Over the past few years, the US EPA has pursued a compliance initiative against colleges and universities, essentially holding educational institutions to the same standards as industrial facilities. The EPA maintains that colleges and universities are required to comply with all applicable environmental regulations, including the Resource Conservation and Recovery Act (RCRA); the Spill Prevention, Control and Countermeasure (SPCC) requirements of the Clean Water Act (CWA); Underground Storage Tank regulations; and the Clean Air Act (CAA). Violating these requirements can be costly. For example, the University of Hawaii recently paid $1.8 million in civil penalties for violating federal law by poorly managing laboratory waste.
EPA Regions 1 (New England) and 2 (New York, New Jersey and Puerto Rico) are continuing to conduct multi-media inspections of colleges and universities, but have added an additional target: Healthcare facilities. Hospitals and healthcare facilities have several of the same compliance issues faced by colleges and universities, including medical waste, hazardous waste, fuel burning equipment permitting, wastewater discharges, and bulk petroleum storage tanks. Hospitals have historically been inspected by several agencies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the Department of Public Health, and the College of American Pathologists, but have been overlooked by federal and state environmental regulators.
For the most part, these regulators have little experience with the inner workings of a hospital, and may need some time to get up to speed. When most people think of hospitals, they think clean and sterile -- which is correct. However, most people do not know that hospitals typically have more waste management issues to deal with than many manufacturing facilities! During a routine day, a hospital will generate a wide variety of solid, chemical, infectious, hazardous, and radioactive waste streams that fall under state and federal regulations. For example, there are several pharmaceutical drugs that are listed hazardous wastes, and there are many wastes generated by laboratories that are both a hazardous waste and a biomedical waste. Chemicals such as formaldehyde, xylene, ethanol, and toluene are commonly used. Microbiology cultures and blood products are generated every day, and radioactive materials are used to treat illnesses.
Hospitals must prepare for the possibility that they may be inspected by the EPA in the near future, and must also realize that they need to be aware of their environmental compliance issues to better respond to requests from inspectors. Very few healthcare facilities have environmental compliance staff, and environmental compliance responsibilities are typically handled on a department-by-department basis. Hospitals should be proactive in the near future and review their environmental compliance status. This can be accomplished by assembling personnel from key departments and conducting a self-audit or by hiring a qualified environmental consulting firm.
The EPA is still in the process of developing this hospital initiative but is clearly quite serious; Regions 1, 2 and 3 are planning workshops devoted to Compliance Guidance for Hospitals.
Hospitals can prepare for this advancing initiative by viewing it as a serious issue, but one that can be met successfully with forethought, preparation, training, and action.
Being Prepared in Case EPA Knocks on Your Door
Below are some helpful hints that you might use in preparing for a possible inspection:
Develop a procedure for handling the arrival of an inspector at your facility - make sure the Information Desk or volunteers at the hospital entrance know who to call. ERL recommends that you have more than one contact in case the main contact is not available.
The EPA has the legal authority to come into your facility during normal business hours to conduct an inspection and review your files. If you try to block the inspection process, the EPA can obtain a search warrant.
It is important to always have knowledgeable hospital staff accompany the inspector. Answer their questions directly - be truthful but don't ramble. When the inspector takes notes or photographs, hospital staff should do the same.
When asked, provide the inspector with applicable environmental files. Make a list of the information you provide them. Do not give them every environmental record you have for your facility since 1930, and do not let them alone with all of your files - give the inspector only the files he or she requests.
At the conclusion of the inspection, the inspector will likely have an "Exit Interview" with the main contact to discuss the findings of the inspection. Ask the inspector for a copy of their inspection report and do not be afraid to ask the inspector what they saw, or if any violations were noted.
EPCRA Reporting Requirements
It is not too early to start thinking about your Emergency Planning and Community Right-to-Know Act (EPCRA) reporting requirements. The pertinent requirements of EPCRA include:
Annual Inventory (Section 311 and 312) - Any facility that has more than 10,000 pounds or more of an EPA hazardous chemical, for which an MSDS is required under OSHA regulations must submit an inventory form (Tier II) to the state and local governments - Due March 1st of each year.
Emergency Planning (Section 302 and 303) - Any facility with the Threshold Planning Quantity or more of an Extremely Hazardous Substance (EHS) must submit a letter to the State Emergency Response Coordinator (SERC) - submit with Tier II report in a cover letter.
Emergency Release Notification (Section 304) - Any facility that has a spill of the Reportable Quantity or more of an EHS or of a CERCLA hazardous substance must notify the state and federal government.
However, there are exemptions to SARA Title III that may relieve universities and medical facilities from reporting: "Any substance is exempt to the extent it is used in a research laboratory, hospital or other medical facility under the direct supervision of a technically qualified individual." Therefore, reporting is only required for non-research or medical chemicals, such as heating oil, gasoline, and water treatment chemicals. It should be noted that there has been a lot of discussion lately after the EPA mentioned at a conference that a facility should count the number of batteries at their facility (e.g., car batteries) that contain sulfuric acid to see if reporting is required (based on the total quantity of acid). This is a major challenge!!
The EPA EPCRA Guidance document can be viewed on the "Universities" page of the EPA website.
