Rochester Regional Healthcare Association / Joint Ventures Corporation USEPA – Region 2 Hospital Environmental Compliance Initiative

Posted on July 29, 2015

Major Components

  • Multimedia Environmental Compliance Audits
  • Standard Operating Procedures and Corrective Action Program
  • Facility Audit Agreement Support
  • Personnel Training

Project Description


Dvirka and Bartilucci Consulting Engineers (D&B) was retained to implement a Multimedia Environmental Compliance Program  at 14 hospitals and numerous affiliated off-site locations located in upstate New York. These facilities included the main hospital sites as well as medical offices, nursing homes, ambulatory care centers and, in one case, an affiliated industrial facility involved  in the production of prosthetics. All of the healthcare facilities participating in the program were members of the Rochester Regional Healthcare Association/Joint Ventures Corporation (RRHA). The facilities spanned the area encompassing regions of New York State commonly referred to as the Southern Tier and Western New York, and included locations in ten counties (i.e., Chemung, Ontario, Seneca, Monroe, Stueben, Allegany, Orleans, Livingston, Schuyler and Yates) and two New York State Department of Environmental Conservation (NYSDEC) Regions (i.e., Regions 8 and 9). In total, D&B audited over 60 individual facilities.

D&B was originally retained to assist the participating members of RRHA in implementing a self-audit program under the United States Environmental Protection Agency (USEPA) Region 2’s Hospital Environmental Compliance Initiative. Technical services provided by D&B in support of the program included the following:

• Assisting in the preparation of the Facility Audit Agreement (FAA).
• Conducting personnel training in the program areas included in the FAA.
• Performing comprehensive multimedia environmental compliance audits at each facility.
• Developing a corrective action plan and strategy to address non-compliant situations identified as part of the audit.
• Preparing Standard Operating Procedures (SOPs) and implementing an interactive website to be utilized by the participating members to achieve compliance with the various program areas included in the FAA.
• Implementing several corrective actions at specific locations in order to assist those facilities in achieving compliance with the applicable environmental regulations.

Facility Audit Agreement

D&B assisted RRHA with the development of the FAA and negotiations with the USEPA regarding the terms of the agreement. In addition, D&B assisted RRHA in coordinating the signing of the agreements by all of the participating members to ensure that the requirements and intent of the program and applicable schedules were met.

The FAA stipulated the scope of the audits to be completed, the schedule for completion of the audits and various terms and conditions pertaining to the implementation of the program. As outlined by the FAA, the following major federal and New York State environmental/regulatory programs were addressed as part of the multimedia environmental compliance program:

• Air Programs
• Water Programs
• Pesticide Programs
• Solid and Hazardous Waste Programs
• Hazardous Substances and Chemicals, Environmental Response, Emergency Planning, and Community Right-to Know Programs
• Toxic Substances Programs

Personnel TrainingRRHA3

Prior to completing the compliance audits, D&B held a two-day technical training program for the participating members of the FAA. The training was held at a central location in Rochester, New York and was open to personnel responsible for compliance with the various regulatory programs included in the FAA from each of the participating members. The training program included a summary of each of the regulatory programs, an outline of how each of the applicable regulations affects healthcare facilities, and methods and procedures for achieving compliance.

Compliance Audits

D&B conducted a comprehensive multimedia environmental compliance audit of the participating RRHA members to evaluate compliance with respect to environmental statues and regulations administered by the USEPA and the NYSDEC. As part of this assignment, D&B conducted a review of existing procedures, permit applications, permits, inspection reports and other appropriate records in the participating members’ files in order to ensure that applicable environmental regulations were being adequately addressed. In addition, the audit team met with representatives of each facility for the purpose of conducting site inspections and interviews to clarify any questions regarding the operations performed at the facility and to obtain information regarding the status of the existing environmental programs.

Upon completion of the audit, D&B prepared a preliminary findings table for each facility outlining all of the regulations included in the program and the facility’s status of compliance with each regulation. This preliminary findings table was used as the basis for the preparation of a Disclosure Report documenting the findings of the audit program with respect to areas of non-compliance, as well as the required corrective action for each area of non-compliance. Once finalized, in accordance with the FAA, the Disclosure Report was submitted to the USEPA. D&B then assisted the participating members, as necessary, with responding to any comments or follow-up questions posed by the USEPA after receiving the Disclosure Report for each facility.

Standard Operating Procedures

Subsequent to completing the compliance audits, D&B developed Standard Operating Procedures (SOPs) to be utilized by each of the participating members in achieving compliance with the program areas included in the FAA. The SOPs were focused on the regulatory programs where D&B identified the most non-compliant issues during performance of the compliance audits and generally contained step-by-step instructions, policies and procedures for achieving compliance with the regulations.

The SOPs were posted on a website developed by D&B specific to this program and only accessible to the participating  members. In addition, the website included a “Question and Answer” feature allowing the participating members to pose  questions regarding the SOPs, regulatory programs and aspects of the corrective actions requiring completion. These questions were subsequently answered by D&B and posted to website for all of the participating members to view. Finally, the website
also included links to the applicable regulatory agencies, regulations, guidance documents, application forms and other pertinent environmental compliance resources, as well as a copy of the all of the training modules prepared by D&B as part of the personnel training program completed at the beginning of the project.

Corrective Actions

The firm has subsequently been retained by several of the participating members of RRHA to provide technical support for environmental compliance and to implement corrective action for issues identified as a result of the audit program. Specific assignments included, but are not limited to, the following:

• Preparation of Spill Prevention, Control and Countermeasure (SPCC) Plans.
• Screening of ethylene oxide emissions in accordance with NYSDEC criteria and providing recommendations for facility modifications to achieve compliance with the NYSDEC guidelines.
• Preparation of Air Facility Registrations to properly register ethylene oxide emission sources.
• Completion of a follow-up audit to assess and track the progress of implementing the corrective actions identified during the original audit.

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