The Mount Sinai Medical Center

Posted on July 31, 2015

Client: The Mount Sinai Medical Center
Location: New York, NY

Major Components

  • Multimedia Environmental Compliance Audit
  • Corrective Action Program
  • Environmental Management System

Project Description

IntroductionAerial view of Mount Sinai Hospital location in Manhattan

The Mount Sinai Medical Center (MSMC) includes The Mount Sinai Hospital and Mount Sinai School of Medicine.

Founded in 1852, The Mount Sinai Hospital is one of the country’s oldest and largest voluntary teaching hospitals. Mount Sinai is internationally acclaimed for excellence in clinical care, education and scientific research in nearly every aspect of medicine. Mount Sinai’s 1,171-bed tertiary-care teaching hospital, with a medical staff of nearly 1,800, provides physicians who deliver the most advanced inpatient and outpatient care. Mount Sinai School of Medicine is internationally recognized for ground-breaking clinical and basic science research, and innovative approaches to medical education. Located at 98th Street and Madison Avenue, The Mount Sinai Hospital serves Manhattan’s Upper East Side and Harlem.

Dvirka and Bartilucci Consulting Engineers (D&B) was originally retained by MSMC after the Center had entered into a Facility Audit Agreement (FAA) with the United States Environmental Protection Agency (USEPA)-Region 2. The scope of this assignment was threefold. First, the firm was charged with conducting a comprehensive multimedia environmental compliance audit in conformance with the FAA. Secondly, once any areas of noncompliance or deficiencies were uncovered, D&B systematically developed a corrective action plan and strategy to address the noncompliant situations. Third, the firm was requested to assist in the development of an Environmental Management System (EMS) designed not only to maintain current compliance, but also to be responsive and flexible to changes to existing processes, operations and regulatory requirements.

To support this MSMC assignment, D&B conducted a multimedia environmental compliance audit
of MSMC’s facilities to evaluate compliance with respect to environmental statutes and regulations administered by the USEPA and the New York State Department of Environmental Conservation (NYSDEC) at the following operations:

  • over 750 state-of-the-art research laboratories
  • the entire hospital/medical center complexMount Sinai Hospital building

As part of this assignment, D&B conducted a review of existing procedures, permit applications, permits, inspection reports and other appropriate records in Mount Sinai’s files in order to ensure that applicable environmental regulations were being adequately addressed. In addition, the audit team met with representatives of The Mount Sinai Hospital and Mount Sinai School of Medicine for the purpose of conducting site inspections and interviews to clarify any questions regarding the operations at the facility and to obtain information regarding the status of existing environmental programs. Consistent with the FAA, the following major Federal and New York State environmental/regulatory programs were addressed as part of this multimedia environmental compliance audit:

  • 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 Substance Programs

Upon completion of the audit, D&B prepared a written compliance report for The Mount Sinai Hospital and Mount Sinai School of Medicine. The report was prepared based on inspections of the two facilities, as well as a review of available files.

The firm has subsequently been retained by MSMC to provide ongoing technical support for the Center’s environmental compliance and to implement corrective action for issues identified as a result of the audit program. Specific assignments include, but are not limited to:MSMC employees

  • Development of a Hazardous Waste Contingency Plan
  • Preparation of an updated Spill Prevention, Control and Countermeasure (SPCC) Plan
  • Communication with regulatory agencies, including USEPA-Region 2 and the NYSDEC, on behalf of Mount Sinai regarding regulatory issues
  • Compilation of a comprehensive chemical inventory to ensure compliance with the New York City Community Rightto-Know and Department of Homeland Security regulatory requirements and preparation of Facility Inventory Forms for submittal
  • Implementation of an ongoing auditing program to monitor the effectiveness of the training and compliance program
  • Development of a pilot database to document and track the results of the audit program and for use by the MSMC IT Department in development of a software program for the Environmental Health and Safety Department
  • Preparation of “Email Updates” for research laboratory personnel to communicate new information and to reinforce key compliance requirements
  • Review of hazardous waste manifests and land disposal restriction (LDR) notifications for accuracy utilizing a checklist adapted for use at MSMC by D&B
  • Implementation of a collection program for waste pharmaceuticals regulated by the USEPA

The backbone of the compliance program has been a comprehensive training program developed to address ongoing compliance at various levels within the management and support staff at MSMC. In addition, standard operating procedures (SOPs) have been developed targeting specific areas on environmental compliance that form the basis for the training programs.

With regard to the third, and perhaps most important aspect of this assignment, D&B was tasked with the planning, design, development and implementation of MSMC’s Environmental Management System Plan.

As part of this task, in consultation with MSMC, D&B embarked on planning for and designing a practical, common-sense approach to preparing an EMS, while still conforming to the goals and objectives of the “plan-do-check act” model supported by the USEPA. Starting with the draft of a number of environmental policies for management consideration and moving into the development and refinement of an organization chart and the preparation of a compendium of standard operating procedures, D&B began to forge the basic elements of the Plan.

Next, the compliance plan for the overall facility was developed and merged with the organization chart defining the specific roles and responsibilities for in-house and consultants in support of the program. The performance of the EMS was to be periodically assessed by a system of third party audits designed to determine the effectiveness of the plan in managing changing regulatory requirements, operations and personnel.

D&B has also been tasked with conducting multimedia environmental compliance audits at associated MSMC offsite locations including the following:

  • The Mount Sinai Hospital of Queens
  • The Mount Sinai Real Estate Division residential properties
  • North Shore Medical Group

As with the Medical Center, the firm was “tapped” to provide technical support to address many of the compliance issues identified as a result of these audits. Assignments completed under this scope of work included the following:

  • Oversight of removal of underground storage tanks and preparation of a site assessment report for submittal to the NYSDEC
  • Compilation of chemical inventory data for submittal under the New York City Community Right-to-Know Program
  • Preparation of a NYSDEC Minor Facility Air Registration
  • Development of site-specific SOPs and training packages to ensure ongoing compliance with environmental regulatory requirements

MSMC has recently embarked on a major demolition/construction project with respect to its Basic Sciences Building. In support of that capital reconstruction program, D&B has been retained to conduct a comprehensive hazardous materials assessment of buildings that will be demolished to make room for the new construction. D&B is also charged with providing oversight of pre-demolition activities, including the removal of hazardous materials and hazardous waste, and the clean out and decontamination of research laboratories, clinical laboratories and mechanical spaces in these buildings.

MSMC senior management continues to meet regularly with our multimedia environmental compliance team for updates and feedback, and to allow for an opportunity to support additional compliance improvement needs.

See all Profiles related to Multimedia Environmental Compliance

For more information about this service, email us at