(s Q 'v

EPA/310-R-05-002

EPA Office of Compliance Sector Notebook Project

Profile of the Healthcare Industry

Chapters VII., VIII. and IX.

February 2005

Office of Compliance
Office of Enforcement and Compliance Assurance
U.S. Environmental Protection Agency
1200 Pennsylvania Avenue, NW (MC 2224-A)
Washington, D.C. 20460

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VII.	COMPLIANCE AND ENFORCEMENT HISTORY

VILA.	Background

Until recently, EPA focused much of its attention on ensuring compliance with
specific environmental statutes. This approach allows the Agency to track compliance with the
Clean Air Act, the Resource Conservation and Recovery Act, the Clean Water Act, and other
environmental statutes. Within the last several years, the Agency has begun to supplement
single-media compliance indicators with facility-specific, multimedia indicators of compliance.
In doing so, EPA is in a better position to track compliance with all statutes at the facility level,
and within specific industrial sectors.

A major step in building the capacity to compile multimedia data for industrial
sectors was the creation of EPA's Integrated Data for Enforcement Analysis (IDEA) system.
IDEA has the capacity to "read into" the Agency's single-medium databases, extract compliance
records, and match the records to individual facilities. IDEA uses the Facility Registry System
(FRS) maintained Master Source ID identification number to "glue together" separate data
records from EPA's databases. This is done to create a "master list" of data records for any
given facility. Some of the data systems accessible through IDEA are: AIRS (Air Facility
Indexing and Retrieval System, Office of Air and Radiation), PCS (Permit Compliance System,
Office of Water), RCRAInfo (Resource Conservation and Recovery Information System, Office
of Solid Waste), NCDB (National Compliance Data Base, Office of Prevention, Pesticides, and
Toxic Substances), CERCLIS (Comprehensive Environmental and Liability Information System,
Superfund), and TRIS (Toxic Release Inventory System). IDEA also contains information from
outside sources such as Dun and Bradstreet and OSHA.

The IDEA system can match Air, Water, Waste, Toxics/Pesticides/EPCRA, TRI,
and Enforcement Docket records for a given facility, and generate a list of historical permit,
inspection, and enforcement activity. IDEA also has the capability to analyze data by
geographic area and corporate holder. As the capacity to generate multimedia compliance data
improves, EPA will make available more in-depth compliance and enforcement information.
Additionally, sector-specific measures of success for compliance assistance efforts are under
development.

EPA has also developed Enforcement and Compliance History Online (ECHO).
This database was developed in partnership with the Environmental Council of the States
(ECOS), a national association representing state and territorial environmental commissioners.
ECHO provides users detailed facility reports, which include:

•	Federal and state compliance inspections;

•	Environmental violations;

•	Recent formal enforcement actions taken; and

•	Demographic profile of surrounding area.

The data in ECHO covers a two-year period of information and includes information drawn from
the following EPA databases:

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AIRS;

PCS;

RCRAInfo;

•	Integrated Compliance Information System (ICIS);

•	Facility Registry System (FRS); and

•	U.S. Census Data.

The ECHO database can be found at http://www.epa. xov echo index.html.

VII.B.	Compliance and Enforcement Description

This section discusses how EPA collects data on the historical compliance and
enforcement activity of each sector. The Agency compiles compliance and enforcement records
from its data systems to the facility level using the Facility Registry System's (FRS) Master
Source ID, which links records from virtually any of EPA's data systems to a facility record. For
each facility (i.e., Master Source ID), EPA uses the facility-level SIC code that is designated by
IDEA, as follows:

1.	If the facility reports to TRI, then the designated SIC code is the primary
SIC reported in the most recent TRI reporting year.

2.	If the facility does not report to TRI, the first SIC codes from all linked
AFS, PCS, RCRAInfo, BRS ID/permits are assembled. If more than one
permit/ID exists for a particular program, then only one record from that
data system is used. The SIC code that occurs most often, if there is one,
becomes the designated SIC code.

3.	If the facility does not report to TRI and no SIC code occurs more often
than others, the designated SIC code is chosen from the linked programs.
If more than one permit/ID exists for a particular program, then only one
record from that data system is used.

Note that EPA does not attempt to define the actual number of facilities that fall
within each sector. Instead, the information presented in this section reflects the records of a
subset of facilities within the sector that are well defined in EPA databases.

To compare the number of reported facilities in EPA's database to the total sector
universe, most Sector Notebooks contain an estimated number of facilities within the sector
according to the Bureau of Census (See Section II). With sectors dominated by small businesses,
such as metal finishers and printers, the reporting universe in the EPA databases may be small in
comparison to Census data. However, the group selected for inclusion in this data analysis
section should be consistent with this sector's general make-up.

This subsection contains four tables that summarize enforcement and compliance
activities for the healthcare industry. Tables VII-1 and VII-2 look exclusively at the healthcare
industry for the past five years. Tables VII-3 and VII-4 provide a general overview of

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compliance and enforcement activities across each of the sectors discussed in a Sector Notebook,
for the past five years. Following this introduction is a list defining each column in the tables
presented in this section. The data in these tables solely reflect EPA, state, and local compliance
assurance activity data that have been entered into EPA databases. EPA ran data queries, for the
past five calendar years (February 19, 1998 to February 19, 2004). For up-to-date compliance
data, visit the Sector Notebook data refresh web page at: http://epa.20v/compliance/resources/
publications/assistance/sectors/notebooks/data refresh.html.

Because most inspections focus on single-media requirements, the data presented
in this section result from queries of single-medium databases. These databases do not provide
data on whether inspections are state/local- or EPA-led. However, the table presenting the
universe of violations generally measures EPA's and states' efforts within each media program.
The presented data illustrate the variations across Regions for certain sectors10. This variation
may result from state/local data entry variations, specific geographic concentrations, proximity
to population centers, sensitive ecosystems, highly toxic chemicals used in production, or
historical noncompliance. Therefore, the data do not rank regional performance or necessarily
reflect which regions may have the most compliance problems.

VII.C.	Compliance and Enforcement Data Definitions

Facilities in Search (Tables VII-1, 2, 3, and 4) — the number of the FRS-
maintained Master Source IDs that were designated to the listed SIC code range.

Facilities Inspected (Tables VII-1, 2, 3, and 4) — the number of EPA and state
agency inspections for the facilities in this data search. These values show what percentage of
the facility universe is inspected in a 24- or 60-month period.

Number of Inspections (Tables VII-1, 2, 3, and 4) — the total number of
inspections conducted in this sector. An inspection is counted each time it is entered into a
single-medium database.

Average Months Between Inspections (Tables VII-1 and 3) — the average
length of time, expressed in months, between compliance inspections at a facility within the
defined universe.

Facilities with One or More Enforcement Actions (Tables VII-1 and 3) — the

number of facilities that were party to at least one enforcement action within the defined time
period. This category is broken down further into federal and state actions in subsequent
columns. EPA obtained these data for administrative, civil/judicial, and criminal enforcement
actions. Administrative actions include Notices of Violation (NOVs). A facility with multiple

10 EPA Regions include the following states: 1 (CT, MA, ME, RI, NH, VT); 2 (NJ, NY, PR, VI); 3 (DC, DE, MD,
PA, VA, WV); 4 (AL, FL, GA, KY, MS, NC, SC, TN); 5 (IL, IN, MI, MN, OH, WI); 6 (AR, LA, NM, OK, TX); 7
(IA, KS, MO, NE); 8 (CO, MT, ND, SD, UT, WY); 9 (AZ, CA, HI, NV, Pacific Trust Territories); 10 (AK, ID, OR,
WA).

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enforcement actions is counted only once in this column. All percentages that appear are
referenced to the number of facilities inspected.

Total Enforcement Actions (Tables VII-1, 2, 3, and 4) — the total number of
enforcement actions identified for an industrial sector across all environmental statutes. In this
column, a facility with multiple enforcement actions is counted multiple times (e.g., a facility
with three enforcement actions counts as three).

State-Led Actions (Tables VII-1 and 3) ~ the percentage of the total
enforcement actions taken by state and local environmental agencies. Note that this number may
not reflect the total number of state enforcement actions; some states extensively report
enforcement activities to EPA to include in its data systems, while other states may use their own
data systems.

Federal-Led Actions (Tables VII-1 and 3) — the percentage of the total
enforcement actions taken by EPA. This number includes cases that were referred to EPA from
state agencies. Many of these actions result from coordinated or joint state/federal efforts.

Enforcement-to-inspection Ratio (Tables VII-1 and 3) — shows how often
enforcement actions result from inspections; this number is presented for comparative purposes
only. This number simply indicates historically how many enforcement actions can be attributed
to inspection activity. This ratio includes and enforcement actions under the CWA (PCS), CAA
(AFS) and RCRA. Inspections and enforcement actions from the TSCA/FIFRA/EPCRA
databases are not factored into this ratio because most of the actions taken under these programs
are not the result of facility inspections. This ratio also does not account for enforcement actions
arising from noninspection compliance monitoring activities (e.g., self-reported water
discharges) under the CAA, CWA and RCRA.

Media Breakdown of Enforcement Actions and Inspections (Tables VII-2

and 4) — four columns identify the proportion of total inspections and enforcement actions
within EPA's Air, Water, Waste, and TSCA/FIFRA/EPCRA databases.

VII.D.	Healthcare Industry Compliance History

Table VII-1 provides an overview of the reported compliance and enforcement
data for the healthcare industry over the past five years (February 19, 1998 to February 19,
2004). These data are broken out by EPA Region, thereby permitting geographical comparisons.
Observations from the data are listed below:

•	Regions 2, 3, and 4 contain the most healthcare facilities and conducted
the most inspections;

•	Region 3 conducted, by far, the most inspections of healthcare facilities
and had the lowest average time between inspections; and

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•	Region 2 had both the most enforcement actions, and the most
enforcement actions per inspection.

Table VII-2 provides a more in-depth comparison between the healthcare industry
and other sectors by breaking out the compliance and enforcement data by environmental statute
for the same five-year period (February 19, 1998 to February 19, 2004). These data are also
broken out by EPA Region, thereby permitting geographical comparisons. Observations from
the data are listed below:

•	The majority of inspections and actions are conducted under the CAA,
followed by RCRA; and

•	Regions 7 and 8 have only conducted enforcement actions under the CAA.

EPA's Region 2 office identified the following most common healthcare facility
violations based on the inspections performed in their region, listed below.

Most Common CAA Healthcare Facility Violations

•	Failure to use properly trained and accredited asbestos personnel;

•	Failure to notify EPA of asbestos removal projects and to keep required
documentati on/records;

•	Failure to properly dispose of asbestos debris;

•	Failure to have CFC leak rate records for chillers and air conditioning
units more than 50 pounds of charge;

•	Failure to have EPA certified technicians for CFC-containing air
conditioning and refrigeration systems;

•	Failure to get boilers permitted with the state agency;

•	Failure to apply for Title V operating permit;

•	Failure to close parts washer lids when not in use; and

•	Failure to include spray paint booths and parts degreasers in air permit.

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Table VII-1: 5-Year Enforcement and Compliance Summary for the Healthcare Industry (SIC 8000), By Region

Region

Facilities in
Search

Facilities
Inspected

Number of
Inspections

Average
Months
Between
Inspections

Facilities with

1 or More
Enforcement
Actions

Total
Enforcement
Actions

Percentage of
State Actions

Percentage of
Federal
Actions

Enforcement-
to-inspection
Ratio

National

1,798

1,187

3,953

27

195

343

96%

4%

0.09

1

205

126

265

46

21

31

100%

0%

0.12

2

277

136

391

43

66

130

93%

7%

0.33

3

314

256

1,413

13

20

51

98%

2%

0.04

4

321

235

854

23

24

37

95%

5%

0.04

5

218

120

296

44

25

35

97%

3%

0.12

6

111

75

131

51

9

14

100%

0%

0.11

7

142

105

268

32

6

11

100%

0%

0.04

8

53

40

127

25

1

1

100%

0%

0.01

9

96

55

138

42

18

28

96%

4%

0.2

10

59

37

67

53

5

5

100%

0%



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Compliance and Enforcement History

Table VII-2: 5-Year Enforcement and Compliance Summary for the Healthcare Industry (SIC 8000), by Region and Statute

Region

Facilities In
Search

Facilities
Inspected

Number of
Inspections

Total
Enforcement
Actions

Clean Air Act

Clean Water Act

RCRA

FIFRA/TSCA/EPCRA

% of Total
Inspections

% of Total
Actions

% of T otal
Inspections

% of Total
Actions

% of Total
Inspections

% of Total
Actions

% of T otal
Inspections

% of Total
Actions

National

1,798

1,187

3,953

343

78%

82%

0%

2%

21%

16%

1%

1%

1

205

126

265

31

81%

74%

0%

0%

19%

26%

0%

0%

2

277

136

391

130

71%

85%

2%

2%

24%

12%

3%

1%

3

314

256

1,413

51

ox
00
00

90%

0%

0%

12%

10%

0%

0%

4

321

235

854

37

73%

60%

0%

0%

27%

41%

0%

0%

5

218

120

296

35

83%

ox
O
00

2%

6%

15%

11%

0%

3%

6

111

75

131

14

45%

79%

0%

0%

55%

21%

0%

0%

7

142

105

268

11

ox
O
00

100%

0%

0%

20%

0%

0%

0%

8

53

40

127

1

67%

100%

0%

0%

33%

0%

0%

0%

9

96

55

138

28

70%

ox
00

0%

0%

29%

14%

1%

0%

10

59

37

67

5

43%

ox
O
00

0%

0%

52%

20%

4%

0%

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Healthcare Industry	Compliance and Enforcement History

Most Common RCRA Healthcare Facility Violations

•	Failure to comply with hazardous waste generator regulations and lack of
documentation;

•	Failure to comply with Underground Storage Tank regulations and lack of
documentation;

•	Improper or lack of hazardous waste labeling;

•	Failure to have waste batteries/fluorescent lamps stored in proper
universal waste containers and labeled;

•	No or infrequent weekly inspections of hazardous wastes storage/satellite
areas;

•	Open containers of hazardous wastes;

•	Failure to have hazardous waste determinations on file for all wastes (i.e.,
some pharmaceutical wastes are classified as RCRA hazardous wastes);

•	Failure to have procedures in place to ensure spent aerosol containers are
empty before disposal as solid waste;

•	Malfunctioning leak detection systems on underground storage tanks;

•	Labeling of hazardous waste not done or incorrect;

•	Improper disposal of chemotherapy drugs;

•	Hazardous waste determination not done or incorrect;

•	No or inadequate hazardous waste manifest;

•	Disposal of hazardous waste down the drain;

•	Improper management of expired pharmaceutical, paints, etc.;

•	Lack of contingency plan;

•	Lack of or inadequate training for employees in hazardous waste
management;

•	Failure to ensure that hazardous waste meets Land Disposal Restrictions;

•	Failure to upgrade or close USTs by December 22, 1998; and

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•	Improper consolidation of wastes from nearby facilities.

Most Common CWA Healthcare Facility Violations

•	No permit for noncompliance with wastewater discharges;

•	Failure to know about local treatment plant sewer use regulations and
possible prohibited discharges for indirect dischargers;

•	No or inadequate secondary containment for storage tanks;

•	Improper disposal down floor drains; and

•	No Spill Prevention, Control and Countermeasure Plan.

Most Common EPCRA Healthcare Facility Violations

•	Failure to report certain accidental chemical releases to the local
authorities along with emissions data; and

•	Storage of chemicals (i.e., heating oil and gasoline) on site above
threshold amounts (hazardous chemicals above 10,000 lbs and or
extremely hazardous substances present at 500 lbs or the threshold
planning quantity, whichever is lower).

Most Common FIFRA Healthcare Facility Violations

•	Misuse of a registered pesticide product;

•	Use of an unregistered product;

•	Lack of proper records concerning pest control application within the
hospital and or on the hospital grounds; and

•	Failure to report pesticide poisonings either occurring within the hospital
or of admitted patients.

Common Violations and Problems Found at Hospitals for TSCA Issues

TSCA inspectors are primarily interested in any PCBs and lead-based paint at
hospitals. Typical staff residential area lead paint violations/issues are:

•	Failure to notify residents of lead paint in building or lack of knowledge
of any lead hazard; and

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•	Failure to provide EPA's pamphlet, "Protect Your Family from Lead in
Your Home" as required under 40 CFR Part 745.107(a)(1) (see
http://www.epa. 2Qv/opptintr/lead/leadpdfe.pdf).

Visit the Healthcare Environmental Resource Center at http://www.here.or 2 for
plain language explanations on how to comply with environmental regulations and to learn about
pollution prevention opportunities. The Center web site also links to state rules and permitting
contacts. Its resource sections contain selected compliance assistance and pollution prevention
tools. If you don't have access to the Internet, refer to Section VI and to the Bibliography in
Section IX.B for additional resources.

VILE.	Comparison of Enforcement Activity Among Selected Industries

Table VII-3 compares the compliance history of the healthcare sector to the other
industries covered by the industry Sector Notebooks. Observations from these five years of data
are listed below:

•	Sixty-six percent of healthcare facilities have been inspected over the past
five years, which is about equal to the average (62 percent) for all other
sectors listed;

•	The inspected healthcare facilities have been inspected an average of three
times each; and

•	The healthcare, ground transportation, and oil and gas extraction
industries have the highest percentage of state-led enforcement actions (96
percent).

Tables VII-4 provides a more in-depth comparison between the healthcare
industry and other sectors by breaking out the compliance and enforcement data by
environmental statute. As in Table VII-3, the data cover the last five years. Observations from
the data are listed below:

•	The majority of inspections and actions are conducted under the CAA,
followed by RCRA;

•	The healthcare industry has a higher percentage of CAA inspections (78
percent) than the average of the other sectors (60 percent); and

•	The healthcare industry has one of the lowest percentages of CWA
inspections and actions of any of the sectors listed in these tables.

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Table VII-3: 5-Year Enforcement and Compliance Summary for Selected Industries

Sector

Facilities In
Search

Facilities
Inspected

Number of
Inspections

Average
Months
Between
Inspections

Facilities with

1 or More
Enforcement
Actions

Total
Enforcement
Actions

Percentage
of State-Led
Actions

Percentage of
Federal-Led
Actions

Enforcement-
to-inspection
Ratio

Healthcare (SIC Code 8000)

1,798

1,187

3,953

27

195

343

96%

4%

0.09

Aerospace

764

526

2,704

17

246

238

65%

35%

0.09

Ag Chem Pesticide & Fertilizer

585

345

2,123

17

138

107

57%

43%

0.05

Ag Crop Production

131

69

165

48

12

7

ox
00

14%

0.04

Ag Livestock Production

53

17

58

55

14

28

11%

89%

0.48

Air Transportation

428

211

619

41

80

62

71%

29%

0.1

Dry Cleaning

3,345

1,620

2,944

68

232

178

92%

ox
00

0.06

Electronics & Computer

1,852

906

2,486

45

286

196

75%

25%

0.08

Fossil Fuel Elec Power Gen

3,520

2,543

18,758

11

1,170

1,582

78%

22%

0.08

Ground Transportation

4,970

3,338

13,612

22

1,084

880

96%

4%

0.06

Inorganic Chemical

1,007

629

5,291

11

352

414

79%

21%

0.08

Iron and Steel

683

480

6,060

7

312

536

78%

22%

0.09

Lumber & Wood Products

3,038

2,045

10,728

17

872

814

85%

16%

0.08

Metal Casting

1,346

797

3,549

23

348

340

79%

21%

0.1

Metal Fabrication

8,279

5,092

16,568

30

2,138

1,716

76%

24%

0.1

Metal Mining

281

183

980

17

70

71

85%

16%

0.07

Motor Vehicle Assembly

1,886

1,211

5,531

20

500

448

77%

23%

0.08

Non-Fuel, Non-Metal Mining

3,778

2,005

9,291

24

522

524

95%

6%

0.06

Nonferrous Metals

531

327

2,968

11

242

395

ox
00
00

12%

0.13

Oil & Gas Extraction

2,783

1,681

6,371

26

1,120

949

96%

4%

0.15

Organic Chemical

1,050

787

8,483

7

558

846

73%

27%

0.1

Petroleum Refining

438

297

5,405

5

352

1,335

69%

31%

0.25

Pharmaceutical

572

414

2,108

16

174

199

84%

16%

0.09

Plastic Resins & Fibers

709

502

4,637

9

344

444

85%

15%

0.1

Printing

2,384

1,460

4,913

29

476

435

90%

10%

0.09

Pulp and Paper

566

467

5,830

6

336

498

90%

10%

0.09

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Table VII-3: 5-Year Enforcement and Compliance Summary for Selected Industries (Continued)

Sector

Facilities In
Search

Facilities
Inspected

Number of
Inspections

Average
Months
Between
Inspections

Facilities with

1 or More
Enforcement
Actions

Total
Enforcement
Actions

Percentage
of State-Led
Actions

Percentage of
Federal-Led
Actions

Enforcement-
to-inspection
Ratio

Rubber and Plastic

3,823

2,294

9,239

25

962

787

90%

10%

0.09

Shipbuilding & Repair

235

168

870

16

96

83

81%

19%

0.1

Stone Clay Glass&Concrete

3,388

2,013

12,190

17

876

930

89%

11%

0.08

Textiles

1,226

814

3,859

19

304

310

87%

13%

0.08

Water Transportation

269

158

384

42

40

36

89%

11%

0.09

Wood Furniture & Fixtures

1,652

1,047

5,515

18

440

382

89%

12%

0.07

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Table VII-4: 5-Year Enforcement and Compliance Summary by Statute for Selected Industries

Sector

Facilities In
Search

Facilities
Inspected

Number of

Total
Inspections

Total
Enforcement
Actions

Clean Air Act

Clean Water Act

RCRA

FIFRA/TSCA/
EPCRA/Other

% of T otal
Inspections

% of T otal
Enforcement
Actions

% of T otal
Inspections

% of T otal
Enforcement
Actions

% of T otal
Inspections

% of T otal
Enforcement
Actions

% of T otal
Inspections

% of Total
Enforcement
Actions

Healthcare
(SIC Code 8000)

1,798

1,187

3,953

343

78%

82%

0%

2%

21%

16%

1%

1%

Aerospace

764

526

2,704

238

52%

43%

3%

3%

44%

51%

0%

3%

Ag Chem Pesticide &
Fertilizer

585

345

2,123

107

55%

34%

12%

8%

27%

31%

6%

27%

Ag Crop Production

131

69

165

7

50%

71%

0%

0%

46%

29%

4%

0%

Ag Livestock Production

53

17

58

28

53%

89%

0%

7%

47%

0%

0%

4%

Air Transportation

428

211

619

62

38%

23%

1%

2%

61%

74%

0%

2%

Dry Cleaning

3,345

1,620

2,944

178

26%

35%

0%

0%

74%

65%

0%

0%

Electronics & Computer

1,852

906

2,486

196

31%

14%

4%

5%

64%

67%

1%

15%

Fossil Fuel Elec Power Gen

3,520

2,543

18,758

1,582

75%

o~-
co

CO

18%

8%

6%

3%

0%

1%

Ground Transportation

4,970

3,338

13,612

880

78%

76%

0%

1%

21%

23%

0%

1%

Inorganic Chemical

1,007

629

5,291

414

48%

54%

13%

10%

37%

31%

1%

6%

Iron and Steel

683

480

6,060

536

61%

67%

13%

10%

26%

20%

0%

3%

Lumber & Wood Products

3,038

2,045

10,728

814

75%

76%

1%

0%

24%

23%

1%

1%

Metal Casting

1,346

797

3,549

340

60%

59%

3%

2%

36%

33%

1%

6%

Metal Fabrication

8,279

5,092

16,568

1,716

45%

46%

2%

1%

52%

46%

1%

7%

Metal Mining

281

183

980

71

56%

52%

28%

39%

15%

7%

1%

1%

Motor Vehicle Assembly

1,886

1,211

5,531

448

60%

56%

1%

1%

38%

40%

0%

3%

Non-Fuel, Non-Metal Mining

3,778

2,005

9,291

524

97%

99%

1%

0%

2%

1%

0%

0%

Nonferrous Metals

531

327

2,968

395

64%

70%

9%

5%

27%

22%

0%

2%

Oil & Gas Extraction

2,783

1,681

6,371

949

97%

98%

0%

1%

3%

2%

0%

0%

Organic Chemical

1,050

787

8,483

846

47%

55%

12%

13%

39%

28%

2%

5%

Petroleum Refining

438

297

5,405

1,335

57%

83%

15%

6%

27%

10%

1%

1%

Pharmaceutical

572

414

2,108

199

40%

49%

7%

8%

52%

37%

1%

6%

Plastic Resins & Fibers

709

502

4,637

444

51%

59%

19%

17%

29%

22%

1%

3%

Printing

2,384

1,460

4,913

435

65%

66%

0%

0%

34%

33%

1%

1%

Pulp and Paper

566

467

5,830

498

67%

75%

26%

18%

7%

4%

0%

3%

Rubber and Plastic

3,823

2,294

9,239

787

71%

73%

1%

0%

27%

23%

1%

5%

Shipbuilding & Repair

235

168

870

83

59%

34%

6%

8%

35%

57%

1%

1%

Stone Clay Glass&Concrete

3,388

2,013

12,190

930

85%

87%

1%

1%

13%

10%

1%

2%

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Table VII-4: 5-Year Enforcement and Compliance Summary by Statute for Selected Industries (Continued)

Sector

Facilities In
Search

Facilities
Inspected

Number of

Total
Inspections

Total
Enforcement
Actions

Clean Air Act

Clean Water Act

RCRA

FIFRA/TSCA/
EPCRA/Other

% of T otal
Inspections

% of T otal
Enforcement
Actions

% of T otal
Inspections

% of T otal
Enforcement
Actions

% of T otal
Inspections

% of T otal
Enforcement
Actions

% of T otal
Inspections

% of Total
Enforcement
Actions

Textiles

1,226

814

3,859

310

76%

59%

12%

23%

12%

14%

1%

3%

Water Transportation

269

158

384

36

42%

50%

1%

0%

56%

50%

1%

0%

Wood Furniture & Fixtures

1,652

1,047

5,515

382

76%

75%

0%

1%

23%

23%

0%

2%

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VII.F.	Review of Major Legal Actions

This subsection discusses major legal cases and pending litigation within the
healthcare industry. Following are several press releases that discuss recent major cases
regarding healthcare facilities:

DEPARTMENT OF VETERANS AFFAIRS AGREES TO $133.000 SETTLEMENT FOR
LEAD PAINT DISCLOSURE VIOLATIONS IN MAINE AND MASSACHUSETTS

EXCERPTS FROM: EPA Region 1 Press Release, April 6, 2004, Release # 04-04-04

BOSTON - The U.S. Department of Veterans Affairs has agreed to pay a $10,068
penalty and perform environmental projects worth $123,050 to settle claims by the U.S.
Environmental Protection Agency that it failed to properly inform tenants about potential lead
hazards at employee housing provided by the department.

The three EPA complaints allege violations of the federal Lead Disclosure Rule
for employee housing at VA Medical Centers in Northampton and Bedford, Mass. and Togus,
Maine. The three medical centers include a total of about 41 on-site housing units, which the VA
leases to employees and their families. Settlement of this case represents the first time a federal
facility has paid a penalty for violations of the Lead Disclosure Rule.

In addition to paying the fine, the VA agreed to assign a person to be responsible
for environmental compliance at each facility, and to implement a lead-based paint abatement
project in employee housing at a total cost of $123,050. Of the case penalty, the Bedford facility
will pay $3,080; the Togus facility will pay $3,908; and the Northampton facility will pay
$3,080. This case abates health risks posed by lead paint in 16 units of employee housing divided
between the three locations and addresses the facilities' underlying barriers to compliance.

The case is among numerous lead-related civil and criminal cases EPA New
England has taken to make sure landlords and property owners and managers are complying with
the federal Lead Disclosure Rule. EPA New England's work to implement the Residential Lead-
Based Paint Hazard Reduction Act has included more than 150 inspections around New
England, as well as numerous compliance assistance workshops.

Low-level lead poisoning is widespread among American children, affecting as
many as three million children under the age of six, with lead paint the primary cause. Elevated
lead levels can trigger learning disabilities, decreased growth, hyperactivity, impaired hearing
and even brain damage. Lead is also harmful to adults. Adults can suffer from difficulties during
pregnancy, other reproductive problems, high blood pressure, digestive problems, nerve
disorders, memory and concentration problems, and muscle and joint pain.

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EPA ORDERS CLOSURE OF MEDICAL WASTE INCINERATORS AT GUAM

MEMORIAL HOSPITAL

FOR RELEASE: June 2004

HONOLULU — In response to an order from the U.S. Environmental Protection
Agency, the Guam Memorial Hospital Authority has shut down one of its medical waste
incinerators and will soon shut down a second in order to meet federal Clean Air Act standards.

Guam Memorial Hospital Authority has agreed to comply with the EPA's order
by ceasing to operate its incinerators and putting an alternative medical waste treatment method
into place.

The first of two incinerators was shut down on May 18. The second incinerator
was switched to emergency back-up status on June 11 and will be permanently shut down by
Nov. 30. The EPA determined that both incinerators were violating the emissions standards set
by the Clean Air Act.

"It is critical that medical waste incinerators meet all of the required emission
standards to protect the public's health," said Deborah Jordan, the EPA's air division director for
the Pacific Southwest region. "Developing alternative medical waste treatment will further
ensure clean air and proper disposal of medical waste for Guam's residents."

During the initial source tests, one of the incinerators violated the particulate
matter, dioxins and furans, hydrogen chloride and lead emissions limits, while the second
incinerator violated the particulate matter and hydrogen chloride emission limits. At that time,
Guam Memorial Hospital Authority also failed to submit to the EPA the required waste
management plan and necessary incinerator operating parameters and other required data for
both incinerators.

In response to the order, Guam Memorial Hospital Authority has given the EPA a
plan to transport all hospital, medical and infectious waste to a commercial medical waste
treatment and disposal facility while the hospital develops an alternative waste treatment system.

The EPA's order also requires the Guam Memorial Hospital Authority to:

•	Provide to the EPA a copy of its waste management plan which will
include plans to separate solid waste from medical waste and other waste
minimization opportunities; and

•	Complete the shut down of both incinerators by Nov. 30 and complete
final removal and proper disposal of the two incinerators by Dec. 30.

All medical waste incinerators need to be permitted and have the necessary air
pollution controls to meet all Clean Air Act standards. Medical waste can be a source of

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pollution from the pathological and biological waste, along with any chemicals produced during
incineration from plastics and other medical waste materials.

SLOAN-KETTERING FINED FOR FA III RE TO PROPERLY MANAGE

HAZARDOUS WASTE

FOR RELEASE: Tuesday, January 27, 2004

New York, N.Y. - The U.S. Environmental Protection Agency (EPA) announced
today that it has cited Memorial Sloan-Kettering Cancer Center in New York City for violating
numerous hazardous waste management requirements. The Agency is seeking full compliance
and $214,420 in penalties for the violations.

"Hospitals and healthcare facilities must consider the proper handling of
hazardous waste an integral part of their mandates to protect people's health," said Jane M.
Kenny, EPA Regional Administrator. "Chemotherapy waste is an especially toxic waste
produced by many medical facilities. Hazardous waste regulations are in place to help to ensure
that facilities like Sloan-Kettering do not release these or other toxic chemicals into the
environment.

EPA discovered violations of the Resource Conservation and Recovery Act
(RCRA) at Sloan- Kettering during a March 2003 inspection. They included improper storage
and disposal of chemotherapy and dental solid wastes, as well as a general failure to determine
whether they were hazardous wastes. Sloan-Kettering has 30 days to respond to the complaint.

In 2002, EPA started the Hospital and Healthcare Initiative to help hospitals and
healthcare facilities comply with environmental regulations as part of a larger EPA voluntary
audit policy. The Agency established the policy to encourage prompt disclosure and correction
of environmental violations, safeguarding people's health and the environment. Many hospitals
and healthcare facilities were not aware of their responsibilities under various environmental
laws or had failed to implement effective compliance strategies. As part of the initiative, EPA
sent letters to 480 facilities in New Jersey, New York, Puerto Rico and the U.S. Virgin Islands
and held free workshops to help hospitals comply. In addition, the Agency established a web
site that provides information about their duties under the law, and warned hospitals that EPA
inspections of their facilities - with risk of financial penalties - were imminent.

Hospitals that wish to take advantage of the Agency's voluntary self-audit
program can investigate and disclose environmental violations to EPA and, if certain conditions
are met, receive a partial or complete reduction in financial penalties. To date, fourteen
healthcare organizations have entered into voluntary self-audit disclosure agreements with EPA.
The Agency is continuing to conduct inspections. More information about the healthcare
initiative can be found on EPA's web site at: www.epa. xov Region! healthcare index.html and
about hazardous waste regulation in general at: www,epa. eov/epaoswer/osw/index.htm.

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EPA FINES NASSAU HEALTH CARE CORPORATION FOR VIOLATING
HAZARDOUS WASTE REGULATIONS

FOR RELEASE: Monday, October 20, 2003

New York, N.Y. - The U.S. Environmental Protection Agency (EPA) announced
today that it will seek $279,900 in penalties from the Nassau Health Care Corporation Nassau
University Medical Center in East Meadow, New York for violating numerous requirements of
the federal and New York State hazardous waste regulations. The medical research, diagnostic
and treatment facility must comply with all hazardous waste management requirements under the
Resource Conservation and Recovery Act (RCRA).

"Hazardous waste regulations help to ensure that facilities like Nassau Health do
not release toxic chemicals into the environment and protect workers, patients and visitors at the
hospital," said EPA Regional Administrator Jane M. Kenny. "Many toxic compounds easily
contaminate air, ground or water and exposure can cause or aggravate many illnesses. Though
there were no releases in this case, it is essential that companies with hazardous chemicals in
their waste follow EPA and state regulations very carefully to ensure that they don't endanger
people or the environment."

The discovery of violations at Nassau Health grew out of EPA inspections of the
facility this past winter. These violations included storage or abandonment of several types of
solid waste and chemicals, and failure to determine whether or not they were hazardous wastes.
In addition, the hospital did not have a permit to store hazardous waste, and did not meet the
protective management requirements needed to be exempt from a permit. Hazardous waste
containers were not identified with the required markings or inspected regularly; emergency
response agencies were not notified of hazardous waste being stored; and the hospital did not
minimize the possibility of fire, explosion or unplanned release of hazardous substances into the
environment. Finally, a number of hospital personnel responsible for hazardous waste
management were not trained in how to handle it, and no hazardous waste emergency response
plan was in place. Since the inspection, Nassau Health has been correcting the violations. The
company has 30 days to respond to the complaint.

Nassau Health could have avoided this enforcement action by taking advantage of
EPA's Hospitals and Healthcare Initiative. EPA Region 2 started the Hospital and Healthcare
Initiative in the fall of 2002 to help hospitals and healthcare facilities comply with environmental
regulations as part of a larger EPA Voluntary Audit Policy. The Agency established the policy
to encourage prompt disclosure and correction of environmental violations, safeguarding human
health and the environment. Many hospitals and healthcare facilities were not aware of their
responsibilities under various environmental laws or failed to implement effective compliance
strategies. As part of the initiative, EPA sent letters to 480 facilities in New Jersey, New York,
Puerto Rico and the U.S. Virgin Islands and held free workshops to help hospitals comply. In
addition, the Agency established a web site that provides information about their duties under the
law, and warned hospitals that EPA inspections of their facilities - with risk of financial penalties
- were imminent.

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Hospitals can take advantage of the Agency's Voluntary Audit Policy, through
which they can investigate and disclose environmental violations to EPA and, as a compliance
incentive, receive a partial or complete reduction in financial penalties. To date, eleven hospitals
have entered into voluntary self-audit disclosure agreements with EPA.

More information about hazardous waste regulations can be found on EPA's web
site at: http://www.epa.20v/epa0swer/0sw/index.htm.

NORTH SHORE PAYS FINES FOR VIOLATING FEDERAL HAZARDOUS WASTE

HANDLING RULES

FOR RELEASE: Thursday, June 12, 2003

NEW YORK, N.Y. - North Shore University Hospital on Community Drive in
Manhasset has agreed to pay $40,000 in penalties to the federal government for violations of the
Resource Conservation and Recovery Act (RCRA) hazardous waste regulations, the U.S.
Environmental Protection Agency (EPA) announced today.

EPA Regional Administrator Jane M. Kenny explained. "The only way hospitals
and other healthcare facilities can ensure that wastes that have the potential to harm people and
the environment are properly handled is to strictly adhere to federal hazardous waste rules."

As part of a region-wide initiative to bring hospitals into compliance with federal
rules, EPA is inspecting healthcare facilities in New York, New Jersey, Puerto Rico and the U.S.
Virgin Islands. The discovery of the violations at North Shore Hospital grew out of EPA
inspections of the facility in April and May of 2002.

EPA issued a complaint last year against North Shore hospital alleging it failed to
determine if spent fluorescent bulbs and chemotherapy waste were hazardous prior to disposal,
and had improperly documented the transport of hazardous waste. The Agency also cited North
Shore for failing to properly label storage drums containing hazardous waste and to minimize the
risk of explosion, fire and release that could have affected people's health and the environment.
As part of the settlement between the facility and EPA, the facility agreed to take corrective
actions that would prevent any recurrence of the violations in the future.

EPA operates a Voluntary Audit Policy, through which the Agency can
substantially reduce civil penalties for those that voluntarily disclose and promptly correct
violations that are identified through self-policing and meet certain other specified conditions,
except in cases involving serious harm to public health or the environment. In most cases, the
punitive component of the penalty may be fully eliminated, but EPA would still be able to collect
any economic benefit as a result of non-compliance.

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EPA PROPOSES TO FINE PONCE HOSPITAL FOR ILLEGAL DISCHARGE

FOR RELEASE: Wednesday, November 19, 2003

New York, N.Y. - The U.S. Environmental Protection Agency (EPA) has
proposed a $137,500 penalty against Quality Health Services of Puerto Rico, Inc. (Hospital San
Cristobal) for discharging wastewater to a small creek, a tributary to the Rio Inabon, in violation
of the federal Clean Water Act. The EPA issued a complaint based on the hospital's continuing
failure to comply with the requirements of its wastewater discharge permit.

"Wastewater discharge permits protect public health and the environment," said
EPA Regional Administrator Jane M. Kenny. "The hospital has been out of compliance since
February 2000. As a healthcare facility, Hospital San Cristobal should understand the
importance of properly managing its waste."

The September 30, 2003 complaint charges that Quality Health Services violated
the requirements of its National Pollutant Discharge Elimination System (NPDES) permit, issued
under the Clean Water Act. In March 2003, EPA inspected the hospital and ordered Quality
Health Services to comply with the requirements of its NPDES permit. However, Quality Health
Services allegedly continued to violate the Clean Water Act (for a total of 226 times from
February 2000 through May 2003) with its discharge of sanitary wastewaters from the hospital's
wastewater treatment plant. Specifically, the discharge exceeded permit limitations for
ammonia, biochemical oxygen demand, color, fecal coliform, flow, fluoride, nitrate-nitrite,
phenolics, phosphorus, silver, sulfide, surfactants and zinc. Under federal regulations, Quality
Health Services has the right to request a hearing on the proposed penalty.

NEW YORK PRESBYTERIAN HOSPITAL

BASED ON NOVEMBER 2004 PRESS RELEASE

New York Presbyterian Hospital was charged with failing to provide tenants,
including pregnant women and families with young children, with the required lead paint hazard
information (i.e., failing to provide a lead warning statement, statement disclosing any
knowledge of lead-based paint, and list of any existing records or reports pertaining to lead-
based paint, nor obtaining a statement by the lessee of receipt of a lead hazard information
pamphlet.) These failures are violations of 42 U.S.C. Section 4852d(b)(5) and § 409 of TSCA,
15 U.S.C. § 2689.

Lead poisoning presents an environmental health hazard for young children living
in apartments constructed before 1978, due to the potential chipping or peeling of lead paint, or
lead-contaminated dust. New York Presbyterian Hospital owned and leased at least twenty-nine
housing units to families of physicians at their facility in White Plains, New York. Region 2
suggested possible activities that could be undertaken as Supplemental Environmental Projects,
and New York Presbyterian Hospital submitted a proposal for a SEP that involved exterior
maintenance and repair, but the parties were unable to reach agreement on an appropriate SEP.
New York Presbyterian Hospital entered into a cash settlement with EPA for $248,000, which is

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the largest monetary settlement in the history of the Lead-based Paint Disclosure Program. On
July 10, 2003, the Regional Administrator signed the Final Order memorializing the settlement
in the Consent Agreement and Final Order. (T. Bourbon/L. Livingston)

EPA FINES ATLANTIC HEALTH SYSTEMS INC. FOR FATLTTRE TO PROPERLY

MANAGE HAZARDOUS WASTE

FOR RELEASE: Tuesday, November 25, 2003

New York, N.Y. — The U.S. Environmental Protection Agency (EPA) announced
today that it will seek $64,349 in penalties from Atlantic Health System Inc., owner and operator
of Mountainside Hospital in Montclair, New Jersey. The Agency cited the company for violating
numerous hazardous waste management requirements under the Resource Conservation and
Recovery Act (RCRA).

"Hospitals and healthcare facilities should consider the proper handling of
hazardous waste as an integral part of their mandates to protect people's health," said Jane M.
Kenny, EPA Regional Administrator."We are pleased that Mountainside Hospital has recognized
its responsibility to its patients, employees and neighbors, and is taking action to correct the
violations."

EPA discovered the violations at Mountainside Hospital during an April 2003
inspection. The violations included improper storage or disposal of several types of solid waste,
and failure to determine whether they were hazardous wastes. In addition, the hospital did not
have a permit to store hazardous waste and did not meet the protective management
requirements needed to be exempt from a permit. Hazardous waste containers were not clearly
identified with the required markings or inspected regularly, and emergency response
information was not posted. Mountainside is working to correct the violations. Its parent
company, Atlantic Health, has 30 days to respond to the complaint.

In 2002, EPA started the Hospital and Healthcare Initiative to help hospitals and
healthcare facilities comply with environmental regulations as part of a larger EPA voluntary
audit policy. The Agency established the policy to encourage prompt disclosure and correction
of environmental violations, safeguarding people's health and the environment. Many hospitals
and healthcare facilities were not aware of their responsibilities under various environmental
laws or had failed to implement effective compliance strategies. As part of the initiative, EPA
sent letters to 480 facilities in New Jersey, New York, Puerto Rico and the U.S. Virgin Islands
and held free workshops to help hospitals comply. In addition, the Agency established a web site
that provides information about their duties under the law, and warned hospitals that EPA
inspections of their facilities - with risk of financial penalties - were imminent.

Hospitals that wish to take advantage of the Agency's voluntary self-audit
program can investigate and disclose environmental violations to EPA and, if certain conditions
are met, receive a partial or complete reduction in financial penalties. To date, eleven hospitals
have entered into voluntary self-audit disclosure agreements with EPA. The Agency is
continuing to conduct inspections.

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YALE-NEW HAVEN HOSPITAL ACCEPTS EPA PLAN FOR ENVIRONMENTAL

AUDIT

Yale-New Haven Hospital and EPA say they have reached an agreement under
which the hospital will voluntarily carry out a comprehensive environmental audit. The
agreement between EPA Region I and the hospital in New Haven, Conn., is the first of its kind to
be signed in New England and is part of an agency effort to improve hospital compliance with
environmental laws. EPA Region I launched its hospital initiative earlier this year, citing the
experience of EPA's New York/New Jersey regional office, which took enforcement actions
against several hospitals after significant noncompliance was found during inspections of
hospital facilities.

Source: http://pubs.bna.com/ip/BNA/den.nsf/is/a0b0d4kld7

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VIII.	COMPLIANCE ACTIVITIES AND INITIATIVES

This section highlights organizations, resources, and the voluntary activities being
undertaken by the healthcare sector, public agencies, and nongovernmental organizations to
improve the sector's environmental performance. These activities include those independently
initiated by industrial trade associations.

VIII.A. Healthcare Related Programs and Activities

Healthcare Environmental Resource Center (Compliance Assistance Center)

Using an EPA grant the National Center for Manufacturing Sciences with the
cooperation of the American Hospital Association, the American Nurses Association, and EPA,
via the Hospitals for a Health Environment (H2E) program and other stakeholders, is creating an
on-line compliance assistance center (or Healthcare Environmental Resource Center - HERC)
serving the healthcare industry. The HERC will address issues relevant to hospitals, ambulatory
clinics, and other specialized medical facilities. It will serve as a first stop for environmental
compliance and pollution prevention information for the healthcare industry. Among its many
compliance assistance and pollution prevention features, the HERC will include plain language
explanations of applicable regulations and feature links to state and local permitting agencies
where users can find information on local regulations and contacts. Look for the Healthcare
Environmental Resource Center at www.HERCenter. ore.

Hospitals for a Healthy Environment (H2E)

Hospitals for a Healthy Environment (H2E) is a voluntary program jointly
sponsored by the EPA, the American Hospital Association, the American Nurses Association,
and Health Care Without Harm. The primary goal of the H2E effort is to educate healthcare
professionals about pollution prevention opportunities in hospitals and healthcare systems and
make significant reductions in mercury-containing healthcare waste, and waste volume overall.
Through activities such as the development of best practices, model plans for total waste
management, resource directories, and case studies, the project hopes to provide hospitals and
healthcare systems with enhanced tools for minimizing the volumes of waste generated and the
use of persistent, bioaccumulative, and toxic chemicals. Such reductions are beneficial to the
environment and health of our communities. Furthermore, improved waste management
practices will reduce the waste disposal costs incurred by the healthcare industry. For more
information, see the web site at http://www.h2e-online.ore/.

Resource Conservation Challenge (RCC)

EPA's Resource Conservation Challenge (www.epa.gov/rcc) is a voluntary, joint
effort between EPA, businesses, and communities. RCC aims to find flexible, yet more
protective ways of improving waste reduction, public health, and the environment. As part of the
Resource Conservation Challenge, EPA is asking the hospital industry to develop projects for the

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reuse and recycling of hospital items and the reduction of waste. For more information, see the
web site at http://www. epa. xov epaoswer osw conserve clusters hospital, htm.

Lead needed to protect healthcare workers from CatScan radiation, mercury in
ultraviolet lamps, and residual or expired pharmaceuticals are just a few examples of the hospital
waste that can harm the environment if disposed of improperly. EPA's RCC is committed to
supporting projects that:

•	Reduce the volume of nonhazardous solid waste, including paper,
packaging, yard waste, food waste, and electronic equipment, from the
healthcare industry and promote its recycling and safe reuse;

•	Virtually eliminate all mercury waste from the healthcare industry waste
stream;

•	Reduce the volume of other toxic chemicals; and

•	Improve the management of pharmaceutical waste by reducing the amount
of expired/unused pharmaceuticals that are disposed of in landfills.

Performance Track

Performance Track is a public/private partnership recognizing top environmental
performance among participating U.S. facilities of all types, sizes, and complexity, public and
private. Program partners are providing leadership in many areas, including preventing pollution
at its source and implementing environmental management systems. Currently, the program has
about 300 members and welcomes all qualifying facilities. Applications are accepted twice a
year: February 1-April 30 and August 1-October 31. For more information, contact the
Performance Track hotline at (888) 339-PTRK or visit the web site at
www. epa. xov performancetrack.

EPA Audit Policy

EPA encourages companies with multiple facilities to take advantage of the
Agency's Audit Policy (Incentives for Self-Policing: Discovery, Disclosure, Correction and
Prevention of Violations, 65 Fed. Reg. 19618 (April 11, 2000)) to conduct audits and develop
environmental compliance systems. The Audit Policy eliminates gravity-based penalties for
companies that voluntarily discover, promptly disclose, and expeditiously correct violations of
federal environmental law. More information on EPA's Audit Policy can be obtained from the
web site at http://www. epa. xov compliance resources policies incentives auditing index.html.
EPA Region 2 (NY, NJ, PR, VI) has been actively promoting use of the policy; see voluntary
audit policy at http://www.epa. eov/reeion02/healthcare/.

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Office of Solid Waste and Emergency Response (OSWER) Innovations Pilot

The Office of Solid Waste and Emergency Response (OSWER) initiated a series
of innovative pilots to test new ideas and strategies for environmental and public health
protection to find creative approaches to waste minimization. For additional information on
OSWER Innovations Pilots, visit the EPA OSWER Innovations web site at
www. epa. eov/oswer/iwe.

Expanding Pharmaceutical Waste Management in Hospitals

Hospitals for a Healthy Environment is partnering with EPA Region 1,
Dartmouth-Hitchcock Medical Center, New Hampshire Department of Environmental Services,
New Hampshire Hospital Association, and H2E Champion, PharmEcology Associates, to
pioneer pharmaceutical management techniques that ensure regulatory compliance, implement
best management practices, and identify and implement waste minimization opportunities.
Baseline data on costs and quantities of end-of-life pharmaceuticals will be compiled and
evaluated. This information will be used to assess where pharmaceuticals are being discarded,
how much is being wasted, and how wasting can be minimized. Based on the results of the
baseline assessment, the pilot will develop best management practices incorporating waste
reduction activities. A blueprint will be developed providing a step-by-step approach to program
implementation and lessons learned. For more detailed information on the pharmaceutical pilot,
visit H2E's web site at www.h2e-online.ore.

Collaborative Partnership to Improve Environmental Performance in the

Healthcare Sector

The overall goal of this project is to institutionalize regulatory compliance and
pollution prevention practices in the healthcare sector. To achieve this the project seeks to
establish a formal lasting partnership with multiple healthcare and regulatory organizations and
JCAHO to maximize EPA compliance assistance and pollution prevention resources, improve
the environmental performance of the healthcare sector, and create incentives for continuous
improvement. The final product will be a set of matrices for JCAHO surveyors and hospital
personnel that align environmental regulations and environmental improvement with the JCAHO
standards. The matrices will be available electronically on EPA's forthcoming Healthcare
Environmental Resource Center's web site at www.HERCenter.ore. For more detailed
information on the JCAHO project, visit H2E's web site at: www.h2e-online.ore.

National Strategies for Healthcare Providers: Pesticide Initiative

The Pesticide Initiative is an initiative created by EPA and the National
Environmental Education & Training Foundation (NEETF) in collaboration with the U.S.
Departments of Health and Human Services, Agriculture, and Labor. It is aimed at incorporating
pesticide information into the education and practice of healthcare providers. The goal is to

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improve the recognition, diagnosis, management, and prevention of adverse health effects from
pesticide exposures. This initiative also serves as a model for broader efforts to educate
healthcare providers about the spectrum of environmental health issues. Seven federal agencies
and 16 professional associations of healthcare providers were involved in launching this
initiative. For additional information, visit the EPA Pesticide Initiative web site at
http://www.epa. 20v/oppfeadl/safetv/healthcare/healthcare. htm

EPA and Veterans Health Administration (VHA) Cooperative Environmental

Partnership

Stemming from EPA inspections of VA medical centers in 2002 that revealed
repeated violations of environmental regulations, particularly those involving federal hazardous
waste management regulations, EPA and VHA are conducting environmental management
reviews (EMRs) at select VA medical centers. EMRs evaluate the current status of the
management system and identify steps to establish a comprehensive management system for
environmental compliance as well as continual improvement beyond compliance. The
partnership has fostered environmental training through both EPA Headquarters and the
Regions, and assisted in the development of the VA's Green Environmental Management
Systems (GEMS). These efforts and others are underway to improve environmental compliance
and performance at VA medical centers. For additional information visit
http://www.epa. 2ov compliance assistance sectors federal epavha.html.

The Green Suppliers Network (GSN)

The Green Suppliers Network (GSN) is a collaborative venture between industry,
EPA, and 360vu, the national accounts organization of the Department of Commerce's National
Institute of Standards and Technology Manufacturing Extension Partnership (NIST MEP). GSN
provides expert technical assistance to small and medium-sized suppliers, through 360vu's
national network of technical assistance centers. This assistance provided in a GSN Review
enables suppliers to optimize processes and products, eliminate waste, reduce their
environmental impacts, identify cost-saving opportunities, and remain competitive. GSN
engages both original equipment manufacturers and their suppliers to achieve environmental and
economic benefits throughout the supply chain. GSN has launched a pharmaceutical/healthcare
initiative piloted in Puerto Rico. For additional information on the program, contact Kristin
Pierre at pierre.kristin(a),epa.20V or (202) 564-8837.

Waste WiSe Program

The WasteWi$e Program was started in 1994 by EPA's Office of Solid Waste and
Emergency Response. The program is aimed at reducing municipal solid wastes by promoting
waste minimization, recycling collection, and the manufacturing and purchase of recycled
products. As of February 17, 2004, WasteWise has 1,377 partners (including alumni) spanning
more than 54 industry sectors. Members agree to identify and implement actions to reduce their

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solid wastes and must provide EPA with their waste reduction goals along with yearly progress
reports. EPA in turn provides technical assistance to member companies and allows the use of
the WasteWi$e logo for promotional purposes. Sixty-one medical services companies are
partners. For more information, contact the Hotline at (800) EPA-WISE (372-9473) or the web
site at www. epa. xov wastewise.

Energy Star®

In 1991, EPA introduced Green Lights®, a program designed for businesses and
organizations to proactively combat pollution by installing energy efficient lighting technologies
in their commercial and industrial buildings. In April 1995, Green Lights® expanded into
Energy Star® Buildings — a strategy that optimizes whole-building energy-efficiency
opportunities. The energy needed to run commercial and industrial buildings in the United
States produces 19 percent of U.S. carbon dioxide emissions, 12 percent of nitrogen oxides, and
25 percent of sulfur dioxide, at a cost of $110 billion a year. If implemented in every U.S.
commercial and industrial building, the Energy Star® Buildings upgrade approach could prevent
up to 35 percent of the emissions associated with these buildings and cut the nation's energy bill
by up to $25 billion annually.

The more than 7,000 participants include corporations, small businesses,
universities, healthcare facilities, nonprofit organizations, school districts, and federal and local
governments. Energy Star® has successfully delivered energy and cost savings across the
country, saving businesses, organizations, and consumers more than $7 billion a year. Over the
past decade, Energy Star® has been a driving force behind the more widespread use of such
technological innovations as LED traffic lights, efficient fluorescent lighting, power
management systems for office equipment, and low standby energy use. For more information,
contact the Energy Star Hotline, (888) STAR-YES ((888) 782-7937) or the web site at
http://www.ener2vstar. 2QV/healthcare.

Small Business Compliance Policy

The Small Business Compliance Policy promotes environmental compliance
among small businesses (those with 100 or fewer employees) by providing incentives to discover
and correct environmental problems. EPA will eliminate or significantly reduce penalties for
small businesses that voluntarily discover violations of environmental law and promptly disclose
and correct them. A wide range of resources are available to help small businesses learn about
environmental compliance and take advantage of the Small Business Compliance Policy. These
resources include training, checklists, compliance guides, mentoring programs, and other
activities. Businesses can find more information through links on the web site at
http://www.epa. 2Qv/smallbusiness/.

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Healthy Building Network (HBN)

Healthcare institutions are increasingly embracing green building goals driven by
several important factors: public health, market competitiveness, operation costs, and social
responsibility. HBN is a national network of green building professionals, environmental and
health activists, socially responsible investment advocates, and others who are interested in
promoting healthier building materials as a means of improving public health and preserving the
global environment. For more information, contact HBN at (202) 898-1610 or the web site at
http://www.healthvbuildin2. net/healthcare/index, html.

Health Care Without Harm (HCWH)

HCWH is an international coalition of hospitals and healthcare systems, medical
professionals, community groups, health-affected constituencies, labor unions, environmental
and environmental health organizations, and religious groups.

In 1994, EPA's draft Dioxin Reassessment identified medical waste incineration
as the single largest source of dioxin air pollution. The HCWH campaign was formed in 1996 to
respond to this serious problem. Since then, the campaign has grown from an initial 28 founding
organizations into a broad-based international coalition. The mission of HCWH is to transform
the healthcare industry worldwide, without compromising patient safety or care, so that it is
ecologically sustainable and no longer a source of harm to public health and the environment.
For more information, contact the HCWH web site at http://www.noharm.or2/.

The Sustainable Hospitals Project (SHP)

SHP's mission is to provide technical support to the healthcare industry for
selecting products and work practices that reduce occupational and environmental hazards. The
SHP is based at the University of Massachusetts Lowell Center for Sustainable Production
(LCSP). The project includes in-hospital research on implementing new products and practices,
using SHP's Pollution Prevention and Occupational Safety and Health (P20SH) model.
Additionally the SHP web site, http://www.sustainablehospitals. or2. provides a list of alternative
products to help hospitals identify and evaluate more benign alternatives to existing products.
SHP also provides technical support by email (shp a iiml.edu) or phone ((978) 934-3386). For
more information, contact the web site at http://www.sustainablehospitals. or2.

Nightingale Institute for Health and the Environment (NIHE)

NIHE assists healthcare professionals recognize the inextricable link between
human and environmental health and their role in changing practices to improve the health of
humans and the environment. There are three initiatives associated with this program: the
Trustees Initiative, the Clinicians Initiative, and the Environmental Procurement Initiative. Each
initiative is designed to educate the target audience on the environmental impact of the

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healthcare industry, and to offer resources that enable them to improve the environmental
performance of their organizations or processes and minimize the adverse ecological impact in
the communities they serve. Inherent in this project is an emphasis on sustainability, resource
conservation, and life cycle thinking. For more information, contact the web site at
http://www.nihe. orx.

Canadian Centre for Pollution Prevention (Healthcare EnviroNet)

Healthcare EnviroNet provides the healthcare community with access to
environmental information, products, and services that support a commitment to quality
healthcare, protection of the environment, and sustainability. Healthcare EnviroNet delivers a
unique collection of Canadian-based information including:

•	Green alternatives for healthcare facilities;

•	Regulatory updates and government initiatives; and

•	Canadian case studies.

Healthcare EnviroNet was established with funding from Environment Canada
and is developed and maintained by the Canadian Centre for Pollution Prevention in consultation
and partnership with healthcare and nongovernment organizations. For more information, go to
the web site at http://www.c2p2online.com/main.php3? section=83&docid= 169.

Recovered Medical Equipment for the Developing World (REMEDY)

Founded in 1991 at Yale University School of Medicine, REMEDY is a group of
healthcare professionals and others promoting the nationwide practice of recovery of open-but-
unused surgical supplies with the goal of providing international medical relief while reducing
solid medical waste from U.S. hospitals. For more information, go to the web site at
http://www. remedvinc. or 2/about us. cfm.

Public Entity Environmental Resource (PEER) Center

The PEER Center is the Public Entity Environmental Management System
Resource Center. A virtual clearinghouse, it is specifically designed to aid local, county, and
state governments that are considering implementing or have implemented an environmental
management system (EMS) and want to access the knowledge and field experience of other
public entities that have done so. For more information, go to the web site at
http://www.peer center, net/.

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ISO 14000

ISO 14000 is a series of internationally accepted standards for environmental
management. The series includes standards for EMS, guidelines on conducting EMS audits,
standards for auditor qualifications, and standards and guidance for conducting product lifecycle
analysis. Standards for auditing and EMS were adopted in September 1996, while other
elements of the ISO 14000 series are currently in draft form. While regulations and levels of
environmental control vary from country to country, ISO 14000 attempts to provide a common
standard for environmental management. The governing body for ISO 14000 is the International
Organization for Standardization (ISO), a worldwide federation of over 110 country members
based in Geneva, Switzerland. The American National Standards Institute (ANSI) is the United
States representative to ISO. Information on ISO is available at the following Internet site:
http://www.iso.ch/iso/en/ISOOnline.openerpa2e.

VIII.B. Summary of Trade Organizations and Industry Organizations

There are dozens of trade organizations associated with the healthcare industry.
The following list is meant to act as a representative sample, not a comprehensive list.

Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

JCAHO is an independent nonprofit organization whose mission is to improve the
safety and quality of care through its accreditation process. JCAHO standards promote patient
safety and care and good operational practices in all aspects of healthcare organizations. Nearly
17,000 healthcare organizations worldwide are accredited by JCAHO. Extensive on-site reviews
are conducted at least once every three years. The reviews currently only cover environmental
issues in a limited manner. See Collaborative Partnership to Improve Environmental
Performance in the Healthcare Sector in Section VIII. A of this Notebook to see how H2E is
working with JCAHO to help healthcare facilities improve their environmental performance.
Contact Information: One Renaissance Blvd, Oakbrook Terrace, IL 60181, Phone: (630) 792-
5000, Fax: (630) 792-5005, web site: http://www.icaho.org/.

American Hospital Association (AHA)

The AHA provides education for healthcare leaders and is a source of information
on healthcare issues and trends. Through its representation and advocacy activities, AHA
ensures that members' perspectives and needs are heard and addressed in national health policy
development, legislative and regulatory debates, and judicial matters. AHA advocacy efforts
include the legislative and executive branches and the legislative and regulatory arenas. Contact
Information: One North Franklin, Chicago, IL 60606-3421, Phone: (312) 422-3000, web site:
http://www.aha. oris.

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American Medical Association (AMA)

The AMA serves as the steward of medicine and leader of the medical profession.
The AMA is the national professional organization for all physicians and the leading advocate
for physicians and their patients. The AMA's envisioned future is to be an essential part of the
professional life of every physician and an essential force for progress in improving the nation's
health. Contact Information: 515 N. State Street, Chicago, IL 60610, Phone: (800) 621-8335,
web site: http://www.ama-assn.ore/.

American Dental Association (ADA)

The ADA is the professional association of dentists committed to the public's oral
health, ethics, science and professional advancement and leading a unified profession through
initiatives in advocacy, education, research and the development of standards. Contact
Information: 211 East Chicago Ave., Chicago, IL 60611-2678, Phone: (312) 440-2500, web site:
http://www.ada. ore/.

American Nurses Association (ANA)

ANA focuses its work on core issues of vital concern to the nation's registered
nurses - nursing shortage, appropriate staffing, health and safety, workplace rights, and patient
safety/advocacy - in addition to its cornerstone work, ethics and standards.

The ANA, composed of professional nurses dedicated to the promotion of health
and the care of the sick, has served as the forum in which the nation's critical health issues have
been discussed throughout the last century.

Functioning as a democracy, the ANA provided the structure in which views were
expressed, ideas were debated and evaluated, and positions and goals were formulated. Because
it represented the views of administrators, clinical practitioners in institutions and community
agencies, educators, and researchers, it has served for 100 years as the public voice for the
diversity of America's professional nurses. Contact Information: 600 Maryland Ave. SW., Suite
100W, Washington D.C. 20024, Phone: (202) 651-7000, Fax: (202) 651-7001, web site:
http://www. ana, ore/.

American Veterinary Medical Association (AVMA)

The AVMA, established in 1863, is a not-for-profit association representing more
than 69,000 veterinarians working in private and corporate practice, government, industry,
academia, and uniformed services. Structured to work for its members, the AVMA acts as a
collective voice for its membership and for the profession.

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The AVMA provides a number of tangible benefits to its members, including
information resources, continuing education opportunities, quality publications, and discounts on
personal and professional products, programs and services. Contact Information: 1931 North
Meacham Road - Suite 100, Schaumburg, IL 60173, Phone: (847) 925-8070, Fax: (847) 925-
1329, web site: http://www.avma.ore/.

American Health Care Association (AHCA)

The AHCA is a nonprofit federation of affiliated state health organizations,
together representing nearly 12,000 nonprofit and for-profit assisted living, nursing facility,
developmentally disabled, and subacute care providers that care for more than 1.5 million elderly
and disabled individuals nationally.

AHCA represents the long-term care community to the nation at large - to
government, business leaders, and the general public. It also serves as a force for change within
the long-term care field, providing information, education, and administrative tools that enhance
quality at every level.

At its Washington, D.C. headquarters, the association maintains legislative,
regulatory and public affairs, as well as member services staffs that work both internally and
externally to assist the interests of government and the general public, as well as member
providers. In that respect, AHCA represents its membership to all publics, and national
leadership to its members. Contact Information: 1201 L Street, N.W., Washington, D.C. 20005,
Phone: (202) 842-4444, Fax: (202) 842-3860, web site: http://www.ahca.ore/.

American Society for Healthcare Environmental Services (ASHES)

Setting the standard for environmental excellence, ASHES advances healthcare
environmental services, textile care professions and related disciplines. ASHES leads, represents
and serves our members by promoting excellence, best practices, innovation, and leadership
through advocacy, education and certification. Web site: http://www.ashes.ore/.

American Society for Healthcare Engineers (ASHE)

ASHE is the advocate and resource for continuous improvement in the healthcare
engineering and facilities management professions. Web site: http://www.ashe.ore/.

College of American Pathologists (CAP)

The CAP, the principal organization of board-certified pathologists, serves and
represents the interest of patients, pathologists, and the public by fostering excellence in the
practice of pathology and laboratory medicine.

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The CAP's Strategic Plan is intended to help ensure that the College fulfills its
mission in a thoughtful and effective manner. The plan contains 13 specific directions that the
College will follow in carrying out its commitment to members, their patients, and the public.
CAP members can download a copy of the Strategic Plan; log in to access the file. Contact
Information: 325 Waukegan Road, Northfield, IL 60093-2750, Phone: (847) 832-7000, Fax:
(847) 832-8000, web site: http://www.cap,org/.

National Indian Health Board (NIHB)

The NIHB represents Tribal Governments operating their own healthcare delivery
systems through contracting and compacting, as well as those receiving healthcare directly from
the Indian Health Service (IHS). Contact Information: 101 Constitution Ave. N.W., Suite 8-B02,
Washington, D.C. 20001, Phone: (202) 742-4262, Fax: (202) 742-4285, web site: www.nihb.ore.

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IX.	CONTACTS/ACKNOWLEDGMENTS/RESOURCE MATERIALS/

BIBLIOGRAPHY

For further information on selected topics within the healthcare industry, a list of
publications and contacts is provided below:

IX.A.	Contacts/Document Reviewers11

Name

Organization

Telephone/Email

Subject

Seth Heminway

EPA, Office of
Compliance

(202) 564-7017/

heminwav.seth&.evamail. eva. gov

Overall Notebook
Content and General
Format

Anuj K. Goel, Esq.

Director, Regulatory
Compliance,
Massachusetts
Hospital Association

(781) 272-8000, ext. 140 /

agoel&mhalink. org

Characterization of the
Healthcare Industry

Charlotte A. Smith,
R. Ph., M.S., HEM

President,
PharmEcology
Associates, LLC

(262) 814-2635/
info(a)nharmecolo2v. com

Activity Descriptions

Laura Brannen

Hospitals for a
Healthy Environment

(603) 643-6700 /

laura. brannen(a)h2e-online. org

Hospital Wastes

Jeffrey Keohane

Karshmer &
Associates (P.C.)

(510) 841-5056/

keohane(ci)karshmerindianlaw .com

Environmental
Regulations on Indian
Country

Eydie Pines

Hospitals for a
Healthy Environment

(603)643-6710/

evdie. pines(a)h2e-online. org

Pharmaceutical Waste

Fawzi M. Awad,
M.S., E.H.S. II

Saint Paul-Ramsey
County Department of
Public Health,
Environmental Health
Section

(651)773-4459/

fawzi. awad(a).co. ramsev. mn. us

Minnesota Pollution
Control Agency Fact
Sheets

Catherine Galligan

Sustainable Hospitals
Project Clearinghouse
Manager

(978) 934-3386 /
shv@uml.edu

Healthcare Wastes and
Sustainable Hospitals
Project Fact Sheets

Kathleen Malone

EPA, Region 2

(212) 637-4083 /
malone. kathleen&.eva. gov

Federal Statutes and
Regulations

11 Many of the contacts listed in this section have provided valuable background information and comments during
the development of this document. EPA appreciates this support and acknowledges that the individuals listed do not
necessarily endorse all statements made within this Notebook.

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Contacts and References

Name

Organization

Telephone/Email

Subject

Susan A. Moak,
CHSP

Director of
Occupational and
Environmental Safety,
Long Island Jewish
Medical Center

(718) 470-4784/

Smoak(a).lii. edu

Overall Notebook
Content

Linda Longo

Regional Compliance
Assistance
Coordinator
EPA Region 2

(212) 637-3565/
longo. linda(a)eva. gov

Federal Statutes and
Regulations

Linda Martin

Veterans Health
Administration

(314) 543-6719/

linda. martin5(a)med. va. gov

Overall Notebook
Content

Michelle Yaras

EPA, Office of
Compliance -
Agriculture Division

(202) 564-4153 /

varas. michelle&.eva. gov

FIFRA Information

Marvin Stillman

Manager of
Environmental
Compliance
University of
Rochester Strong
Memorial Hospital

mstillman(a)facilities.rochester.edu

Overall Notebook
Content

Glenn McRae

CGH Environmental
Strategies, Inc.

(802) 658-5863 /

cghenviro(a),aol. com

Overall Notebook
Content

Hollie Schaner, RN,
FAAN

CGH Environmental
Strategies, Inc.

(802) 658-5863 /

cghenviro(a),aol. com

Overall Notebook
Content

Dale Woodin

Deputy Executive
Director, American
Society of Healthcare
Engineering (ASHE)

(312) 422-3813 /

dwoodin(a)aha. org

Healthcare Wastes

Cathy Knox

Director, EHS Parker
Hughes Cancer Clinic
(PHCC)

cknox@ih.org

Healthcare Wastes

Chen Wen

EPA, Office of
Pollution Prevention
and Toxics

(202) 564-8849 /
wen. chen&.eva. gov

H2E

John Gorman

EPA, Region 2

(212) 637-4008 /

gorman. iohn(a),epa. gov

Hazardous Waste
Compliance

Diane Buxbaum,
M.P.H.

EPA, Region 2

(212) 637-3919/
buxbaum. diane(a)eva. gov

Industry Specific

Environmental

Requirements

Diane Lynne

EPA, Federal
Facilities Enforcement
Office

(202) 564-2587 /
diane. Ivnne&.eva. gov

EPA-Veterans Health
Administration (VHA)
Compliance Assistance
Programs

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Contacts and References

Name

Organization

Telephone/Email

Subject

Linda Martin

Veterans Health
Administration

(314) 543-6719/

linda. martin5(a)med. va. sov

EPA-Veterans Health
Administration (VHA)
Compliance Assistance
Programs

Michael Fagan

EPA, Region 10 H2E
Coordinator

(206) 553-6646 /
fagan. michael&.eva. sov

Web Site Information

Jan Pickrel

EPA, Water Permits
Division, Industrial
Branch

(202) 564-7904 /
vickrel. ian(a).ena. sov

Healthcare Wastewater

Daniel Schultheisz

EPA, Radiation
Division

(202) 343-9349 /
schultheisz. daniel&.eva. sov

Mixed Waste

Carey Johnston

EPA, Office of Water

(202) 566-1014/
iohnston. carev(a).eDa. sov

Healthcare Wastewater

Kristina Meson

EPA, Office of Solid
Waste

(703) 308-8488 /
meson. kristina(a),epa. sov

Hazardous Waste

IX.B.	Bibliography

Below is a list of references used in compiling this Sector Notebook, by section.
The Healthcare Environmental Resource Center contains additional details on most of the
subjects touched on in this Notebook and is an excellent follow-up reference for locating
information on state and local requirements. For your convenience, the Center maintains
current URLs for all of the sites mentioned in this document at www.HERCenter. or2/links.

Section II - Introduction to the Healthcare Industry

American Hospital Association, http://www.hospitalconnect.com/aha/resource center/
fastfacts/fast facts US hospitals.html

The Centers for Medicare & Medicaid Services (CMS), http://www. cms.hhs. gov/.

The MedPAC reports, http://www. medpac. gov/.

U.S. Census Bureau, http://www.census.2Qv/prod/ec97/97s62-sz.pdf.

Webster's Medical Dictionary, http://www.abms.ore/Downloads/Which%20Med%20Spec.pdf.

The American Veterinary Medical Association, http://www.avma. ors/membshp/marketstats/

usvets.asp. Note: veterinary market statistics 2003 Economic Report on Veterinarians &
Veterinary Practices is available for purchase

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The TrendWatch report by the Lewin Group released at the 2004 AHA Annual Meeting in
Washington, www.hospitalconnect.com/aha/pressj-oom-info/specialstudies.html.

Section III - Activity Descriptions

Centers for Disease Control and Prevention, http://www.cdc.20v ncidod hip sterile steri/isp.htm

Hospitals for a Healthy Environment (H2E),

http://www.h2e-online.or2/pubs/chemmin/master.pdf
http://www.h2e-online.or2/pubs/wr2uide/wappe.pdf.

Occupational Health and Safety Administration,

http://www. osha. 20V/SL TC/e tools/hospital/index, html.

PRO ACT, http://www. afcee. brooks, af.mil/pro-act/pro-acthome. asp.

U.S. EPA Region 2 presentation. Identification and Management of Regulated Hazardous
Waste, A Workshop Geared Toward Healthcare Facilities, February 2004.

U.S. EPA Region 2, Draft Healthcare Hazardous Waste Management, February 2004.

U.S. EPA Region 3, http://www.epa.2Qv/re23artd/airre2ulations/ap22/incin2.htm.

World Healthcare Organization,

http://www.who.int/water sanitation health/medicalwaste/en/2uide2.pdf.

Emmanuel, Jorge,Ph.D., CHMM, REP, PE. Non-Incineration Medical Waste Treatment
Technologies. Health Care Without Harm, August 2001,
http://www.noharm.or2/nonincineration.

Hospitals for a Healthy Environment (H2E). Managing Healthcare's Waste: Developing a
Pollution Prevention Model, http://www.h2e-online, or2/.

Shaner, H.G., C.L. Bisson, G. McRae. An Ounce of Prevention: Waste Reduction Strategies for
Health Care Facilities. American Society of Healthcare Environmental Services,
Chicago, 1993.

Shaner, HG, G. McRae. Guidebook for Hospital Waste Reduction Planning and Program
Implementation. American Society of Healthcare Environmental Services. Chicago,
1996.

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Contacts and References

Smith, Charlotte A. Identifying and Managing Hazardous Pharmaceutical Waste.
PharmEcology Associates, LLC. H2E Teleconference, September 12, 2003,
http://www .h2e-online. org/tools/chem-pharm.htm.

University of Iowa Virtual Hospital Site, http://www.vh. om/welcome/aboutus/index. html.

U.S. Department of Labor Program Highlights Fact Sheet No. OSHA 91-38. Waste Anesthetic
Gases, http://www.0sha.20v/pls/0shaweb/0wadisp.sh0w document?
v table=FACT SHEETS&v id=128.

Section IV - Waste and Emissions Profile

EPA's Hospital/Medical/Infectious Waste Incinerators,

http://www.epa. 2Qv/ttn/atw/l 29/hmiwi/rihmiwi. html.

Health Care Without Harm, http://www. noharm. or 2 library docs /SHEA Proceedings Waste
Management White Paper.pdf:

http://www.noharm.or2/librarv/docs/Goin2 Green 4-1JVasteJMinimization
Se2re2ation.pdf:

http://www.noharm.or2/nonincineration:

http://www.noharm.or2/details. cfm?tvpe =document&id=599: and

http://www.noharm.or2/librarv/docs/Goin2 Green TheJMercurv Problem - Fast Fact
s.pdf.

Hospitals for a Healthy Environment, http://www.h2e-online.or2/tools/chemplan.htm.

U.S. EPA FRN 40 CFR Part 60 Standards of Performance for New Stationary Sources and
Emission Guidelines for Existing Sources: Hospital/Medical/Infectious Waste
Incinerators; Final Rule September 15, 1997,
http://www.epa. 2Qv/ttn/atw/l 29/hmiwi/fr9159 7.pdf.

U.S. EPA Region 2 presentation. Identification and Management of Regulated Hazardous
Waste, A Workshop Geared Toward Healthcare Facilities, February 2004.

U.S. EPA Region 2. Draft Healthcare Hazardous Waste Management, February 2004.

Western Regional Pollution Prevention Network,

http://www. w estp2ne t. or2/hospital/pdf/Minimizin2%2 0Red%2 0Ba2%2 0 Waste.ppt.

World Health Organization, http://www.who. int/inf-fs/en/fact253.html.

Environmentally Conscious Manufacturing Strategic Initiative Group. Hospitals and Health
Care Impacts, Risks and Regulations, http://ecm. ncms. or2/eri/new/IRRhosp. htm.

www, her center. or2/links

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Healthcare Industry

Contacts and References

Kentucky Cancer Registry Online Abstractor Manual, Appendix H,
http://www. kcr. ukv. edu/manuals/abstractor/appendix h.pdf.

Section V - Pollution Prevention Opportunities

California Integrated Waste Management Board. Fact Sheet: Waste Reduction Activities for
Hospitals, December 2003.

Davis, Stephanie C. 10 Ways to Reduce Regulated Medical Wastes (RMW). Waste Reduction
Remedies, June 2002.

Health Care Without Harm. Non-Incineration Medical Waste Treatment Technologies, August
2001.

Shaner, H.G., C.L. Bission, G. McRae. An Ounce of Prevention: Waste Reduction Strategies
for Health Care Facilities. American Society of Healthcare Environmental Services,
Chicago, 1993.

Shapiro, Karen, et.al. Healthy Hospitals: Environmental Improvements Through Environmental
Accounting. Tellus Institute, Submitted to U.S. EPA's Office of Prevention, Pesticides
and Toxic Substances, Boston, MA, July 2000.

Sustainable Hospitals Project Fact Sheets: These are available online at

http://www.sustainablehospitals. ore. Over two dozen short, informative summaries
address EPP, Glutaraldehyde, Laboratory Practices, Latex & Medical Gloves, Mercury,
Microfiber Mopping, and Safe Sharps Devices. (Note: A list of SHP fact sheets follows
this table). Contact: Catherine Galligan, SHP Clearinghouse Manager, phone (978) 934-
3386 or shp(a),uml.edu.

Minnesota Pollution Control Agency Health Care Fact Sheets: These are available online at
http://www.pca. state.mn. us/industry/healthcare, html. Over three dozen short,
informative summaries covering all aspects of the healthcare industry.

Section VI - Summary of Federal Statutes and Regulations

U.S. Army Center for Health Promotion and Preventive Medicine. Management of Unused

Pharmaceutical Nitroglycerin, http://chppm-www. apzea. army. mil/documents/FA CT/3 7-
019-702.pdf.

U.S. EPA Monthly Hotline Report December 1994 RCRA/UST, Superfund, and EPCRA.
Notification Requirements for Exported Wastes,
http://www. epa. 2Qv/epaoswer/hotline/94report/l2 94. txt.

www, her center, org links

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Healthcare Industry

Contacts and References

U.S. EPA Region 2 presentation dated February 2004. Identification and Management of
Regulated Hazardous Waste, A Workshop Geared Toward Healthcare Facilities.

U.S. EPA Region 2. Draft Healthcare Hazardous Waste Management, February 2004.

Kentucky Pollution Prevention Center. Healthcare Guide to Pollution Prevention
Implementation through Environmental Management Systems,

http://www.kppc.or2/Publications/Print%20Materials/Healthcare%20Guide/index.cfm.

Electronic Code of Federal Regulations (e-CFR) BETA TEST SITE for 40 CFR:

http://ecfr. spoaccess. gov/csi/t/text/text-idx?&c =ecfr&tpl=/ecfrbrowse/Title40/40tab 02.
tpl.

The Office of Wastewater Management, NPDES Stormwater Program web site:
http://www.epa. 20v npdes stormwater.

EPA's Office of Solid Waste and Emergency Response web site:
http://www. epa. 20v epaoswer osw laws-reis. htm.

EPA's Oil Program web site: http://www.epa.2Qv/oilspill/.

EPA's Poly chlorinated Biphenyl (PCB) Homepage, http://www. epa. sov/pcb/.

EPA's Air Program Mobile Sources web site:
http://www. epa. sov/ebtpases/airmobile sources, html.

EPA's Asbestos Management and Regulatory Requirements web site:
http://www. epa. 2Qv/fedsite/cd/asbestos. html.

www, her center. or2/links

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