Hospital/Healthcare Facilities – USEPA Region 2 Hospital Environmental Compliance Initiative

Posted on July 30, 2015

Client: Hospital/Healthcare Facilities
Project Type: USEPA Region 2 Hospital Environmental Compliance Initiative

Project Description


The firm has been retained by a number of hospital/healthcare facilities to provide engineering services in support of participation in the United States Environmental Protection Agency (USEPA) – Region 2 Hospital Environmental Compliance Initiative. As part of the initiative, USEPA has encouraged healthcare facilities to perform voluntary self-audits of their hospitals, medical offices, nursing homes, ambulatory care centers and other related off-site facilities and disclose any violations found to USEPA. The initiative describes conditions that, when met, allow the institution to receive reduced penalties under USEPA’s policy “Incentives for Self Policing: Discovery, Disclosure, Correction, and Prevention of Violations.” Healthcare facilities that have signed a Facility Audit Agreement with the USEPA and have retained the firm to support this effort include the following:


• The Mount Sinai Hospital and Mount Sinai School of Medicine, New York, New York

Montefiore Medical Center Logo

• Montefiore Medical Center including Moses Division, Bronx, New York; J.D.Weiler/Einstein Hospital, Bronx, New York; Children’s Hospital at Montefiore, Bronx, New York; and numerous off-site locations.

New York Hospital Queens Logo

 • New York Hospital Queens and numerous off-site locations, Flushing, New York.

Kingsbrook Jewish Medical Center Logo

• Kingsbrook Jewish Medical Center, Brooklyn, New York.
Long Beach Medical Center Logo • Long Beach Medical Center, Long Beach, New York
Lenox Hill Hospital Logo • Lenox Hill Hospital, New York, New York including Manhattan Eye, Ear and Throat Hospital, New York, New York and off-site locations
Saint Barnabas Health Care System Logo • Saint Barnabas Health Care System including ten hospitals, nine nursing homes and numerous off-site locations.
Rochester Regional Healthcare Association/Joint Ventures Corporation Logo • Rochester Regional Healthcare Association/Joint Ventures Corporation, including 14 hospitals and numerous off-site locations.
Solaris Health Care System Logo • Solaris Health Care System including John F. Kennedy Medical Center, Edison, New Jersey; Muhlenberg Regional Medical Center, Plainfield, New Jersey and off-site locations.

As part of the audit process, the firm’s audit team reviewed relevant paperwork and conducted onsite inspections and interviews with key hospital personnel to assess compliance at each facility with regard to the following federal regulatory programs:

Air Programs

Part 52 Section 21 Prevention of Significant Deterioration of Air Quality
Part 60 Standards of Performance for New Stationary Sources
Part 61 National Emission Standards for Hazardous Air Pollutants, Subpart M, National Emission Standard for Asbestos
Part 62 Subpart HHH – Federal Plan Requirements for Hospital/Medical/Infectious Waste Incinerators
Part 63 National Emission Standards for Hazardous Air Pollutants for Source Categories (all applicable provisions)
Part 68 Chemical Accident Prevention Provisions
Part 70 State Operating Permit Programs
Part 82 Protection of Stratospheric Ozone
All applicable provisions of; and the State Implementation Plan Regulations (promulgated pursuant to Section 110 of the Clean Air Act) including the New Source Review regulations

Water Programs

Part 112 Oil Pollution Prevention
Part 122 EPA Administered Permit Programs: The National Pollutant Discharge Elimination System Part 141 National Primary Drinking Water Regulations
Part 142 National Primary Drinking Water Regulations Implementation
Part 143 National Secondary Drinking Water Regulations
Part 144 Underground Injection Control (“UIC”) Program
Part 145 State UIC Program Requirements
Part 146 UIC Program: Criteria and Standards
Part 147 State UIC Programs
Part 148 Hazardous Waste Injection Restrictions
Part 403 General Pretreatment Regulations for Existing and New Sources of Pollution

Pesticide Programs

Part 160 Good Laboratory Practice Standards
Part 162 State Registration of Pesticide Products
Part 170 Worker Protection Standard
Part 171 Certification of Pesticide Applicators
Part 172 Experimental Use Permits

Solid and Hazardous Wastes

Part 260 Hazardous Waste Management System: General
Part 261 Identification and Listing of Hazardous Waste
Part 262 Standards Applicable to Generators of Hazardous Waste
Part 263 Standards Applicable to Transporters of Hazardous Waste
Part 264 Standards for Owners and Operators of Hazardous Waste Treatment, Storage, and Disposal Facilities
Part 265 Interim Status Standards for Owners and Operators of Hazardous Waste Treatment, Storage, and Disposal Facilities
Part 266 Standards for the Management of Specific Hazardous Wastes and Specific Types of Hazardous Waste Management Facilities
Part 268 Land Disposal Restrictions
Part 273 Standards for Universal Waste Management
Part 279 Standards for the Management of Used Oil
Part 280 Technical Standards and Corrective Action Requirements for Owners and Operators of Underground Storage Tanks (USTs)

Hazardous Substances and Chemicals, Environmental Response,Emergency Planning, and Community Right-to-Know Programs

Part 302 Designation, Reportable Quantities, and Notification
Part 355 Emergency Planning and Notification
Part 370 Hazardous Chemical Reporting: Community Right-to-Know
Part 372 Toxic Chemical Release Reporting: Community Right-to-Know Toxic Substances
Part 745 Lead-Based Paint Poisoning Prevention in Certain Residential Structures
Part 761 Polychlorinated Biphenyls (PCBs) Manufacturing, Processing, Distribution in Commerce, and Use Prohibitions
Part 763 Asbestos

Where applicable the audit team included the following records, activities and areas of the facility as part of the inspection:

Documents reviewed (for the three years prior to the audit)

• Verify EPA identification numbers and permits
• Hazardous waste manifests
• Training records
• Land disposal restriction notifications
• Exception reports
• Lead disclosure statements in leases, or associated with leases of residential housing
• Contingency plans and annual reports (for contingency plans, only the current plan will be reviewed)
• Required certifications

Facilities Operation and Maintenancemachine

• Air conditioning/refrigeration service
• Appliance and equipment repair, including medical equipment
• Building cleaning and maintenance
• Building renovation and construction
• Cafeteria
• Chemical storage areas
• Drinking water treatment systems
• Fabrication shops
• Furniture repair
• Heating and power plants (e.g., boilers, emergency generators)
• House or architectural structure painting
• Landscaping operations • Laundry
• PCB transformers and switches
• Pesticide storage facilities
• Resource recovery/incinerator facilities
• Waste disposal areas (landfills)
• Wastewater treatment facilities
• Waste treatment facilities such as autoclaves

Fleet MaintenanceAbove ground Diesel storage tank

• Automotive, truck, and ambulance servicing areas
• Gasoline service stations
• Garages

Hazardous Waste / Tanks / Wells

• Aboveground and current operating underground storage tanks and their containment areas/systems, and documentation concerning closures of regulated tanks previously removed from service.
• Dry wells, septic systems, cesspools, floor drains, sink drains, and disposal wells.
• Facilities treating, storing or disposing of hazardous wastes.
• Hazardous waste satellite accumulation areas.
• Hazardous waste storage areas.
• Tanks that have been permanently or temporarily closed.
• Transformers and oil-containing electrical equipment (PCB and non-PCB).
• Universal waste storage areas.

LaboratoriesBiohazard-Infectious Waste Dispose of Properly sign

• All clinical, pathology and dental laboratories
• All teaching and research laboratories with regular chemical use.

Patient Care

• Anesthesiology
• Chemotherapy
• Dentist’s offices
• Doctor’s offices
• Floor Pharmacies
• Histology
• Intensive Care Units
• Neonatal Areas
• Nursing Stations
• Operating Rooms
• Pathology, microbiology
• Patient’s Rooms
• Patient treatment areas
• X-Ray/Radiology

Main Pharmacy

• Storage areas
• Outdated pharmaceuticals

Sterile Supply and Materials Management

• Autoclaving Units
• Ethylene Oxide (EtO) Units
• Glutaraldehyde
• Use and disposal of disinfectants

Use and Disposal of Known Chemicals/Products of Concern

• Computers/monitors, circuit boards, and other lead-bearing electronics
• Ethanol and formaldehyde/ethanol solutions
• Fluorescent light bulbs and other types of lamps, including high-intensity discharge, neon, mercury vapor, high pressure sodium, and metal halide lamps
• Formaldehyde/Formalin
• Mercury and Mercury-containing devices and products
• PCB-containing devices
• Xylene
• Batteries
• Solvents
• Photographic chemicals and scrap film

Other Services

• Athletic and training facilities
• Photo processing/publishing
• Morgue/Crematorium
• Animal care areashospitalhealth14

Upon completion of the document review and onsite inspections and interviews, findings tables listing each regulatory program area along with a description of the facility’s compliance status were prepared. These tables were reviewed and discussed with the responsible healthcare facility staff to ensure accuracy and provided the basis for preparation of the Facility Disclosure Report that was prepared for submittal to USEPA Region 2. The Facility Disclosure Report listed each violation found by regulatory program area, the specific corrective action to be implemented and the status of the corrective action. In the case of a minor violation, such as compliance with labeling requirements for universal waste, the corrective action was typically completed immediately. Other violations that required more complicated corrective action, such as training of personnel or a capital expenditure, typically included a request for additional time to complete the corrective action.

A number of the healthcare facilities have also, upon completion of the initial audit process, retained the firm to provide additional services to ensure ongoing compliance with the environmental regulations. These services have included preparing a Hazardous Waste Management Plan and providing hazardous waste management training to hospital personnel; developing facility-specific Standard Operating Procedures for regulatory compliance, and conducting annual multimedia environmental compliance audits.

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