POLICY DESCRIPTION: Environmental – Air
Pollution Emission and Control
REPLACES POLICY DATED: 1/12/99, 7/21/99,
11/1/05 (DC.004)
EFFECTIVE DATE: May 1, 2007
REFERENCE NUMBER: ENV.004
APPROVED BY: Ethics and Compliance Policy Committee
DEPARTMENT: Engineering and Facility
Management
PAGE: 1 of 4
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 require each facility to comply with environmental permitting, operating, response
and reporting procedures with respect to air or gaseous emissions and air pollution controls in
accordance with Environmental Protection Agency (EPA), state, and/or local regulations.
POLICY:
1. Federal and state environmental regulations affect a facility’s compliance plan for air emissions.
The Facility Manager or Director must be familiar with all potential air pollutant emission sources at
the facility.
2. Facilities must report incidents of an unpermitted (usually associated with an accident) or
uncontrolled (exceeding the permitted level) air pollutant emission episode occurring at the facility
to the state air pollution control agency.
3. In the event of an unplanned release of an air pollutant, a facility must follow these basic priorities:
a. protect patients, visitors, and employees from injury;
b. prevent further release of air pollutants to the environment;
c. protect property from damage; and
d. report regulated air pollutant release to appropriate agencies.
4. If a facility is located in a non-containment area, facility personnel must follow the special
procedures/requirements approved by relevant local authorities.
This policy addresses federal regulatory requirements. State laws or regulations may impose
additional requirements. Each facility should consult with Corporate Engineering and Facility
Management and the facility’s Operations Counsel to identify and comply with any such additional
requirements.
DEFINITION:
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.
4/2007
POLICY DESCRIPTION: Environmental – Air
Pollution Emission and Control
REPLACES POLICY DATED: 1/12/99, 7/21/99,
11/1/05 (DC.004)
EFFECTIVE DATE: May 1, 2007
REFERENCE NUMBER: ENV.004
APPROVED BY: Ethics and Compliance Policy Committee
DEPARTMENT: Engineering and Facility
Management
PAGE: 2 of 4
PROCEDURE:
1. The Responsible Manager shall review health care operations requiring compliance with air
emissions and air pollution control including:
a. on-site incineration of biomedical waste;
b. ethylene oxide sterilization;
c. toxic air emissions;
d. refrigeration chemical management;
e. boiler operation; and
f. emergency generator operation.
2. The Responsible Manger shall be familiar with air pollution emission incidents that may have
federal, state, or local reporting requirements including:
a. fire or explosion;
b. toxic gaseous chemical (e.g., ethylene oxide, chlorine) leak;
c. incinerator malfunction or improper operation of incinerator;
d. improper dust suppression or isolation during construction or renovation activities;
e. deficiency in chemical storage or chemical handling practice; and
f. malfunction of any air pollution control equipment (scrubber or catalytic converter).
3.
The Responsible Manager or Director must review the heat input (in terms of million BTU/hour) of
the gas- or oil-fired boiler against the state regulatory threshold levels to determine whether an air
pollution control permit is needed. Depending on the heat input capacity rating of boilers, a facility
may be subject to air emissions permitting requirements.
4.
The Responsible Manager must determine if a facility uses an incinerator for biomedical waste
treatment. The Responsible Manger must keep a medical waste incinerator permit, a permit
exemption, or proof of permit-by-rule. Reporting requirements and procedures for uncontrolled air
pollutant emissions from the incinerator are usually stated in the air permit.
5.
The Responsible Manager must ensure that asbestos fibers are not released. Asbestos fiber releases
that occur during a fire, flood, or asbestos abatement project must be reported to regulatory
authorities and should be handled jointly by an asbestos abatement contractor and facility personnel.
6.
The Responsible Manager must be aware that EPA has classified ethylene oxide as an “extremely
hazardous air pollutant.” OSHA has classified ethylene oxide as a “highly hazardous chemical.”
By definition, this chemical causes death, injury, serious adverse effects to human health and the
environment if it is accidentally released. All safety procedures recommended by the sterilizer
4/2007
POLICY DESCRIPTION: Environmental – Air
Pollution Emission and Control
REPLACES POLICY DATED: 1/12/99, 7/21/99,
11/1/05 (DC.004)
EFFECTIVE DATE: May 1, 2007
REFERENCE NUMBER: ENV.004
APPROVED BY: Ethics and Compliance Policy Committee
DEPARTMENT: Engineering and Facility
Management
PAGE: 3 of 4
manufacturer must be followed. In some states, a catalytic converter is required to abate ethylene
oxide sterilizer exhaust. Never disengage any air pollution control device. Do not exhaust the
ethylene oxide sterilizer off-gas to sewer. Major elements requiring routine inspection and regular
maintenance include:
a. tank/cylinder storage room, and loading room;
b. ethylene oxide sterilizer;
c. detection instruments and alarm system;
d. emission control equipment;
e. duct work and exhaust piping; and
f. health and safety equipment and material supply.
7.
The Responsible Manager must review the list of 189 chemicals classified by the EPA as hazardous
air pollutants and ensure the facility is operating within the established limits and reporting
requirements. Each facility must review the list of chemicals used at the facility against the
regulatory reporting limits.
8.
The Responsible Manger or designee must make annual notification to federal and/or state
authorities for facilities manufacturing, emitting, or possessing hazardous air pollutants.
9.
The Responsible Manager must ensure compliance with SARA Title III (Section 304) which
requires a facility to provide a notification of any release of an Extremely Hazardous Substance
(EHS) or Comprehensive Environmental Response, Compensation and Liability Act (CERCLA)
hazardous substance in an amount equal to or greater than the reportable quantity (RQ) to the
appropriate authorities.
10. The Responsible Manager may be required by the EPA to file a Risk Management Plan if a facility
stores more than 18,000 gallons of propane. A Risk Management Plan must be updated and
certified every five years. Preparation of a Risk Management plan should be coordinated with the
Corporate Engineering and Facility Management Department.
11. Refrigerants, including chlorofluorocarbons (CFCs) and hydrochlorofluorocarbons (HCFC), are
used in chillers, air conditioners, ice makers, and refrigerators. CFC is also used as a diluent in
ethylene oxide sterilizers. Clean Air Act Amendments (CAAA) prohibit the release of CFCs to the
atmosphere and require use of these substances be phased out. Each facility must use EPA-certified
technicians to service equipment containing CFC and HCFC refrigerants. A facility may store
CFCs in a secure outdoor location; or in a properly lighted, forced-air ventilated room, or a
continuously ventilated room provided that:
a. the location is locked at all times with controlled access and there is a proper sign at the
entrance;
4/2007
POLICY DESCRIPTION: Environmental – Air
Pollution Emission and Control
REPLACES POLICY DATED: 1/12/99, 7/21/99,
11/1/05 (DC.004)
EFFECTIVE DATE: May 1, 2007
REFERENCE NUMBER: ENV.004
APPROVED BY: Ethics and Compliance Policy Committee
DEPARTMENT: Engineering and Facility
Management
PAGE: 4 of 4
b. a respirator is located outside the room at a visible place;
c. forced-air venting is provided before personnel enter the location (manual switch located
outside the entrance);
d. pure and spent refrigerants are separated and properly labeled;
e. inventory is maintained and the room is inspected bi-weekly; and
f. if refrigerants are co-stored with hazardous materials, the stricter health and safety
requirements are observed.
REFERENCES:
EPA regulation: SARA Title III Section 302
29 CFR 1910.109 and 119, OSHA Process Safety Management of Highly Hazardous Chemicals
Federal EPA Clean Air Act Amendments of 1990
HCA CFC Questions and Answers (see attached)
4/2007
AIR POLLUTION EMISSION AND CONTROL
CHLOROFLUOROCARBON (CFC) QUESTIONS AND ANSWERS
1. Do I need to buy recovery equipment to comply with the 1990 Clean Air Act Amendment
(CAAA)?
Yes, if your facility staff will be servicing any CFC-containing equipment. The person servicing
such equipment must not allow refrigerant to be vented to the atmosphere. This is accomplished by
connecting a refrigerant recovery device to the equipment and withdrawing the refrigerant into
storage tank(s) while the equipment is serviced.
The alternative is to contract with a vendor for all maintenance of CFC-containing equipment. You
must ensure that the contractor utilizes a recovery device to prohibit venting of CFC to the
atmosphere.
Historically, facility maintenance personnel maintained small equipment such as through-wall A/C
units, ice machines, etc., but contract for maintenance of chillers and large DX equipment. Now,
facilities must either re-think their policy on in-house maintenance or purchase a recovery device
(approximate cost $1,700). If a recovery device is to be purchased, units from national vendors such
as Trane™ or Carrier™ are recommended.
2. Do I need to install a high efficiency purge on my chiller(s)?
Yes, this is required in chillers using R-11 refrigerants only. If this has not already occurred or you
have questions, please contact the HCA Engineering and Facility Management Department for
information and support.
3. Should I have facility personnel attend refrigeration equipment/maintenance seminars to
obtain a refrigerant handling certification now?
You are required to ensure personnel who perform maintenance on CFC-containing equipment are
properly trained and certified by EPA. Have your staff enroll only in those certification or training
programs approved by the EPA or your state or local authority.
4. Should I assign facility personnel to service refrigeration units?
Only if you have a recovery device and have trained certified staff. Otherwise, you need to retain a
qualified contractor to perform maintenance. During emergency maintenance, your staff or service
contractor may respond as necessary. Release of CFC during an emergency is reportable to the
authority having jurisdiction (i.e., EPA or state air pollution control office).
2/2007
Attachment to ENV.004
Page 1 of 2
5. Do I need to sign a Hazardous Waste Manifest when I remove a shipment of spent refrigerant?
It depends on the final destination of the shipment. If the shipment is to be recycled, a receipt or
invoice indicating the type, quantity, date of removal from the facility and the person receiving the
shipment should suffice.
If the shipment is for any purpose other than transfer to another company facility or for recycling,
the shipment is classified as a hazardous waste. The shipment must then comply with all hazardous
waste regulations, and be accompanied by a Hazardous Waste Manifest.
6. What should I do to plan for the phase-out of CFCs?
a. If you have major chilling equipment which uses a CFC-type refrigerant (R-11, R-12, R-113, R500, etc.), contact HCA Engineering and Facility Management personnel (listed below) to insure
that your facility’s equipment is included in the corporate CFC Compliance Phase-Out
Replacement Program.
b. Do not dispose of any CFC-type refrigerant (R-11, R-12, R-113, R-500, etc.). If you are
removing equipment which uses CFC-type refrigerant or if the refrigerant becomes
contaminated, contact HCA Engineering and Facility Management Department for recovery and
reclamation support.
c. If you need to acquire a CFC-type refrigerant, contact the HCA Engineering and Facility
Management Department for availability of refrigerant under the corporate program.
7. How do I properly store CFCs at my facility?
You may store CFCs in a secure outdoor location or in a properly lighted, forced-air ventilated room
(e.g., existing hazardous material storage room) provided that:
a. the location is locked at all times with controlled access and a proper sign at the entrance;
b. a respirator is located outside the room at a visible place;
c. forced-air venting is provided before personnel enter the location (manual switch located outside the
entrance);
d. pure and spent refrigerants are separated and properly labeled;
e. inventory is maintained and the room is inspected bi-weekly; and
f. if refrigerants are co-stored with hazardous materials, the stricter health and safety requirements are
observed.
8. What should I do about the CFCs used in my Ethylene Oxide (ETO) sterilizer?
Many ETO sterilizers use a mixture that is 88% CFC and 12% pure ETO. Technically, the CFC
used is a diluent, not a refrigerant and therefore not subject to the CAAA (subject to change). You
should plan for replacing the 88/12 sterilizer with a 100% ETO type when the sterilizer is due for
replacement. If a compatible replacement for CFC becomes available, you should consider
switching to the new diluent until the (88/12) sterlizer is due for replacement.
2/2007
Attachment to ENV.004
Page 2 of 2