ENVIRONMENTAL MANAGEMENT
PROGRAM REVIEW
DEPARTMENT OF VETERANS AFFAIRS
OLIN E. TEAGUE VETERANS CENTER
TEMPLE, TEXAS
PREPARED BY
U.S. ENVIRONMENTAL PROTECTION AGENCY
REGION 6
FEDERAL FACILITIES COMPLIANCE PROGRAM
SEPTEMBER 1994
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ENVIRONMENTAL MANAGEMENT
*
PROGRAM REVIEW
FOR THE
DEPARTMENT OF VETERANS AFFAIRS
OLINE. TEAGUE
VETERANS CENTER
\
TEMPLE, TEXAS
September 1994
U.S. Environmental Protection Agency
Federal Assistance Section, Federal Activities Branch
Environmental Services Division
*.''' s P
1445 Ross Avenue
Dallas, Texas 75202-2733
Prepared Bv: J W^X^^ZS Date:
James T. High^nd>P-E.
EnvironmentalvEnEMieer
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CONTENTS
REPORT ON REVIEW OF
ENVIRONMENTAL MANAGEMENT PROGRAM
OLIN E. TEAGUE VETERANS' CENTER
EXECUTIVE SUMMARY i
I. BACKGROUND AND GENERAL INFORMATION 1
A. Background and Purpose of Site Visit 1
B. General Facility Information 2
C. Scope of the Review 2
II. FINDINGS 3
A. Organization and Environmental Management Program (EMP) 3
1. Organizational Structure, Agency and OTVC 3
2. EMP Applicability, Basis and Support 4
3. Basic Goals and Objectives of the OTVC EMP 4
4. Communication to Facility Personnel 5
5. Public Information and Community Perception of the OTVC
EMP 5
6. NEPA Involvement 5
B. Resources and Training 5
1. Environmental Staffing 5
2. Staff Training 5
3. Facilities and Equipment 6
4. Funding Resources 6
5. Staff Performance Evaluation 6
C. Environmental Management Program (EMP) Implementation 6
1. Knowledge of Executive Orders, OMB Circulars 6
2. Use of the A-106 Process to Address Needs 7
3. Knowledge of Environmental Laws, Regulations and
Regulators 7
4. Environmental Auditing and Self-Monitoring 7
5. Identification and Correction of Violations 7
6. Tracking Compliance, Permits, Reporting Requirements 8
7. Reported Compliance Status, Open Enforcement Actions 8
8. Environmental Restoration 8
9. Pollution Prevention, Waste Reduction 8
10. Protection of Natural and Cultural Resources 9
11. Applications of New and/or Innovative Technologies 9
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III. CONCLUSIONS AND RECOMMENDATIONS 9
A. Environmental Management Program (EMP) And Organization 9
1. Conclusions . '[.:.':,,,.--. 9
2. Recommendations . . 10
* '
B. EMP Resources and Training 11
.. * 1. . Conclusions 11
2. Recpmmen'datioris -. 11
C. EMP Implementation . '. . . 12
1. Conclusions . . >. . 12
2. Recommendations . . . 12
APPENDICES^
I. VA Organization Charts
II. Olio E. Teague Veterans' Center Organization Charts
III. Olin E. Teague Veterans' Center Memoranda
IV. Acronyms Used in the Report
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EXECUTIVE SUMMARY
The Environmental Management Program (EMP) Review concept was developed by the
Federal Facilities Compliance Program (FFCP) in EPA Region 6 as a means of expanding
our outreach'efforts and enhancing communication and coordination between Region 6 and
other Federal agencies. In FY 1993, the FFCP staff chose to concentrate the EMP review
efforts on minor Federal facilities (FF), particularly those of Civilian Federal Agencies
(agencies other than the Departments of Defense and Energy). In addition to enhancing
cross-communication and coordination, the purpose of the EMP review is to assess the
overall health of the facility's environmental management program and to provide
recommendations to the facility and its parent agency for their consideration. We
emphasize to the facility from the outset that our review visit is not a compliance
enforcement inspection and that the EPA representative is not looking at the facility to
determine compliance status.
The Department of Veterans Affairs (VA) Olin E, Teague Veterans' Center (OTVC) in
Temple, Texas was chosen for an EMP review visit during FY94. This facility is a 1,000+
bed general medical, surgical and psychiatric hospital, domiciliary and nursing home for
military service veterans. In addition to providing health care for veterans, OTVC activities
include health care education and research and, in a national emergency, support of the
Department of Defense. Besides the medical and health care facilities, OTVC has
laboratories, vehicles and service shops (plumbing, carpentry, electrical, etc.). These varied
operations and activities generate or involve handling of domestic and industrial
wastewaters, hazardous and other solid wastes, air pollutants and toxic and hazardous
substances subject to the environmental laws and regulations administered by the EPA. The
OTVC has no environmental management office (EMO) or full-time environmental staff.
The EMP review consisted primarily of on-site discussions and observations and generally
covered the areas of:
o Organization (facility and parent agency) and the facility's existing EMP.
o Facility resources and environmental training of personnel.
o Implementation of the existing EMP.
o Current environmental restoration and pollution prevention activities and compliance
status.
Review findings and recommendations are divided into three major categories: 1)
Organization and EMP; 2) Resources and Training; and 3) EMP Implementation.
Environmental restoration, pollution prevention and compliance status are included under
EMP implementation. Review findings and other observations are those of the EPA
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representative conducting the review, and the recommendations presented reflect his
judgement. The recommendations are offered for consideration by the OTVC and the VA
and are summarized below:
ORGANIZATION AND ENVIRONMENTAL MANAGEMENT PROGRAM
o Consider OTVC reorganization to separate environmental coordination from health
and safety, putting environmental program responsibility under a full-time
Environmental Coordinator. Changes would demonstrate higher priority for
environmental issues, reduce competition for budget dollars, facilitate expansion of
the total EMP and increase environmental awareness and support.
o VA Headquarters should review its organization, environmental responsibility
assignments and budget to ensure that environmental matters are given proper
priority and support.
o Expand scope, change name of Waste Management Committee, make it a focal point
for addressing and resolving all environmental compliance issues, information
dissemination and health and safety related coordination.
o Consider developing a Center strategic plan for environmental, safety and health
compliance to consolidate guidance, make necessary revisions, provide a formal
statement of the Center's EMP and address all areas of environmental concern and
roles of OTVC services and programs.
o Ensure that basic environmental awareness training is available and mandatory for
all OTVC employees.
o Institute a public relations program to keep local community aware of OTVC
environmental activities, plans and issues.
EMP RESOURCES AND TRAINING
o Provide full-time Environmental Coordinator and staff assistance to satisfy immediate
program needs.
o Include management indicators in recommended Environmental Coordinator's
performance standards.
o Assess current environmental training for Center personnel, especially that for
hazardous waste/materials handling and spill response. Ensure that all appropriate
employees are included and necessary refresher training is available.
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o Increase EMP funding to cover recommended additional resources. Recurring
operations-type activities funds should be reflected in VA O&M budget.
EMP IMPLEMENTATION
o Continue VA plans under way to implement an effective environmental auditing
program,either internal external audits, or a combination of both.
o Assess all OTVC operations to identify additional pollution prevention and waste
reduction opportunities.
o Assess OTVC operations also for potential opportunities for applying or testing of
innovative technologies with potential application to current or future OTVC or
other VA operations.
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REPORT ON ENVIRONMENTAL MANAGEMENT PROGRAM REVIEW
AT VA OLIN E. TEAGUE VETERANS' CENTER
I. BACKGROUND AND GENERAL INFORMATION
A. x Background and Purpose of Site Visit
On September 13, 1994, a representative of Region 6, U.S. Environmental Protection
Agency, James T. Highland, visited the Olin E. Teague Veterans'Center (OTVC or Center)
to review and evaluate the total environmental management program (EMP) at that facility.
The visit was a part of the Region 6 Federal Facilities (FF) technical assistance and
outreach initiative and not an enforcement inspection visit to determine compliance status.
OTVC management personnel were so informed both prior to and during the visit. The
visit was informal and consultative in nature, and no part of this report should be
interpreted as a formal finding of actual compliance status.
OTVC personnel involved in the visit in-briefing or contacted during the visit included:
Mr. Jerry B. Boyd, OTVC Director
Mr. Edgar Tucker, Associate OTVC Director
Mr. Theodore A. Martin, Chief, Environmental Management Service (EMS)
Mr. Randy Blodgett, Chief, Engineering Service (ES)
Mr. David Vick, Assistant Chief, Engineering Service (ES)
Mr. Nate Wilson, Safety and Occupational Health Specialist (ES)
Ms. Myra Winfield, Industrial Hygienist and OTVC Environmental Coordinator (ES)
Ms. Marilyn Waggoner, Regional Industrial Hygienist, VA Regional Division Office, Grand
Prairie, Texas, attended as an observer of the review visit and also participated in the visit
interviews. An informal out-briefing of the visit was provided to Messrs. Blodgett and
Wilson and Ms. Winfield.
Information and data obtained during the review visit, and in subsequent telephone
communications with OTVC personnel, were examined, along with personal observations
made during the visit, and the following evaluation report prepared. Review conclusions
and recommendations for either improving or expanding the existing environmental
management program are presented at the end of this report.
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B. General Facility Information
The Olin E. Teague Veterans' Center (OTVC) is a large general medical and psychiatric
service hospital and resident patient care complex of the Department of Veterans Affairs
(VA). The OTVC complex occupies approximately 184 acres of urban land located in the
southern edge of Temple, Texas. The complex consists of 68 buildings with a total of
almost 1.4 million square feet of floor area. Current resident patient population totals
approximately 640, and hospital employees number about 1,600. Outpatient visits average
about 20,000 per month.
The primary mission of the OTVC includes patients health care, food and lodging, health
care training and research, logistics, and service support for the Center. These OTVC
activities generate or involve handling of domestic wastewaters, hazardous, infectious and
other solid wastes, air pollutants and toxic and hazardous substances subject to the various
environmental laws and regulations administered by the EPA. Domestic and pre-treated
wastewaters are discharged to the local municipal sewers. The Center water supply is
obtained from the City of Temple, and the only treatment provided by OTVC is softening
for boiler water at the steam plant. The Center does have underground storage tanks
(UST), but no longer has a PCB involvement and is not involved in any environmental
restoration activities. Therefore, OTVC does not have a significant involvement with
NPDES, SDWA, CERCLA or TSCA. It does, however, have some involvement with CAA,
RCRA, UST and NEPA. This facility has a pathological incinerator having a State
operating permit, which classifies the OTVC as a Class A source under the State
Implementation Plan and therefore a major air emissions source. It is currently listed as
a RCRA hazardous waste conditionally exempt small quantity generator, maintains a
number of underground fuel storage tanks, and has NEPA activity currently underway.
These activities are discussed further in later parts of this report.
C. Scope of the Review
In the OTVC environmental management program (EMP) review, I surveyed the OTVC
organization VA hierarchy; OTVC environmental program goals, objectives, resources, staff
and training; upper management awareness and support; communication mechanisms and
employee awareness. I also explored the facility's needs, plans and activities in the three
areas of installation or site restoration, environmental compliance (including NEPA
involvement), and pollution prevention, as well as protection or enhancement of natural
resources and use or testing of new or innovative technologies. Findings are presented in
Section II under three main headings; Environmental Management Program (EMP) and
Organization, EMP Resources and Training, and EMP Implementation. Conclusions and
recommendations for improving or expanding the OTVC EMP are given in Section III.
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II. FINDINGS
A. Organization and Environmental Management Program (EMP)
1. Organizational Structure. Agency and OTVC - The OTVC is one of
171 medical centers nationwide under the Department of Veterans Affairs (VA). These
centers are divided between four VA regions, and the OTVC is one of 42 centers in VA
Region 3. The VA is Headquartered in Washington, DC, and the OTVC Director reports
directly to VA Headquarters through the Under Secretary for Health, Veterans Health
Administration. Environmental program guidance and technical assistance is provided to
the medical centers by an Environmental Engineering Division located in an Operations
office under the same Under Secretary. This organization is shown in Appendix I in the
back of this report.
The OTVC hierarchy is the Center Director, Center Associate Director and the Chief of
the Engineering Service. The designated Environmental Coordinator for the Center, and
most of the environmental compliance responsibilities and involved staff are located in the
Engineering Service. However, there is also an Environmental Management Service which
has responsibility for control of medical and solid waste, pest control and recycling. The
Environmental Coordinator is primarily occupied as an industrial hygienist and only spends
a small percent of her tune on environmental matters. She also has two layers of
management between her and the Center Director. OTVC organization charts and
pertinent responsibilities for this hierarchy are also included as report Appendices III and
IV, respectively.
The Center also has a Waste Management Committee to coordinate the Center's Hazardous
Waste Management (HWM) Plan. This Committee is chaired by the Chemist, Pathology
and Laboratory Medicine Service and meets at the call of the Chairperson but not less than
quarterly. Duties of the Committee include 1) review regulations and waste classifications
to determine hazardous classification, 2) review waste handling procedures of all Services,
and 3) review each Service's training to determine effectiveness. Members of the Waste
Management Committee are:
Chief, Environmental Management Service
Chief, Anatomic Pathology Section
Safety and Occupational Health Specialist
Chief, Pharmacy Service or designee
Industrial Hygienist
Associate Chief of Staff for Research and Development or designee
Chief, Acquisition and Materiel Management Service or designee
Radiation Safety Officer
Infection Control Nurse
AFGE Union representative
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The hospital services also have sub committees advising the Waste Management Committee
on their particular areas. The OTVC Hazardous Waste Management Plan includes
guidance for handling and disposal of infectious wastes, waste gases, radioactive waste,
hazardous chemical waste, and antineoplastic (chemotherapy medication) waste. The
OTVC HWM Coordinator is also the designated OTVC Environmental Coordinator.
% 2. EMP Applicability. Basis and Support - The mission, facilities and
varied operations at the OTVC are sufficient to make an EMP applicable to this facility.
Ms. Winfield, Mr. Wilson and Mr. Blodgett initially questioned the need for an EMP, but
after our discussion of the Center's environmental responsibilities, they agreed with this
assessment. Their current "environmental program" is almost totally focused on hazardous
waste and hazardous materials (Hazmat) handling and disposal, with other environmental
areas ah" but ignored. With the exception of documents on HWM, Hazmat management
and emergency and spill procedures, OTVC policy and procedural guidance documents
observed deal primarily with industrial hygiene, health and safety.
Winfield, Wilson and Blodgett said the primary basis for their current environmental activity
is guidance generated locally by the OTVC. Excerpts from this guidance, showing purpose
and responsibility assignments, are included in Appendix III of this report. OTVC guidance
is supplemented by guidance the OTVC receives from VA Headquarters Environmental
Engineering Division regarding environmental compliance and issues, safety and health and
industrial hygiene. The latter guidance, however, is described as limited. Other sources
impacting on their EMP activities include Federal and State regulations, local ordinances,
guidance from the American Hospital Association and other hospital industry organizations
and information on new processes, state-of-the-art equipment, etc.
Two key indicators of agency and upper management support for environmental issues and
management programs are policy directives and funding. OTVC representatives perceive
that upper level (VA Headquarters) support is beginning to improve in the issuance of
policy guidance, but total support for environmental issues is still hindered by an inadequate
budget and staffing. They feel that too little resources are left over for proper
environmental management after their patient care mission is served. Hospitals are not
being given staffing and other resources necessary for a viable EMP. They believe, however,
that more support from Congress (personnel ceilings and money) would result in more EMP
support to the hospitals from the VA. Inadequate EMP support is also reflected at the
Center level, with an inadequate budget and personnel ceiling for an environmental
management staff. Part of the support problem is attributed to the competition for funds
between environmental issues and other facility planning issues.
3. Basic Goals and Objectives of the OTVC EMP - The current
environmental focus at OTVC is on management and/or disposal of hazardous wastes and
materials, spill prevention, emergency response and recyling used materials. The major
emphasis is on personnel safety and health and industrial hygiene rather than compliance
and pollution prevention. With the exception of employee safety and health concerns, the
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OTVC does't appear to have defined environmental program goals and objectives relating
to environmental cleanup and restoration, compliance with regulations and Executive
Orders, risk assessment and adverse environmental impacts, pollution prevention and
protection of natural resources.
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4. Communication to Facility Personnel - Safety, Health, industrial
hygiene and environmental management initiatives at the OTVC are currently conveyed to
facility personnel through OTVC and VA memoranda, OTVC committee and subcommittee
meetings, VA policy statements, Service Hotlines, hazardous and medical waste and
chemicals handling training, accreditation regulations from the Joint Commission on
Accreditation of Healthcare Organizations, regular OTVC briefings on various levels,
Center Partnership Council (with employees union), weekly newsletter and new employee
orientations and annual reviews.
5. Public Information and Community Perception of the QTVC EMP -
The OTVC currently has no organized public relations program on environmental issues,
and staff interviewed say they doubt if the community is aware whether they have an EMP
or not. The Center has apparently been perceived by the community as doing well
environmentally, probably due to a history lacking in apparent environmental problems.
Little, if any public perception of their EMP has been vocalized or presented in the local
news media.
6. NEPA Involvement - OTVC recently had a NEPA involvement in
connection with a new hospital wing for which construction is to begin in 1995. An
Environmental Assessment was conducted and a Finding of No Significant Impact issued.
B. Resources and Training
1. Environmental Staffing - There is currently no one assigned full time
to environmental management program at the OTVC. Even the designated Environmental
Coordinator, Myra Winfield, spends most of her time at the duties of an industrial hygienist
and only about ten percent with environmental management activities. In addition to her
OTVC responsibilities, she also has the same responsibilities for the Marlin, Texas Hospital.
There are other personnel, located in the various hospital services, who are also involved
part time with hazardous wastes and materials handling in their respective services and the
training required. There are really no centralized environmental management responsibility
or sufficient dedicated resources to carry out a viable EMP at the OTVC.
2. Staff Training - The OTVC representatives report that staff
development training opportunities are available but are mostly off-site. Environmental
training also has to compete with other mission-oriented training for limited travel funds.
Opportunities availabe include annual safety conferences at the regional level, ongoing
health and safety training, and some environmental training, at the Little Rock, AR
Engineering Training Center, EPA annual conferences, annual refresher training on
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handling of hazardous wastes and materials, initial orientation of new employees, and
annual refresher training given by the various hospital services that touch on environmental
areas. This training is only minimally adequate for management of a viable environmental
program.
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3. Facilities and Equipment - Housing, space and data management, other
office, laboratory and vehicular equipment needed for an environmental program currently
and in the near future appear to be available at the OTVC. These areas would have to be
reassessed after centralizing the environmental management responsibilities and necessary
resources.
4. Funding Resources - The OTVC does not designate funds specifically
for environmental management activities, but funds for such activities conducted come
primarily out of the budgets for the Engineering and Environmental Management Services.
Except for dedicated staff salaries and travel funds for training, funds for current activities
have generally been adequate. The OTVC Director does have authority to delegate
monetary resources and personnel to the area of environmental management, but these
resources must compete with the higher priority patient care mission. OTVC
representatives report that annual VA Headquarters' budgets also have not adequately
addressed environmental program needs.
5. Staff Performance Evaluation - The Environmental Coordinator, Ms.
Winfield, does not have performance standards by which to evaluate her performance
relative to environmental management. The exact basis of her performance evaluation
appears unclear. This situation likely exists for other staff personnel engaged in related
environmental activities, at least as far as those activities are concerned. In light of the lack
of a designated environmental staff, staff turnover has obviously not been a problem at the
OTVC. The main environmental staff problem at OTVC appears to be the lack of staff.
C. Environmental Management Program (EMP) Implementation
1. Knowledge of Executive Orders. OMB Circulars - None of the OTVC
staff appear to have a working knowledge of and familiarity with Presidential Executive
Order 12088 concerning Federal facilities compliance with environmental laws and
regulations and with Office of Management and Budget (OMB) Circulars A-ll and A-106.
Circular A-ll is the OMB guidance for preparing and submitting annual budgets, and
Circular A-106 is the implementing document for fulfilling the intent of Executive Order
12088. They did demonstrate a better awareness and knowledge of Executive Order 12856
regarding pollution prevention, toxic chemical and waste reporting, and emergency planning
requirements under the Pollution Prevention Act of 1990 and the Emergency Planning and
Community Right-to-Know Act of 1986. Their awareness of EO 12856 was apparently
obtained from information received through agency guidance and recent EPA conferences
and workshops.
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2. Use of the A-106 Process to Address Needs - OTVC apparently has
not been a ready participant in this comprehensive process for identifying environmental
needs and obtaining resources to implement solutions. In the A-106 process, the
Environmental Coordinator prepares required VA documentation for A-106 projects to
meet identified needs. This documentation is forwarded through the OTVC management
and agency ckain to VA Headquarters for agency review, project prioritization and inclusion
in the agency A-106 Plan. The agency Plan is forwarded to EPA for review, evaluation and
priority recommendation to OMB for inclusion in the President's budget request.
The OTVC Environmental Coordinator has been preparing some project documentation,
but had not made the connection with the A-106 process. A-106 funding has been received
in recent years for some asbestos and UST removal projects, and all currently identified
needs at OTVC are apparently covered by projects in the agency A-106 Plan. Asbestos and
UST projects funding received, however, may have been in response to actual or potential
hazardous conditions or enforcement actions and may not necessarily demonstrate a high
priority for environmental issues.
3. Knowledge of Environmental Laws. Regulations and Regulators - The
Environmental Coordinator demonstrates a fair knowledge of environmental laws and
regulations applicable to the OTVC. She admits the need for additional training.
Comprehensive knowledge of requirements specific to OTVC (permits, reporting
requirements, monitoring, registration, etc.) is limited among the balance of the OTVC staff.
Those with a need to know are periodically advised through agency orders, OTVC memos
and instructions, staff briefings, the OTVC newsletter and training opportunities. Ms.
Winfield says she is knowledgeable of the Texas Natural Resource Conservation
Commission organization, but admits to a limited knowledge of EPA, at both the regional
and national levels. She asked for us to send her information to help her know where to
go in EPA for assistance with environmental laws and regulations.
4. Environmental Auditing and Self-Monitoring - The OTVC does not
have an audit or self-monitoring program in place, according to Ms. Winfield and Mr.
Wilson. They informed me that VA Headquarters is setting up an audit program to include
both internal and external audits. They said the agency audit program guidance is expected
to emphasize the need for frequent and regular audits at VA facilities.
5. Identification and Correction of Violations - The OTVC depends
largely on its operating staff and/or the Safety Committee to identify environmental
problems, potential problems or violations. That Committee normally assigns
responsibilities for response actions, depending on the types of actions required. If the
problem or violation concerns hazardous waste (HW) or hazardous materials (HM)
handling, the Environmental Coordinator usually initiates the correction. Corrective actions
involving construction, or in areas outside HW and HM management, usually go through
the Engineering Service. The OTVC Safety Committee follows up on health and safety
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problems. Problems/violations cited by regulatory agencies would normally receive higher
priority for correction than those identified internally. Time taken for correction depends
on urgency of the correction and sometimes requires interim emergency action.
The OTVC-Memorandum for Emergency and Spill Procedures indicates emergency
response to hazardous materials spills or other releases will be handled by OTVC personnel,
and Ms. Winfield is the designated Spill Control Coordinator. However, she and Mr.
Wilson stated that the OTVC does not have on-site emergency response capability and
relies on local emergency agencies for assistance. Required reports to either local, State
or Federal agencies are filed by the Spill Control Coordinator.
6. Tracking Compliance, Permits, Reporting Requirements - The OTVC
has no apparent formal system for logging permit requirements and to keep track of due
dates for reports required. There is also no formal system currently to track violations,
enforcement actions and follow up actions.
7. Reported Compliance Status. Open Enforcement Actions - As
previously stated, this facility has monitoring and regulatory involvements with several
environmental statutes, including CAA, RCRA, UST and NEPA. The recent Presidential
Executive Order 12856 also will place additional requirements on the Center to comply with
all provisions of the Emergency Planning and Community Right-to-Know Act (EPCRA) and
the Pollution Prevention Act (PPA) in connection with the control of releases and emissions
from toxic and hazardous chemicals. OTVC appears to be complying currently with CAA,
RCRA, UST and NEPA requirements, and is taking steps to meet the EPCRA and PPA
requirements, for which compliance benchmark deadlines began coming due in December
1993. No open enforcement actions were identified.
8. Environmental Restoration - OTVC has no CERCLA sites on the
National Priority List (NPL) and, as a RCRA generator only, is not required to have a
RCRA permit. No potential hazardous waste sites have been identified by OTVC that
would require cleanup or other restoration action under CERCLA.
9. Pollution Prevention. Waste Reduction - Current pollution prevention
or waste reduction activities at OTVC are limited to recycling of office paper, corrugated
and other paper boxes and products, aluminum, plastic and glass. Guidance for this
program is included in OTVC Memorandum No. 137-9. OTVC personnel report that not
much is being done by the VA in the way of waste minimization or product substitution,
either at the OTVC or in the agency. Some chemical substitutions, such as cleaning agents,
have been done primarily for safety reasons. A hospital accreditation group, the College
of American Pathology, also requires the hospital labs to have a waste minization program.
OTVC has not been involved in the EPA's voluntary "33/50" Program to reduce releases of
17 priority chemicals by 33% by 1993 and 50% by 1995. However, as stated in paragraph
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C.I. above, OTVC is now required by Executive Order 12856 to seek to reduce by 50%
their emissions of toxic chemicals or pollutants by 1999, as well as comply with all
requirements of the Pollution Prevention Act. These requirements will likely necessitate
a more aggressive pollution prevention/waste reduction program at OTVC.
10. Protection of Natural and Cultural Resources - OTVC personnel report
that the only^work being done at OTVC in the areas of protection of endangered species,
wetlands, natural or cultural resources, or mitigation bank activities is that which may be
connected with NEPA activities when planning major changes or additions to OTVC
facilities and/or operations.
11. Applications of New and/or Innovative Technologies - No new and/or
innovative technologies are being tested, implemented or currently planned at the OTVC,
according to OTVC personnel questioned.
III. CONCLUSIONS AND RECOMMENDATIONS
A. Environmental Management Program (EMP) And Organization
1. Conclusions - Our observations indicate that the OTVC currently does
not have a true Environmental Management Program (EMP), and a well-defined and
empowered EMP is desirable for this facility. The OTVC mission, operations and facilities
necessitate an EMP focused on environmental compliance, pollution prevention, cleanup
and restoration, risk assessment, adverse environmental impacts and protection of natural
resources. Personnel health, safety and industrial hygiene issues are related but are not
necessarily a part of an EMP. Communication among OTVC staff appears to be good,
although lacking in some environmental management areas. It appears also that some
changes in the OTVC organization and priorities would further help the EMP to meet
facility needs, be better defined and supported at all management levels, and widen the
scope of communications on environmental matters among all interested and responsible
parties.
It also appears that funding, a key indicator of agency support for environmental issues and
management programs, is missing both at the facility and Headquarters levels. Support
from the VA Headquarters Environmental Engineering Division has been improving in the
matter of agency policy directives and technical guidance, but because they must compete
with funds for the patient care mission, funding allocations for environmental management
personnel and programs are inadequate. This results in the medical centers not being given
staffing and other resources necessary for a viable EMP and having to utilize staff with
other responsibilities and priorities to provide token attention to environmental issues.
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2. Recommendations
a. Consider organization changes at OTVC level to separate
coordination of environmental matters from health, safety and industrial hygiene and
medical matters. We suggest that environmental coordination responsibility be placed with,
and appropriate funding be provided for, a full-time Environmental Coordinator who may
or may not* need other full-time staff to carry out an appropriate EMP. These
responsibilities would include coordination of all Center activities to comply with
environmental legislation and executive orders administered by the EPA. They would
include some responsibilities now located in the Engineering Service, as well as recycling
and solid waste management responsibility now located in the Environmental Management
Service. These changes would demonstrate a higher priority for environmental issues,
reduce competition between environmental and other facility planning issues for budget
dollars, facilitate expansion of the total EMP to meet OTVC needs and increase facility-
wide environmental awareness and support. The Coordinator's "Environmental
Coordination Office" can be located in either the Engineering Service or the Environmental
Management Service, but placing it in the'former would appear to require less relocation
of responsibilities.
b. VA Headquarters should review the priority and resultant
guidance and support being given to environmental matters at their field installations and
make necessary adjustments in organization, responsibility assignments and/or budgeting to
correct real or perceived shortcomings described above. This would also ensure that the
agency is giving environmental matters the priority mandated in Executive Order 12088 and
the various environmental laws.
c. Expand the scope of the Waste Management Committee (may
want to change the name, too) to go beyond hazardous waste management and make it a
focal point for addressing and resolution of all environmental compliance issues, increasing
employee environmental awareness through information dissemination, and coordinating
environmental, health and safety related compliance.
d. Consider the development of an OTVC strategic plan for
environmental, safety and health compliance, through the Committee recommended in 2c.
Such a plan would consolidate guidance currently contained in the various Center
memorandums, with revisions necessitated by the reorganization of the environmental
coordination responsibility suggested in 2a. It should also contain a formal statement of the
goals and objectives of the OTVC EMP and address all areas of environmental concern and
roles of all OTVC services and programs. Total effectiveness of the OTVC EMP will
depend on cooperation by all parties contributing to waste and other pollutant discharges
and emissions at the Center.
- 10-
-------
e. Continue overall communication on environmental matters at
OTVC by ensuring that basic environmental awareness training is available and mandatory
for all OTVC employees. Recommendations on specialized training for certain employees
are included below under "EMP RESOURCES AND TRAINING".
f. Institute a public relations program to keep the local community
waic of OTxVC environmental activities, plans and issues. Such a program is necessary for
complete environmental communications program for the OTVC.
aware
B. EMP Resources and Training
1. Conclusions - Our observations and reviews of information received on
environmental management resources and training lead us to conclude that there is a need
for additional dedicated personnel and monetary resources to meet current and anticipated
OTVC needs to keep up and comply with the growing number of environmental laws,
regulations and executive orders. Current part-time staff and monetary resources applied
to environmental compliance are too little to manage an effective EMP and maintain a
proactive approach to potential environmental problems. Their primary responsibilities
compete for their time and normally are given higher priority. Current facilities, equipment
and space appear adequate to meet current projected and anticipated future program needs.
Some aditional technical and environmental awareness training may be needed for the
Environmental Coordinator and part-time staff assisting the Coordinator, particularly in the
areas of multi-media compliance, toxic substances inventory, reporting and emergency
release response, pollution prevention, waste reduction, risk assessment, adverse
environmental impacts and natural resources protection. Identified personnel and training
needs will reqire increased funding for the EMP.
2. Recommendations
a. Provide a full-time Environmental Coordinator to oversee the
Center EMP. Additional technician-type assistance may also be required to carry out a
propoer EMP, especially if the Coordinator is to be responsible also for the Marlin
Hospital. If readily available, technician-type assistance to the Coordinator may be provided
from other Center offices or programs. However, if current work load prevents this sharing
of personnel resources, consider adding at least one full-time technician to assist the
Coordinator and preclude the use of "leaner" personnel part-time.
b. Include management indicators in the performance standards
for the Environmental Coordinator.
- 11-
-------
c. Assess all current environmental management training for
Center personnel, especially training for hazardous waste and material handling and spill
response, and expand as necessary to ensure all appropriate Center personnel are included.
Provide refresher training as necessary to maintain competence.
d. Increase EMP funding to cover the recommended additional
resources, as*well as any needed environmental projects identified by the EMP. Funds for
recurring operations-type activities should be reflected in the VA O&M budget.
C. EMP Implementation
1. Conclusions - Since there is currently no real EMP at the OTVC, it is
difficult to evaluate implementation of any EMP elements present. Some elements of a
good EMP have been implemented, but other elements were found to be either non-existent
or only minimally implemented. Basic environmental awareness and capability of staff
personnel currently involved in environmental matters is lacking in some environmental
areas, and the current program in place to maintain a level of staff competence and
knowledge needs to be expanded (see the recommendation in B.2.c above). Environmental
awareness of upper management also could be unproved, as could that of the general
OTVC employee. Goals and objectives need to be set for an appropriate EMP, and
dedicated environmental staff, other resources, training, communication mechanisms and
EMP support improved where necessary to properly implement it.
Procedures for identifying and correcting violations and tracking compliance and reporting
requirements at the Center also need improvement, and a good environmental auditing
program put into place by the VA. Reported compliance with environmental laws and
regulations and NEPA compliance also appear to be in good shape at OTVC. Although
no clean up or environmental restoration needs have been identified, a further look into this
environmental area, at possible former spill and/or disposal sites, may be in order to confirm
that no needs exist. Some pollution prevention and waste reduction activities have been
begun, but additional pollution prevention opportunities, as well as new or innovative
technologies application opportunities may also exist.
2. Recommendations - Recommendations for increasing environmental
staff, other EMP resources, technical training and EMP support are included under III.B.2.
above. Other recommendations for general employee awareness training and public
information communications are included above under III.A.2. Recommendations relative
to other needs mentioned above in this Section are as follows:
a. Continue agency plans already under way to implement an
effective environmental auditing program, either internal or external audits or a combination
of both.
- 12-
-------
b. Conduct an assessment of all OTVC operations to identify
additional pollution prevention and waste elimination or reduction opportunities. These
opportunities may be crucial to toxic chemical and pollutant reductions required by
Executive Order 12856. In consideration of potential funds limitations in the future,
additional action on these opportunities can be on an as-needed or as-desired basis.
* c. Assess OTVC operations also for potential opportunities for
applying or testing of innovative technologies which may have current or future application
to OTVC or other VA facilities and operations.
- 13-
-------
APPENDICES
I. VA Organization Charts
*
A. Department of Veterans Affairs, Headquarters
%
B. Under Sec. for Health, Veterans Health Administration
C. ACMD for Operations, Envir. Engineering Division
II. Olin E. Teague Veterans Center Organization Charts
A. Center Organization
B. Engineering Service Organization
III. OTVC Memoranda
A. Recycling Program
B. Hazardous Material Management Program
C. Safety, Occupational Health and Fire Protection, Rules and Regulations
D. Hazardous Waste Management Plan
E. Environmental Sampling and the Industrial Hygiene Program
F. Emergency and Spill Procedures
IV. Acronyms Used in the Report
- 14-
-------
Department of Veterans Affairs
Inspector General
Chairman,
Board ol Contract Appeals
Director,
Office of Small and Dlsadvantaged
Business Utilization
_L
Assistant Secretary
lor Finance and Information |
Resources Management
Deputy Assistant
Secretary lor Budget
Deputy Assistant
Secretary for Financial
Management
Deputy Assistant
Secretary for Information
Resources Management
Secretary
Deputy Secretary
Under Secretary for Health,
Veterans Health Administration
171 Medical Centers
General Counsel
Chairman.
Board ol Veterans' Appeals
Speclal-Asslslanl to the Secretary
lor Veterans Service Organizations
Liaison
Under Secretary lor Benefits,
Veterans Benefits Administration
. SB Regional Ollices
Director,
National Cemetery System
114 National Cemeteries
-L
Assistant Secretary
lor Policy and
Planning
Aaslslanl Secretary
lor Human Resourcea
and Administration
Assistant Secretary
for Public and
Intergovernmental Affairs
_L
Assistant Secretary
tor Acquisition
and Facilities
Deputy Assistant
Secretary tor Policy
r
Deputy Assistant 1
Secretary lor Planning 1
Director,
National Center lor Veteran
Analysis and Statistics
V
Deputy Assistant I
Secretary lor Equal 1
Opportunity 1
Deputy Assistant I
Secretary lor Human I-
Resources Management 1
Deputy Asslslsnl 1
Secretary lor 1 J
Administration 1
Deputy Asslslsnl
Secretary lor
Public Attain
Deputy Assistant 1
Secretary lor 1
Intergovernmental Attain!
L
_L
Assistant Secretary
for Congressional
Affairs
Deputy Assistant
Secretary for
Acquisition and Material |
Management
Deputy Assistant
Secretary lor Security
and Law Enforcement
Director,
Veterans
Canteen Service
J
}
Deputy Assistant
Secretary lor
Congressional Liaison
Deputy Assistant
Secretary tor
Legislative Allaire
-------
ORGANIZATIONAL CHART 2: VHA OSH RESPONSIBILITIES
(CHAPTER 2, SECTION 6)
Under Secretary for Health (10)
VHAOSH
Official
ACMO lor
Quality
Management
416)
ACMO
ConttMction
Manafement I08f
JCA
TOli
Managing
VHAOSH
Program
ACMD
for Operations 1131
Office of Program
IftenagflmeiH (081
L
VHAOSH
Patten
Safety
1
ACMO far Ctinotol
Director*
(131-134)
s
hd
O
H
X
H
Resident tnglneer*
Facility Responslblltles
Employee Health
Radiation Safety Olltcor
Inlaotlon Control Officer
Chief, Human Resources Management
Chief, Acquisition and Materiel Monngomnnt
Chief, Engineering Service
Chlof, Environmental Management Servian
Sfto
PEป/
raH.
FaoRlty
DfreclBrc
I
Olractor
OlS
II11AI
nCo
InfectlonControl
Attoclclfl
Dfrectort
FซcMyOSN
CamaiHKa
Facility Safety
and Haalth
Oflteert
Engineering Management
and Fletd SuppoH (138)
DABHO
Ua4aon (13IC6)
-------
Environmental Engineering
Division (138C4)
22-J
I
I "^
PM4
(13BC8)
5
TJ
W
Z
D
H
X
o
John G. Staudt, P.E.
Chief
(202) 233-7197
Rita Pittlllo
Industrial Hygienist
DASHO Liaison
(202) 233-7220
John Kordalski, P.E.
Environmental Enginer
(202) 233-3729
Environmental
Engineering Division Do?
Manages VACO environmental
technology and compliance program.
Reviews environmental issues facing
VA.
Develops policy and program guidance.
Provides technical assistance to the
Regions and VAMCs.
Liaisons with EPA and other federal
agencies on environmental issues.
Interacts with DASHO, EMS, A&MM,
OGC, NCS and others.
VHA program manager for Regional
Industrial Hygiene programs.
VACO contact for VAMCs on
environmental issues.
-------
ORGANIZATION CHART
OLIN E. TEAGUE VETERANS' CENTER, TEMPLE, TEXAS
DIRECTOR
ASSOCIATE DIRECTOR
ง
M
a
a
H
x
H
_L
PROSTHETIC i
SENSORY AIDS
SERVICE
\
ITION 1
EL MOT
VICE
1
CANTEEN
SERVICE
CHAPLAIN
SERVICE
1 1
PETtC
VICE
1
NMENTAL
3EMENT
WICE
DOMICILIARY
OPERATIONS
1
FISCAL
SERVICE
1 1
VL ADMIN
WICE
PERSONNEL
SERVICE
ENGINEERING
SERVICE
INFO RESOURCES
MOT SERVICE
PHARMACY
SERVICE
VOLUNTARY
SERVICE
ACOS/AMBULATORY
CARE
ACOS/EXTENDED
CARE
ACO8/RE3EARCH 4
DEVELOPMENT
ACOS
/EDUCATION
ALLIED HEALTH
EDUCATION
LIBRARY
SERVICE
MEDICAL MEDIA
PRODUCTION
AUDIOLOQY/SPEECH
PATHOLOGY
MEDICAL
SERVICE
PSYCHIATRY
SERVICE
RECREATION
THERAPY
SERVICE
SOCIAL WORK
SERVICE
CHIEF OF STAFF
DENTAL
SERVICE
NUCLEAR MEDICINE
SERVICE
PSYCHOLOGY
SERVICE
REHABILITATION
MEDICINE SERVICE
SURGICAL
SERVICE
LABORATORY
SERVICE
NURSING
SERVICE
RADIOLOGY
SERVICE
8OPC-AUSTIN
/, /
SEPTEMBER 10. 1192
APPROVED:
-------
QB8UUZATIOIM. CHART
BtGIHEERHlS SgyiCE
01 in E. league Veteran*' Center
teaple. Teas 7K04
OH-ICE OF IE UUEF
1 Chief
1 Asst Qiief
1 Secretary/Steno
1 Attainting Tedi/Typing
4708
4694
4812
GS-801-14
GS-801-13
6S-31B-06
65-525-05
1.0
1.0
1.0
1.0
1 Chief
1 Engin Tecft
1
1
1
1
I
1
I
DESIGN SEOTOH
4997
5157
Constractton Inspector 4968
Interior Designer 5889
Progran Asst/Typing 4879
Architect 5075
Adiitect 5840
General Eogin 6097
Progran Clerk (OA) 5148
GS-SQS-13
GS-8Q2-OS
GS-30S-07
GS-1008-10
GS-303-06
ss-aos-ii
GS-801-U
GS-303-Q4*"
rCanpletion of Bed Replacement
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
1.0
'Pro jectj (Term Appt/HTE 2/21/96)
OPERAnOHS SECTIOH
1 Chief 4315 VS-4701-L3 1.0
1 Engineering TedJ 4710 GS^02-06 1.0
1 A/C Emrtp Opcr Fran 5713 W-5U5-09 1.0
5 A/C Equip Oper 4Z98A NC-5415-1I 5.0
4 A/C Equip (teen SIZ7A U6-5306-10 4.0
5 Blr Plant Qpor 4095A WG-540^U 5.0
1 Blr P!*nt Oper Fran 3956 US-540Z-09 1.0
1 Maint/Qpe Fnn 929 US-4701-08 1.0
1 Eng &nrip Oper 4702 W-571&-08 1.0
3 Tractor Oper 4103A NE^705-06 3.0
3 Gardener 4I10A W-aX)3-06 3.0
1 Gardener 5*17 K-5003-04 1.0
I fetor Yell Oper S370A K-5703MJ6 Z.O
I tetor Yrt Oper 4S19A U&4703^5 2.0
1 Hater Yeh Oper SB37 W6-5703-06 ^
1 Gardener 6720 V5-SKQ-07 1.0
* (Tegp prontiofi NTE 11/94)
Full Tfoe I
Part Tiae .....
Total tatn {
9.0
1.0
KJ.S
SAFETT ARD IRSPECTTOU SECilUB '
1 Safety Specialist 4827 GS^n8-U l.C
1 Safety Specialist 6105 GS-018-07 1.0
1 Industrial Bygienlst 6009 6S-ฎ0-12 1.0
BIOHEOICAL EQUIPMEVT REPAIR SECTIOH
1 Supv 5itBEd Eng
1 Supv Bfcaed ฃ09 Teen
2 Blaaedical Eng Tecb
2 Bionedical Eng Teen
1 Btaedical Eng Tecs
2 nectrmric Tceft
2 Electronic Teen
6142 6S-S58-I2
4313 GS-S02.11
6T19A GS-802-10
5S68A GS-8B-Q9
5077 GS-802-10
449GA GS-K6-09
8107A GS-ffiS-10
l.C
1.C
2.C
2.C
l.C
2*C
2.C
1 Chief
1 Engineering Tech
1 Kaint Controller
1 (taint (ten Fran
1 Plaster
I Painter LOT
4 Painter
2 Pipe Pitta*
2 Pinter
1 Naint ten Fran
4 Electrician
2 Industrial Equip
1 AatoHftdl
3 Kaint Mecn
3 Kaint Been
Kanager 5353
4902
4105
4130
Necb
SECTION
5131 65-801-12 l.C
5909 GS-802-OS l.C
6S-1601-07 i.C
HS-4749-10 1.C
M6-3605-09 l.C
__ H.-4102-Ofl 1^
4121A iG-4102mB 4.C
4059A HG-4204-10 2.C
SS32A K-420M9 2-C
5320A H6-4607ซQ9 2.C
5620 (C-4607-001.
4801 HS-4749-10 1.
4222A W-2S05-10 4.
4I23A yC-5352-10 2.
4115 K&-5B23-10 I.
S60SA ME-4749-10 3J
600SA VC-4749-09 3.C
REOMOD APPBOVAU
RECOMEED APPROVAL:
APPROVED:
RAB3ALL J. BUibfcU'
Cnief, Engineering Service
Resonrce CoBilttBe
Oirector
QrtBS NOV I 8 1993
JBRTB.'
Director
on*:
HOV1S1393
APPENDIX II.B
-------
--
DEPARTMENT OF VETERANS AFFAIRS
Olin E. Teague Veterans' Center MA
Temple, Texas 76504 U, l\ 10 ^ ^
MEMORANDUM
HO. 137-9' Mav 28, 1991
RECYCLING PROGRAM
-2ffi-S-^^^^
-^Tor:^
participate in recycling efforts. Recycling will reduce energy usage? tne
amount o waste going to our landfills, save natural resources such as trees
reduce the consumption of important minerals used in producing plastics a^in,-
and glass, and lead to reduction in our disposal costs. Olin E Teague Veter-n".
Center encourages recycling and promoting responsible management of w!ste
through education and direct action. waste
3. DEFINITIONS:
-To treat
ปt.ri.ls. making them
b. Recyclable-Materials such as, but not limited to, bond paper, computer
paper, cardboard, aluminum, plastic, glass, etc., containing properties that
allow them ro be processed for reuse.
4. RESPONSIBILITY;
a. A successful recycling program requires the support and assistance
of all staff.
b. The Recycling Committee is comprised of representatives from Acquisition
and Materiel Management, Engineering, and Building Management Services (BMS) Th*
Committee is responsible for establishing procedures, monitoring center recycling
efforts, and recommending changes in the program.
c. The BMS representative is the Recycling Program Coordinator with responsi
bility for coordinating center-wide recycling efforts.
d. Service chiefs will designate an interested individual to serve as
a service coordinator for this program. Service coordinators will be responsible
for developing program support at service meetings, channeling new ideas to
the Recycling Committee, and reporting any problems with center recycling
efforts.
e. BMS will ensure that appropriately labeled containers will be provided
for use in our collection effort. Collection of paper will include typing paper
and computer paper (mixed together is alright) at the site of generation. BMS
will coordinate the collection of full containers of recyclable material and
transfer to appropriate storage area.
APPENDIX III.A
-------
f. Services and sections generating waste cardboard will be responsible
for breaking down boxes (flattening them) so they can be transported easily
and stacked in the least amount of space practical. Staples do not have to
be removed from cardboard boxes.
\ " '
5. PROCEDURE:
a.- Specific procedures for collection of recyclables in each service
will be established by the service coordinator and the Recycling Committee.
b When individual service efforts involve significant levels of a recyclr
material that is relative to^Katr~se'rvi-ce~oh-ly ~ a -service-level -staridard_operat:
procedure (SOP) will be (prepared outlining collection procedures.
6. REFERENCE; None.
7. RESCISSION; None.
p j
\J3
-------
DEPARTMENT OF VETERANS AFFAIRS
01 in E. Teague Veterans' Center
MEMORANDUM
NO. 138-4 October 5, 1992
HAZARDOUS MATERIAL MANAGEMENT PROGRAM
1. PURPOSE: To establish a program for educating employees in the hazards
associated with chemicals and other hazardous materials used throughout the
Center; to collect data on chemicals used in the Center; to assist in proper
selection and safe handling, storage, and use of hazardous materials; and to
assign responsibility for hazardous material management at this Center.
2. POLICY: To contribute a safe and healthful work place for all employees by
ensuring every reasonable precaution against accidental exposure to toxic
substcinu."., or hazardous chemicals. A master file of material safety data sheets
(MSDS) will be maintained in the safety office. A file of the applicable MSDS
will be maintained in the immediate work area of those hazardous materials
utili/ed. This program incorporates the objectives of OSHA Standard 1910.1200,
Haz.ird Conmiunication, and VA Directive 00-86-21, Hazardous Chemicals.
3. RESPONSIBILITY:
a. The Industrial Hygienist is designated as the Hazardous Material Officer
and will be responsible for establishing, implementing, and administering the
Hazardous Material Program. The Hazardous Material Officer will be the
techn-ical advisor on matters relating to any hazardous material and has been
granted the authority to make a decision on the disposition of hazardous
material received without an MSDS.
b. The Industrial Hygienist is responsible for the day-to-day compliance
with this program. This will be accomplished through visual observation,
interviews, and review of records.
c. Service chiefs are responsible for hazardous material management
(including any research, record keeping, etc.) within their service. They will
appoint, in writing, a service-level hazardous material coordinator and
alternate, provide the Safety/Industrial Hygienist Office with a copy of the
letters of appointment, and ensure appointees receive training provided by the
Safety/Industrial Hygienist Office.
d. Service-level coordinators are responsible for all tasks involving
hazardous materials within the service.
4. PROCEDURE;
a. The Safety/Industrial Hygienist Office will provide and document
training of service-level coordinators to enable them to fulfill their
responsibilities as assigned in this memorandum.
APPENDIX III.B
-------
b. The service-level coordinators will:
(1) Train all personnel in the safe use, handling, end storage of hazardous
materials. Training will include deta::s of CSHA.Stann.ird 1910.1200,
such as: physical and health hazards, proper jse of p .rsonal protective
equ Dment, physical detection methods of hazardous chemicals (e.g., odors,
visibility, etc.), emergency procedures in case of accidental overexposure,
method to determine hazards by reading labels and location and use of MSDS.
Personnel will be trained at the time of initial assignment and .whenever a new
product is introduced into the work area, and training will be updated annually.
Documentation of this training will be kept on file in the individual service
with a copy forwarded to the Safety/Industrial Hygienist Office for the master
file. ...
(2) Ensure that MSDS are located in the immediate work area and are easily
identifiable (in a book or folder marked Material Safety Data Sheets or MSDS in
large bright letters) and readily accessible.
(3) Ensure all containers are properly labeled as to content and hazards.
(Include containers of small amounts transferred from bulk containers.)
(4) At the beginning of each fiscal year:
(a) Compile? a complete list/inventory of chemicals and other hazardous
rn.iLcr-i.il1.. I isi. amounts on hand .uul estimate annual usage. Keep one copy
within the service and furnish a copy to the Safety/Industrial Hygienist Office.
(b) Remove any chemicals that are obsolete or no longer needed and turn
them over to the Industrial Hygienist for disposal.
(c) Go through the MSDS folder and remove obsolete MSDS. Maintain a
separate file of the obsolete MSDS.
c. Services will ensure all appropriate IFCAP transactions contain the
words "HAZARDOUS: MATERIAL SAFETY DATA SHEET REQUIRED." The services must
obtain the MSDS for each hazardous material it purchases before the material is
used.
d. The Purchasing Agent will place "HAZARDOUS: MATERIAL SAFETY DATA SHEET
REQUIRED" in bold letters in the description of each line item of the purchase
order when a material is identified as hazardous.
e. Acquisition and Materiel Management Service (A&MMS) will deliver
hazardous materials to the using service only if a MSDS has been obtained from
the supplier. If adequate MSDS is not supplied as required, the Chief, A&MMS
must immediately notify the Industrial Hygienist. The Industrial Hygienist must
either grant an exception allowing the hazardous material(s) to be moved to the
requesting individuals for proper storage or recommend to the Chief, A&MMS that
the material(s) be rejected and returned to the vendor. When granting an
exception, the Industrial Hygienist shall notify the union, the contracting
officer, and the employees affected. The contracting officer is responsible for
-------
contacting the supplier within 72 hours after an exception is granted to obtain
the MSDS. On a quarterly basis, the Industrial Hygienist shall submit a list of
exceptions that were granted through the Director to the Regional Director.
This list will' include the name of the material, its purchase order number, date
of purchase, quantity, vendor, and the name and phone number of the contracting
officer. \
5. REFERENCE:
Aucjust
1985.
G, 1987;
Accreditation
OSHA Standard
Manual for Hospitals, 1992; VA Directive 00-86-21
1910.1200, November 25, 1983; and 29 CFR 1960,
6. RESCISSION: Memorandum 138-4, 1990.
JERRYl'B. BOYD
Director
Distribution B and E
-------
DEPARTMENT OF VETERANS AFFAIRS
Olin E. Teague Veterans' Center
MEMORANDUM* June 2, 1993
NO. 138-5
\
SAFETY. OCCUPATIONAL HEALTH. AND FIRE PROTECTION
RULES AND REGULATIONS
l. PURPOSE: To establish policy, responsibility, and procedure
for a health, safety, and fire protection program at this Center.
2. POLICY: To prevent accidents and injuries, including
occupational disease, to persons under Department of Veterans
Affairs (VA) control and for the protection of VA property against
loss by fire or other accidental damage.
3. RESPONSIBILITY:
a. The Chief, Engineering Service is assigned staff
responsibility for the safety and fire protection program to
assure safety of hospital, nursing care center, and Domiciliary
patients, beneficiaries, visitors, employees, and for the
protection of VA property. Each service chief, supervisor, and
employee must be constantly observant for hazards or potential
hazards.
b. The Safety and Occupational Health Specialist is
responsible for conducting training sessions; obtaining training
aids; coordinating and conducting fire and safety inspections;
fire drills; assisting management in a determined effort to detect
and meet Occupational Safety and Health Administration (OSHA) , VA,
National Fire Protection Association (NFPA),. and Joint Commission
on Accreditation of Healthcare Organizations (JCAHO) safety and
fire protection standards; paperwork management of the fire and
safety program; etc.
c. Each service is responsible for the development of a
Service Safety Plan. The plan must be submitted annually to the
Safety Committee for approval in accordance with the schedule as
set forth by Attachment B. The plan must include, at a minimum, a
:cifety training program; training program on equipment related to
patient care; service safety inspection program; incident
ireporting; and safety policies and procedures inherent for each
service:
4. PROCEDURE: The attached contents outline procedures and work
rtvstl.ods regarding major program elements.
5. REFERENCES: VHS&RA Supplement, MP-3, Part III; VHS&RA
Supplement, MP-l, Chapter 2, Section B; OSHA Regulations; NCRP
Report No. 33; NFPA-101, 1991; and Accreditation Manual for
Hospitals, 1993, JCAHO, Chicago, Illinois.
APPENDIX III.C
-------
6. RESCISSION:
through 3 .
Memorandum No. 138-5, 1990, and Supplements 1
EDWIN A. SAMMER, M.D
Chief of Staff
Attachments: 4
Distribution B and E
-------
DEPARTMENT OF VETERANS AFFAIRS
Olin E. Teague Veterans' Center
MEMORANDUM May 19, 1994
NO. 138-8
HAZARDOUS WASTE MANAGEMENT PLAN
1. PURPOSE: To establish policy, responsibility, and procedure to
establish, implement, monitor, and document evidence of an ongoing
program for the management of hazardous wastes.
2. POLICY:
a. To ensure there is minimal risk to patients, personnel,
visitors, and the community environment by waste created within the
confines of the Olin E. Teague Veterans' Center and its facilities,
including the Austin Satellite Outpatient Clinic (SOPC).
b. To develop a systom that addresses the identification,
handling, storing, using, and disposing of hazardous wastes and
materials from the point of entry into the Center, through use and
hazardous waste, from generation to final disposal (cradle to
grave).
c. To develop a system for safely managing hazardous wastes
after identification.
d. To ensure the policies and procedures related to the
various hazardous wastes are reviewed, revised, and approved, at
least annually, by the appropriate committee(s).
e. To enhance adequate supervision of Center personnel.
f. To enhance coordination and communication among services,
sections, and committees of the Center.
3. RESPONSIBILITY:
a. Director has final authority and responsibility for the
assurance of a comprehensive, flexible, and integrated hazardous
waste management program. Director is responsible for ensuring the
hazardous waste management program is compatible with Federal,
State, and local requirements.
b. Director delegates specific responsibility to each service
chief for the hazardous wastes generated in their service area(s).
c. Director delegates overall coordination for the hazardous
waste management program to the Waste Management Committee, which
reports directly to the Safety Committee, concerning all hazardous
waste management matters. Director delegates authority and
accountability for the hazardous waste management program to the
Safety Committee.
APPENDIX III.D
-------
d. Safety Committee is responsible for reviewing ail policies
and procedures relating to the operation of the hazardous waste
management program and for annually evaluating the effectiveness of
the program. Safety Committee is responsible for reporting its
findings and recommendations to the Clinical Executive Board and to
the Director through minutes or separate reports.
e. Hazardous Waste Management Chairperson is responsible for
ensuring the annual review of all policies and procedures related
to the management of hazardous wastes and for informing the
service (s) of the results of these reviews. Chairperson is
responsible for maintaining a file of all reports submitted.
f . Management of infectious wastes are the responsibility of
the Infection Control Committee. The wastes will be handled and
disposed of in compliance with all relevant Federal, State, and
local regulations .
g. Waste gases are the responsibility of tha Anesthesiology
Section, Surgical Service, and Supply, Processing and Distribution
Section, Acquisition and Materiel Management Service (A&MMS) , who
have written procedures for the disposal of their waste gases.
h. Radioactive wastes are the responsibility of the Radiation
Safety Officer and are disposed of in accordance with the Nuclear
Regulatory Commission rules and regulations.
i. Responsibility for disposing of chemical wastes rests
with Engineering Service, in accordance with all applicable
regulations as set forth by all governing agencies.
j . Disposal of antineoplastic wastes is the joint
responsibility of Pharmacy, Nursing, Environmental Management, and
Engineering Services.
k. Industrial Hygienist, Engineering Service, has been
designated as the Hazardous Waste Management Coordinator. Chief,
Engineering Service, as Center Safety Officer, is designated as
alternate Hazardous waste Management Coordinator.
4. EMFDRrFMRNT ; Hazardous Waste Management Committee will be
responsible for enforcement of this plan. The principal
ingredients of enforcement of this plan will be:
a. Service policies and procedures reviewed, revised, and
approved annually.
b. A Hazardous waste Management Committee to provide liaison
between the staff, administration, and outside agencies and
coordinate enforcement with other appropriate or allied committees,
etc .
c. Review and evaluation of individual case reports of
incidents or accidents.
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d. Systematic follow-up to ensure compliance with the
different segments of the plan annually.
e. A rep*ort summarizing the four ingredients of enforcement
shall be submitted to the Safety Committee annually.
5. TABFT.TNft: An adhesive label with the words "HAZARDOUS WASTE"
will be affixed to all containers of hazardous waste.
Identification of the contents, physical and health haz^.. ซ , and
the accumulation start date will be written on the labe_.
Appropriate labels can be obtained from the Safety Office.
6. ACCUMULATION TTMES ; Environmental Protection Agency (EPA)
regulations prohibit storage of hazardous waste on-site for more
than 180 days. Such wastes must be turned over to the Hazardous
Waste Management Coordinator in a timely manner to facilitate
proper disposal within the allotted timeframe. A Material Safety
Data Sheet (MSDS) must also accompany any chemical waste.
7 . SPTT.T. ppnrKDTTOES-. Spill procedures are addressed in attached
Chapters 2 through 6 for each specific category of hazardous waste.
8. SEEEBEUCE: AS stated in each Chapter.
9. PEsrTSSTQN: Memorandum No. 138-8, dated February 28, 1993.
iYD
Attachments
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CHAPTER 1
WASTE MANAGEMENT
1. PTTRPQSE> To establish membership of the Waste Management
Committee.
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2. iDEMTiFTrATiQM : Committee will coordinate the Center's
Hazardous waste Management Plan.
a. The follows :g programs will be monitored and evaluated by
this Committee:
(1) Identification of waste handling options.
(2) Development cf procedures for waste handling.
(3) Proper classification and description of wastes.
(4) waste handling procedures are developed by each service.
(5) Education is provided for all persons who may be exposed
to potential danger in connection with waste handling.
(6) A waste management plan is written.
b. Duties of the Committee include:
(1) Review regulations and classifications of wastes for
determination of hazardous classification.
(2) Review service waste handling procedures.
(3) Review training by each service to determine
effectiveness.
3. N^KTTNG : Committee will meet at the call of the Chairperson
but not less than quarterly.
4. MINUTES: Minutes will be recorded, published, and distributed
to all Committee members and to the Safety Committee.
5.
Chairman: Chemist, Pathology and Laboratory Medicine Service
Members : Chief , Environmental Management Service
Chief, Anatomic Pathology Section
Safety and Occupational Health Specialist
Chief, Pharmacy Service or Designee
Industrial Hygienist
ACOS for Research or Designee
Chief, Acquisition and Materiel Management Service
or designee
Radiation Safety Officer
Infection Control Nurse
AFGE Representative
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DEPARTMENT OF VETERANS AFFAIRS
Olin E. Teague Veterans' Center
MEMORANDUM June 2, 1993
NO. 138-10
ENVIRONMENTAL SAMPLING AND THE INDUSTRIAL HYGIENE PROGRAM
1. PURPOSE: To establish policy/ responsibility, and procedure
for an Industrial Hygiene Program as a part of the VA Occupational
Safety and Health Program. The following programs are covered in
this memorandum.
a. Respiratory Protection, Chapter l.
b. Hearing Conservation, Chapter 2.
c. Ethylene Oxide, Chapter 3.
d. Formaldehyde, Chapter 4.
e. Mercury, Chapter 5.
f. Waste Anesthetic Gases, Chapter 6.
g. Lead and Other Metals, Chapter 7.
h. Asbestos, Chapter 8.
i. Confined Space Entry, Chapter 9.
2. POLICY: To develop an industrial hygiene program and sampling
plan to monitor chemical contaminants, biological agents, and
physical agents in the work place on a routine basis. This policy
will be in compliance with appropriate laws, rules, and
regulations.
3. RESPONSIBILITY:
a. The Director is responsible for overall administration of
the Industrial Hygiene and Environmental Sampling Program.
b. The Industrial Hygienist will establish, analyze,
schedule, and interpret results from the Environmental Sampling
Program.
c. Service chiefs are responsible for the Industrial Hygiene
Program as it relates to their employees as outlined in the
attached Chapters.
d. Employee Health is responsible for the Industrial Hygiene
Program as outlined in the attached Chapters.
4. PROCEDURE: The attached contents outline procedures for
APPENDIX III.E
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environmental sampling and other industrial hygiene program
requirements.
5. REFERENCES: MP-3, Part III; Occupational Safety and Health
Administration (OSHA) Regulations; National Institute for
Occupational Safety and Health (NIOSH); and Veterans Health
Administration (VHA) Directives.
6. RESSissiQM: Memorandum No. 138-10, 1989, and Supplement 1.
JERRYtB. BOYD
Director
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DEPARTMENT OF VETERANS AFFAIRS
Olin E. Teague Veterans' Center
MEMORANDUM
NO. 138-14. May 27, 1993
EMERGENCY AND SPILL PROCEDURES
%
1. PURPOSE: To establish policy, responsibility, and procedure
for containment and cleanup of hazardous chemical spills.
2. POLICY: To prevent ac~idents, injuries, and illnesses by
implementing proper cleanup of hazardous chemical spills and
subsequent disposal.
3. RESPONSIBILITY:
a. The Industrial Hygienist is responsible for.providing
proper guidance in Spill Control procedures and will be designated
the Spill Control Coordinator. The Safety and Occupational Health
Specialist will serve as Alternate Spill Control Coordinator.
b. All employees are responsible for knowing who to contact in
case of a spill of hazardous chemicals and in knowing their first
line of responsibility.
4. PROCEDURE:
a. The attached contents outline spill policies for:
(1) Mercury
(2) Cytotoxic drugs
(3) Radioactive materials
(4) Formaldehyde
(5) Ethylene oxide
b. Spills of any other nature will be contained and cleaned up
on an individual basis as outlined by the Spill Control
Coordinator.
5. REFERENCE: MP-3, Part III; Occupational Safety and Health
Administration (OSHA) Regulations; and Accreditation Manual for
Hospitals, 1993, Joint Commission on Accreditation of Healthcare
Organizations (JCAHO), Chicago, Illinois.
APPENDIX III.F
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6. RESCISSION: Memorandum No. 138-14, 1989
//
JERRY /ET. BC
Di/reetor .
Kttachments : 5
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APPENDIX IV
ACRONYMS USED IN THE REPORT
ACMD
ACOS
A-106
CAA
CERCLA
CFC
EMP
EPA
EPCRA
FF
NEPA
NPDES
NPL
O&M
OTVC
PCB
PPA
RCRA
SDWA
SPCC
TSCA
VA
VAMC
VHA
Associate Chief Medical Director
Associate Chief of Staff
Office of Management and Budget Circular A-106
Clean Air Act
Comprehensive Environmental Response, Compensation
and Liability Act (Superfund)
Chlorofluorocarbons (CAA)
Environmental Management Program
Environmental Protection Agency
Emergency Planning and Community Right-to-Know Act
Federal Facilities
National Environmental Policy Act
National Pollutant Discharge Elimination System
(Clean Water Act, Section 402)
National Priority List (CERCLA)
Operation and Maintenance
Olin E. Teague Veterans Center
Polychlorinated Biphenyls (TSCA)
Pollution Prevention Act
Resource Conservation and Recovery Act
Safe Drinking Water Act
Spill Prevention, Control and Countermeasures
(Clean Water Act, Section 311)
Toxic Substances Control Act
Department of Veterans Affairs
Veterans Affairs Medical Center
Veterans Health Adnonistration
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