PAGE: 1 of 3 / REPLACES POLICY DATED:
EFFECTIVE DATE: November 1, 2005 / PROCEDURE NUMBER: DC.018
SCOPE: All Company-affiliated facilities including, but not limited to, hospitals, ambulatory surgery centers, outpatient imaging centers, home health agencies, physician practices, and all Corporate Departments, Groups and Divisions and on-site subcontractors.
PURPOSE: To provide the self audit tool to be used in assessing current compliance with the Environmental Policies and Procedures.
POLICY:
1. All employees, subcontractors, and vendors of HCA-affiliated facilities are expected to carry out their roles and responsibilities in a manner that is protective of human health and the environment. Concerns or violations of this policy may be reported to your supervisor or via the Ethics Line at 1-800-455-1996.
2. Pursuant to the Environmental – General Policy, DC.001, facilities must conduct a self-audit at least every three (3) years to demonstrate compliance with corporate policies, environmental statutes and regulations.
3. Facilities must use the Environmental Compliance Questionnaire attached to this policy as the facility self-audit tool
4. Facilities must submit a completed Environmental Compliance Questionnaire to the Facility Management Engineering Services Department every three years as set forth in the procedure section below.
5. The Environmental Compliance Questionnaire serves the following purposes:
· Functions as a checklist so the responsible manager at the facility can verify compliance with the Environmental Policy and Procedures requirements
· Ensures facilities are systematically gathering and preserving important environmental documents
· Provides an off-site, back-up copy of critical environmental documents in case original documents are misplaced through human error or destroyed in a natural disaster. In such cases, the staff of the Facility Management Engineering Services Department will provide the documents to the facilities immediately.
· Assists facilities in identifying actual or potential environmental and operational deficiencies. Some resources for corrective actions may be available through the Facility Management Engineering Services Department or the Insurance Department.
DEFINITIONS:
Responsible Manager – the individual in each facility charged with maintaining compliance with federal, state, and local environmental statutes and regulations for the facility. The Responsible Manager may be a designated Environmental Compliance Officer, ES&H manager, facility manager, or plant operations manager depending on the local organizational structure and management roles and responsibilities.
Facility Executive – the individual with fiscal authority at each facility
Environmental Compliance Corrective Action Log – a facility-based electronic or paper system designed to identify, track, and validate completion of actions taken to correct environmental deficiencies. Existing facility-based tracking systems, if any, may be used.
PROCEDURE:
1. The Responsible Manager for environmental compliance must perform or supervise the completion of the Environmental Compliance Questionnaire.
2. The Responsible Manager for environmental compliance or designee must transmit the completed Environmental Compliance Questionnaire and attachments to the Facility Management Engineering Services Department by June 30th of every third year.
3. The HCA Facility Management and Engineering Services Manager and HCA Legal Counsel will review completed Questionnaire.
4. The Facility Executive at a facility needing corrective action projects must incorporate corrective actions into the facility budget cycle, as appropriate.
NOTE: Corrective action projects may include compliance education, field investigation, remediation construction project, environmental clean-up and so on.
5. The Insurance Department and Facility Management Engineering Services Department personnel review corrective actions projects to determine if the costs are recoverable through insurance coverage.
6. The Responsible Manager for environmental compliance at the facility must enter corrective actions identified during the compliance audit into the Environmental Compliance Corrective Action Log, establish a schedule for corrective actions to be completed, and verify actual completion of the corrective action with an entry in the Environmental Compliance Corrective Action Log – or revise the schedule as necessary.
7. The HCA Facility Management and Engineering Services Manager may review the entries in the Environmental Compliance Corrective Action Log as necessary.
REFERENCE:
Environmental Policy and Procedures:
Environmental – General, DC.001
11/2005
ENVIRONMENTAL COMPLIANCE
QUESTIONNAIRE
Information provided in this report is the sole property of HCA – The Healthcare Company and is not to be distributed, reproduced, or altered without consent of the Corporate Engineering Services Department. The Facility Management, Hospital Plant Operation or Hospital Risk Management staff at the facility should complete this questionnaire.
Facility Name: Date: ______
Address: ______
Municipality:______County: ______Zip Code: ______
Hospital CEO: Phone: ______
Person Completing
Questionnaire: Phone: ______
Years with Company: ______
Person(s) Providing Information for Questionnaire:
Signature:
Print name:
Title:
Date:
7
Attachment to DC.018
DC 004 AIR EMISSIONS COMPLIANCE
Air Emissions Compliance / Comments / In place(yes or no) / Further Action
Is the facility subject to air emissions permitting requirements? Depending on the heat input capacity of boilers, a facility may be subject to air emissions permitting requirements. / The heat input (in terms of million Btu/hour) of the gas fired or oil-fired boiler against the state regulatory threshold levels determine if whether permitting is necessary.
If a facility uses an incinerator for biomedical waste treatment, the facility must maintain a medical waste incinerator permit, a permit exception, or proof of permit-by-rule. / Reporting requirements and procedures are usually stated in the air permit.
Are paint booths and parts washer included on the air permits? / Certain product releases (including VOCs) are subject to emission exposure guidelines
Are the lids of parts washers in place, functional and kept closed when not in use? / This must be done to reduce unwanted emissions.
Are the sterilizers and associated ventilation systems check periodically for proper operation? / If the facility has ethylene oxide sterilizers the sterilizers and associated ventilation and exhaust systems must be properly maintained. Some states require a catalytic converter to abate ethylene oxide exhaust.
Has the facility reviewed the list of EPA hazardous air pollutants and properly reported those chemicals? / The EPA has classified 189 chemicals as hazardous air pollutants and has established limits and reporting requirements.
Does the facility use EPA-certified and qualified technicians to service equipment containing CFCs? / The EPA Clean Air Act prohibits the release of CFCs to the atmosphere and requires that they be phased out.
DC 005 ASBESTOS COMPLIANCE
(yes or no) / Further Action
Does the facility have a formal asbestos Operations and Maintenance (O&M) program? / Facilities must have a written program documenting what ACM material are in the facility and what actions must be taken with these materials when they are disturbed
Does the facility have a current asbestos survey? / If applicable, each facility should have a report of all asbestos containing materials within the facility
Have maintenance and custodial staff received OSHA required annual asbestos awareness training? / If asbestos is in a facility, training is mandatory for custodial and maintenance staff who could contact asbestos containing material (ACM). Initial training is 2 hours in duration. An annual refresher is required.
Are asbestos operations and maintenance personnel conducting ACM repairs properly trained and accredited? / Individuals conducting asbestos repairs must receive OSHA required 16 Hour O&M training. An annual refresher is required.
Is proper notification given on asbestos projects? / The EPA must be notified of asbestos abatement projects greater than 160 square or 260 linear feet. State and local regulations may be more stringent. Copies of all project notifications must be retained at the facility.
Is asbestos waste properly handled, packaged, manifested and disposed? / Asbestos waste requires special packaging, handling and disposal. All asbestos waste from a facility must be properly disposed of and manifested. Copies of all manifests must be retained at the facility.
HAZARDOUS WASTE COMPLIANCE
(yes or no) / Further Action
Does the facility have a policy for handling hazardous wastes that insures compliance with the EPA, DOT and State requirements? / This policy is required and should be readily available for any questions that may arise.
Are hazardous wastes properly characterized, stored, labeled, and shipped? / Required by Federal and State regulations. Following the proper characterization of wastes will help to reduce costs associated with disposal.
Are employees properly trained in hazardous waste management? / Any employee that handles hazardous waste must be trained in proper methods.
Does the facility have a policy for handling Polychlorinated Biphenyls (PCBs)? The policy should address, spill response, handling, disposal. / PCBs were used in nonflammable cooling oils in electrical transformers, hydraulic equipment, capacitors and other electrical equipment. Capacitors are also found in fluorescent light ballasts. PCBs are a regulated hazardous waste.
Does the facility have a policy for handling mercury? The policy should address, spill response, handling, disposal. / Mercury is a regulated waste. Anyone that will handle mercury must be trained in proper methods.
Are chemotherapy drugs being properly handled and disposed? / Chemotherapy drugs are classified by the EPA as U-listed and P-listed hazardous materials.
Does the facility have a waste oil management program? / Waste oil is regulated and should be recycled when possible, disposed of as a final alternative.
Does the facility have a policy for the proper disposal of fluorescent light tubes? / Fluorescent light tubes are regulated under universal wastes and must be handled as such.
HAZARDOUS MATERIAL COMPLIANCE
(yes or no) / Further Action
Does the facility have a Hazard Communications Program? / Hazard Communication is required and should be readily available in the event of questions or emergencies
Are employees properly trained on hazardous materials? / Any employee that handles materials must be trained in proper methods.
Has the facility complied with the chemical reporting requirements of the Emergency Planning and Community Right-to-Know Act (EPCRA)? / Facilities are required to report to the Local Emergency Planning Committees (LEPCs) the presence of certain hazardous materials if certain quantities are exceeded.
Does the facility have an environmental emergency response plan? / Federal regulations require a facility to have a plan for emergencies or environmental disasters. Each facility should develop an environmental emergency response plan that incorporates the requirements of various applicable regulations.
Does the facility have a hazardous materials
plan? / The plan should address hazardous materials stored in each department. The plan should address but should not be limited to the quantities stored, condition of storage, security of substances, disposal, etc.
UNDERGROUND STORAGE TANK COMPLIANCE
Underground Storage Tank (UST) Compliance / Comments / In place(yes or no) / Further Action
Were USTs either upgraded or properly closed by December 12, 1998? / Federal law required upgrade or replacement of all tanks by this date.
Are all UST leak detection systems tested periodically and functioning properly? / Federal law requires these systems be in place and enacted to ensure that no contamination has taken place.
If a leak has occurred from a UST has it been properly reported and documents? / A confirmed release must be reported to the EPA or delegated state agency within 24 hours.
BIOMEDICAL WASTE MANAGEMENT
(yes or no) / Further Action
Does the facility have a policy for handling biomedical wastes? / Biomedical wastes are to be segregated from all other wastes. Untreated biomedical wastes are to be released to a DOT licensed transporter. Biomedical wastes can only be treated by a properly licensed facility. State regulations must be reviewed to insure full compliance.
WATER VIOLATIONS COMPLIANCE
Water Compliance / Comments/questions / In place(yes or no) / Further Action
Does the facility have a wastewater management policy? / The municipal wastewater treatment plant that is permitted by EPA controls all discharge to sewers. Discharge of priority pollutants and certain materials are normally prohibited by the municipality. The facility must review the prohibited discharges contained in the local sewer use ordinance.
Is the facility subject to a pretreatment permit or a National Pollutant Discharge Elimination Permit (NPDES) permit? / An NPDES permit is required for facilities if their discharges go directly to surface waters
Does the facility have a Spill Prevention Control and Countermeasure (SPCC) plan in place? / A plan must be prepared in accordance with EPA regulations, 40 CFR Part 112, “Oil Pollution Prevention.” Spill events subject to the plan include but are not limited to, “ any spilling, leaking, pumping, pouring, emitting and dumping of oil of any kind or any form, including but not limited to, petroleum, fuel oil, sludge, oil refuse, and oil mixed with wastes other than dredged spoils.”
SAFETY COMPLIANCE
(yes or no) / Further Action
Does the safety officer make formal periodic safety rounds? / These safety rounds should be done periodically and documented.
Are proper safety plans in place and followed? / Plans should include general safety, construction safety, fire safety, etc.
INFECTION CONTROL COMPLIANCE
Water Compliance / Comments/questions / In place(yes or no) / Further Action
Does the facility have a formal infection control risk assessment (ICRA)? / The infection control plan should address routine maintenance procedures as well as renovation and construction activities. The plan should incorporate the AIA and CDC guidelines.
7
Attachment to DC.018