DEPARTMENT: Engineering and Facility POLICY DESCRIPTION: Environmental –
Management
Environmental Self-Audit of Facilities
PAGE: 1 of 3
REPLACES POLICY DATED: 11/1/05 (DC.018)
EFFECTIVE DATE: May 1, 2007
PROCEDURE NUMBER: ENV.018
APPROVED BY: Ethics and Compliance Policy Committee
SCOPE: All Company-affiliated facilities including, but not limited to, hospitals, ambulatory
surgery centers, outpatient imaging centers, home health agencies, physician practices, and all
Corporate Departments, Groups and Divisions and on-site subcontractors.
PURPOSE: To provide the self audit tool to be used in assessing current compliance with the
Environmental Policies and Procedures.
POLICY:
1. All employees, subcontractors, and vendors of HCA-affiliated facilities are expected to carry out
their roles and responsibilities in a manner that is protective of human health and the
environment. Concerns or violations of this policy may be reported to your supervisor or via the
Ethics Line at 1-800-455-1996.
2. Pursuant to the Environmental – General Policy, ENV.001, facilities must conduct a self-audit at
least every three (3) years to demonstrate compliance with corporate policies, environmental
statutes and regulations.
3. Facilities must use the Environmental Compliance Questionnaire attached to this policy as the
facility self-audit tool
4. Facilities must submit a completed Environmental Compliance Questionnaire to the Corporate
Engineering and Facility Management Department every three years as set forth in the procedure
section below.
5. The Environmental Compliance Questionnaire serves the following purposes:
 Functions as a checklist so the responsible manager at the facility can verify compliance with
the Environmental Policy and Procedures requirements
 Ensures facilities are systematically gathering and preserving important environmental
documents
 Provides an off-site, back-up copy of critical environmental documents in case original
documents are misplaced through human error or destroyed in a natural disaster. In such
cases, the staff of the Facility Management Engineering Services Department will provide the
documents to the facilities immediately.
 Assists facilities in identifying actual or potential environmental and operational deficiencies.
Some resources for corrective actions may be available through the Corporate Engineering
and Facility Management Department or the Corporate Insurance Department.
4/2007
DEPARTMENT: Engineering and Facility POLICY DESCRIPTION: Environmental –
Management
Environmental Self-Audit of Facilities
PAGE: 2 of 3
REPLACES POLICY DATED: 11/1/05 (DC.018)
EFFECTIVE DATE: May 1, 2007
PROCEDURE NUMBER: ENV.018
APPROVED BY: Ethics and Compliance Policy Committee
DEFINITIONS:
Responsible Manager – the individual in each facility charged with maintaining compliance with
federal, state, and local environmental statutes and regulations for the facility. The Responsible
Manager may be a designated Environmental Compliance Officer, ES&H manager, facility manager,
or plant operations manager depending on the local organizational structure and management roles
and responsibilities.
Facility Executive – the individual with fiscal authority at each facility.
Environmental Compliance Corrective Action Log – a facility-based electronic or paper system
designed to identify, track, and validate completion of actions taken to correct environmental
deficiencies. Existing facility-based tracking systems, if any, may be used.
PROCEDURE:
1. The Responsible Manager for environmental compliance must perform or supervise the
completion of the Environmental Compliance Questionnaire.
2. The Responsible Manager for environmental compliance or designee must transmit the completed
Environmental Compliance Questionnaire and attachments to the Corporate Engineering and
Facility Management Department by June 30th of every third year.
3. The Corporate Engineering and Facility Management Manager and the facility’s Operations
Counsel will review completed Questionnaire.
4. The Facility Executive at a facility needing corrective action projects must incorporate corrective
actions into the facility budget cycle, as appropriate.
NOTE: Corrective action projects may include compliance education, field investigation,
remediation construction project, environmental clean-up and so on.
5. The Corporate Insurance Department and Engineering and the Facility Management Department
personnel review corrective actions projects to determine if the costs are recoverable through
insurance coverage.
6. The Responsible Manager for environmental compliance at the facility must enter corrective
actions identified during the compliance audit into the Environmental Compliance Corrective
Action Log, establish a schedule for corrective actions to be completed, and verify actual
completion of the corrective action with an entry in the Environmental Compliance Corrective
4/2007
DEPARTMENT: Engineering and Facility POLICY DESCRIPTION: Environmental –
Management
Environmental Self-Audit of Facilities
PAGE: 3 of 3
REPLACES POLICY DATED: 11/1/05 (DC.018)
EFFECTIVE DATE: May 1, 2007
PROCEDURE NUMBER: ENV.018
APPROVED BY: Ethics and Compliance Policy Committee
Action Log – or revise the schedule as necessary.
7. The Corporate Engineering and Facility Management Manager may review the entries in the
Environmental Compliance Corrective Action Log as necessary.
REFERENCE:
:
Environmental – General Policy, ENV.001
Environmental Compliance Questionnaire (attached)
4/2007
ENVIRONMENTAL COMPLIANCE
QUESTIONNAIRE
Information provided in this report is the sole property of HCA – The Healthcare Company and
is not to be distributed, reproduced, or altered without consent of the Corporate Engineering
and Facility Management Department. The Facility Management, Hospital Plant Operation or
Hospital Risk Management staff at the facility should complete this questionnaire.
Facility Name:
Date: _____________________
Address: _____________________________________________________________
Municipality:__________________ County: ____________Zip Code: ____________
Hospital CEO:
Phone: ____________________
Person Completing
Questionnaire:
Phone: ____________________
Years with Company: ___________________
Person(s) Providing Information for Questionnaire:
1.
2.
3.
Signature:
Print name:
Title:
Date:
1
4/2007
Attachment to ENV.018
ENV.004 AIR EMISSIONS COMPLIANCE
Air Emissions Compliance
Comments
In place
(yes or no)
Is the facility subject to air
emissions permitting
requirements? Depending on
the heat input capacity of
boilers, a facility may be
subject to air emissions
permitting requirements.
The heat input (in terms of million
Btu/hour) of the gas fired or oil-fired
boiler against the state regulatory
threshold levels determine if whether
permitting is necessary.
If a facility uses an
incinerator for biomedical
waste treatment, the facility
must maintain a medical
waste incinerator permit, a
permit exception, or proof of
permit-by-rule.
Reporting requirements and
procedures are usually stated in the air
permit.
Are paint booths and parts
washer included on the air
permits?
Are the lids of parts washers
in place, functional and kept
closed when not in use?
Are the sterilizers and
associated ventilation
systems check periodically
for proper operation?
Certain product releases (including
VOCs) are subject to emission
exposure guidelines
This must be done to reduce unwanted
emissions.
Has the facility reviewed the
list of EPA hazardous air
pollutants and properly
reported those chemicals?
The EPA has classified 189 chemicals
as hazardous air pollutants and has
established limits and reporting
requirements.
Does the facility use EPAcertified and qualified
technicians to service
equipment containing CFCs?
The EPA Clean Air Act prohibits the
release of CFCs to the atmosphere and
requires that they be phased out.
Further Action
If the facility has ethylene oxide
sterilizers the sterilizers and associated
ventilation and exhaust systems must
be properly maintained. Some states
require a catalytic converter to abate
ethylene oxide exhaust.
2
4/2007
Attachment to ENV.018
ENV.005 ASBESTOS COMPLIANCE
Asbestos Compliance
Comments
Does the facility have a
formal asbestos Operations
and Maintenance (O&M)
program?
Facilities must have a written program
documenting what ACM material are
in the facility and what actions must
be taken with these materials when
they are disturbed
If applicable, each facility should have
a report of all asbestos containing
materials within the facility
If asbestos is in a facility, training is
mandatory for custodial and
maintenance staff who could contact
asbestos containing material (ACM).
Initial training is 2 hours in duration.
An annual refresher is required.
Individuals conducting asbestos
repairs must receive OSHA required
16 Hour O&M training. An annual
refresher is required.
Does the facility have a
current asbestos survey?
Have maintenance and
custodial staff received
OSHA required annual
asbestos awareness training?
Are asbestos operations and
maintenance personnel
conducting ACM repairs
properly trained and
accredited?
Is proper notification given
on asbestos projects?
Is asbestos waste properly
handled, packaged,
manifested and disposed?
In place
(yes or no)
Further Action
The EPA must be notified of asbestos
abatement projects greater than 160
square or 260 linear feet. State and
local regulations may be more
stringent. Copies of all project
notifications must be retained at the
facility.
Asbestos waste requires special
packaging, handling and disposal. All
asbestos waste from a facility must be
properly disposed of and manifested.
Copies of all manifests must be
retained at the facility.
3
4/2007
Attachment to ENV.018
HAZARDOUS WASTE COMPLIANCE
Hazardous Waste
Compliance
Does the facility have a
policy for handling
hazardous wastes that insures
compliance with the EPA,
DOT and State
requirements?
Are hazardous wastes
properly characterized,
stored, labeled, and shipped?
Are employees properly
trained in hazardous waste
management?
Does the facility have a
policy for handling
Polychlorinated Biphenyls
(PCBs)? The policy should
address, spill response,
handling, disposal.
Does the facility have a
policy for handling mercury?
The policy should address,
spill response, handling,
disposal.
Are chemotherapy drugs
being properly handled and
disposed?
Does the facility have a
waste oil management
program?
Does the facility have a
policy for the proper disposal
of fluorescent light tubes?
Comments
In place
(yes or no)
Further Action
This policy is required and should be
readily available for any questions that
may arise.
Required by Federal and State
regulations. Following the proper
characterization of wastes will help to
reduce costs associated with disposal.
Any employee that handles hazardous
waste must be trained in proper
methods.
PCBs were used in nonflammable
cooling oils in electrical transformers,
hydraulic equipment, capacitors and
other electrical equipment. Capacitors
are also found in fluorescent light
ballasts. PCBs are a regulated
hazardous waste.
Mercury is a regulated waste. Anyone
that will handle mercury must be
trained in proper methods.
Chemotherapy drugs are classified by
the EPA as U-listed and P-listed
hazardous materials.
Waste oil is regulated and should be
recycled when possible, disposed of as
a final alternative.
Fluorescent light tubes are regulated
under universal wastes and must be
handled as such.
4
4/2007
Attachment to ENV.018
HAZARDOUS MATERIAL COMPLIANCE
Hazardous Material
Compliance
Does the facility have a
Hazard Communications
Program?
Are employees properly
trained on hazardous
materials?
Has the facility complied
with the chemical reporting
requirements of the
Emergency Planning and
Community Right-to-Know
Act (EPCRA)?
Does the facility have an
environmental emergency
response plan?
Does the facility have a
hazardous materials
plan?
Comments
In place
(yes or no)
Further Action
Hazard Communication is required
and should be readily available in the
event of questions or emergencies
Any employee that handles materials
must be trained in proper methods.
Facilities are required to report to the
Local Emergency Planning
Committees (LEPCs) the presence of
certain hazardous materials if certain
quantities are exceeded.
Federal regulations require a facility to
have a plan for emergencies or
environmental disasters. Each facility
should develop an environmental
emergency response plan that
incorporates the requirements of
various applicable regulations.
The plan should address hazardous
materials stored in each department.
The plan should address but should
not be limited to the quantities stored,
condition of storage, security of
substances, disposal, etc.
UNDERGROUND STORAGE TANK COMPLIANCE
Underground Storage
Tank (UST) Compliance
Were USTs either upgraded
or properly closed by
December 12, 1998?
Are all UST leak detection
systems tested periodically
and functioning properly?
If a leak has occurred from a
UST has it been properly
reported and documents?
Comments
In place
(yes or no)
Further Action
Federal law required upgrade or
replacement of all tanks by this date.
Federal law requires these systems be
in place and enacted to ensure that no
contamination has taken place.
A confirmed release must be reported
to the EPA or delegated state agency
within 24 hours.
5
4/2007
Attachment to ENV.018
BIOMEDICAL WASTE MANAGEMENT
Biomedical Waste
Management
Does the facility have a
policy for handling
biomedical wastes?
Comments
In place
(yes or no)
Further Action
Biomedical wastes are to be
segregated from all other wastes.
Untreated biomedical wastes are to be
released to a DOT licensed
transporter. Biomedical wastes can
only be treated by a properly licensed
facility. State regulations must be
reviewed to insure full compliance.
WATER VIOLATIONS COMPLIANCE
Water Compliance
Comments/questions
Does the facility have a
wastewater management
policy?
The municipal wastewater treatment
plant that is permitted by EPA controls
all discharge to sewers. Discharge of
priority pollutants and certain
materials are normally prohibited by
the municipality. The facility must
review the prohibited discharges
contained in the local sewer use
ordinance.
An NPDES permit is required for
facilities if their discharges go directly
to surface waters
Is the facility subject to a
pretreatment permit or a
National Pollutant Discharge
Elimination Permit (NPDES)
permit?
Does the facility have a Spill
Prevention Control and
Countermeasure (SPCC)
plan in place?
In place
(yes or no)
Further Action
A plan must be prepared in accordance
with EPA regulations, 40 CFR Part
112, “Oil Pollution Prevention.” Spill
events subject to the plan include but
are not limited to, “ any spilling,
leaking, pumping, pouring, emitting
and dumping of oil of any kind or any
form, including but not limited to,
petroleum, fuel oil, sludge, oil refuse,
and oil mixed with wastes other than
dredged spoils.”
6
4/2007
Attachment to ENV.018
SAFETY COMPLIANCE
Safety Compliance
Comments/questions
In place
(yes or no)
Does the safety officer make
formal periodic safety
rounds?
Are proper safety plans in
place and followed?
These safety rounds should be done
periodically and documented.
Further Action
Plans should include general safety,
construction safety, fire safety, etc.
INFECTION CONTROL COMPLIANCE
Water Compliance
Comments/questions
In place
(yes or no)
Does the facility have a
formal infection control risk
assessment (ICRA)?
The infection control plan should
address routine maintenance
procedures as well as renovation and
construction activities. The plan
should incorporate the AIA and CDC
guidelines.
Further Action
7
4/2007
Attachment to ENV.018