclosures: 

Number Of Facilities With Violations From 156 Voluntary Disclosures

Root Causes Of Noncompliance: 

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;

Root Causes Of Noncompliance: 

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

Healthcare RCRA Violations – All R2: 

Healthcare RCRA Violations – All R2

Hazardous Waste (HW) Issues: 

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

Hazardous Waste (HW) Issues: 

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

Common Hazardous Waste Violations: 

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

Hazardous Waste Environmental Compliance Audit Protocols: 

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/protocol.html

Hazardous Waste Environmental Assistance Resources: 

Hazardous Waste Environmental Assistance Resources Hazardous Waste General Resources http://www.hercenter.org/hazmat/hazardouswaste.cfm Hazardous Waste Generator Regulations, User Friendly Guide (web-based) http://www.epa.gov/epaoswer/osw/gen_trans/tool.pd State Hazardous Waste Resource Locator http://www.hercenter.org/hz.cfm EPA’s Office of Underground Storage Tanks http://www.epa.gov/swerust1/index.htm

Hazardous Waste Environmental Assistance Resources (Cont.): 

Hazardous Waste Environmental Assistance Resources (Cont.) Hazardous Identification http://www.hercenter.org/hazmat/hazdeterm.cfm http://www.fedcenter.gov/resources/facilitytour/hazardous/whatis/flowchart/ Universal Waste General Resources http://www.epa.gov/epaoswer/hazwaste/id/univwast/index.htm http://www.hercenter.org/hazmat/druniversal.cfm

Healthcare CAA Violations – All R2: 

Healthcare CAA Violations – All R2

Air Compliance Issues: 

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.

Air (40 CFR 50-99): 

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)

Healthcare CWA Violations – All R2: 

Healthcare CWA Violations – All R2

Water Compliance Issues: 

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

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

Water Regulations (40 CFR Parts 100-136, 403, 460) Clean Water Act general resources http://www.hercenter.org/regsandstandards/cwa.cfm Wastewater Discharges NPDES: http://www.epa.gov/npdes Pretreatment: http://cfpub.epa.gov/npdes/home.cfm?program_id=3 UIC: http://www.epa.gov/ogwdw/uic.html Stormwater Discharges http://cfpub.epa.gov/npdes/home.cfm?program_id=6 Oil above ground and underground tanks - (new inspector guide online) http://www.epa.gov/oilspill/index.htm Other (e.g. filtration plants)

Healthcare EPCRA Violations – All R2: 

Healthcare EPCRA Violations – All R2

EPCRA – General Resources: 

EPCRA – General Resources HERC site http://www.hercenter.org/regsandstandards/epcra.cfm 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/incentives/auditing/apcol-epcra.pdf

Healthcare TSCA Violations – All R2: 

Healthcare TSCA Violations – All R2

Other Requirements: 

Other Requirements Pesticides (40 CFR 150-189) http://www.epa.gov/pesticides/ PCBs (40 CFR Part 761) http://www.epa.gov/opptintr/pcb/ www.epa.gov/compliance/incentives/auditing/protocol.html Lead Paint Region I fact sheet for Colleges http://www.epa.gov/region1/assistance/univ/pdfs/lead-based-paint7-03.pdf

EPA’s Audit Policy: 

EPA’s Audit Policy National Audit policy www.epa.gov/compliance/incentives/auditing/auditpolicy.html

National Tools: 

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

National Tools – Cont.: 

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/h2epharmablueprint41506.pdf Environmental Compliance and Improvement Guide – To improve compliance with JCAHO Environmental of Care Standard http://www.h2e-online.org/regsandstandards/jcahointro.html

National Tools – Cont.: 

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”

Resources – H2E 10 Step Guides: 

Resources – H2E 10 Step Guides Integrated Pest Management Program http://www.h2e-online.org/docs/h2e10stepipm.pdf Green Cleaning http://www.h2e-online.org/docs/h2e10stepgreenclean-r5.pdf Reducing Mercury http://www.h2e-online.org/hazmat/mercguide.html Fluorescent Light Bulb Recycling http://www.h2e-online.org/docs/h2e10stepfluorescent121802.pdf Electronics http://www.h2e-online.org/docs/h2eelectronics40504.pdf Environmentally Preferable Purchasing http://www.h2e-online.org/wastereduction/epp/10steps.html

Regional Resources: 

Regional Resources Regional H2E Champions for Change KH2E program through KSU Pollution Prevention Institute 800-578-8898 Confidential, non-regulatory assistance Iowa DNR 515-281-5353 Region 7 EPA State tables in vendor area