Document MJ1mdnrK2pLR0g4mDGoej58Qx

Report Prepared by: Report Approved by: RCRA COMPLIANCE EVALUATION INSPECTION Columbia Memorial Hospital 71 Prospect Avenue Hudson, New York 12534 NYD080481708 MOLLY Digitally signed by MOLLY HILLENBRAND HILLENBRAND Date: 2025.01.22 ____________1_5:_49_:55_-_05_'00_' _____________ Molly Hillenbrand, Life Scientist PHILIP Digitally signed by PHILIP COCUZZA COCUZZA Date: 2025.01.28 13:22:06 -05'00' ________________________________ Phil Cocuzza, Monitoring Operations Section Supervisor Columbia Memorial Hospital NYD080481708 Inspection Date: December 19, 2024 OBJECTIVE An unannounced Resource Conservation and Recovery Act (RCRA) Compliance Evaluation Inspection (CEI) was conducted at Columbia Memorial Hospital on December 19, 2024. The purpose of the inspection was to obtain information on the facility's hazardous waste management program. This information will be used to determine compliance with the regulations pertaining to RCRA. 2.0 KEY PARTICIPANTS U.S. Environmental Protection Agency Molly Hillenbrand, Life Scientist (732) 321-4452, Hillenbrand.molly@epa.gov Robert Morrell, Geologist (732) 906-6804, Morrel.Robert@epa.gov Columbia Memorial Hospital Stephanie Hisgen, Chief Nursing Officer (518) 757-8523, shisgen@cmh-net.org Tracy Johnson, Pharmacy Supervisor (518) 828-8259, tjohnson@cmh-net.org Nacouban Toure , Director of Environmental Services (518) 364-5424, ntoure@cmh-net.org Ryan Lankford (518) 967-7758, rlankford@cmh-net.org Page 2 of 11 Columbia Memorial Hospital NYD080481708 Inspection Date: December 19, 2024 Facility Description Columbia Memorial Hospital is part of Columbia Memorial Health, a multi-campus health care organization and an affiliate of the Albany Med Health System. Columbia Memorial Hospital, located at 71 Prospect Avenue, Hudson New York, 12534, an acute care hospital began operations at its current address in 1900. The hospital is open 24 hours per day, seven days a week, and has a staff of 1700 employees. The hospital provides a variety of services including emergency services, general surgeries, and psychiatric care. Sector Information NAICS Code: NAICS - 62211- General Medical and Surgical Hospitals Wastewater There is no process wastewater discharge. Sanitary wastewater is discharged to the local Publicly Owned Treatment Works (POTW). Solid and Hazardous Waste Management Columbia Memorial Hospital's hazardous waste is generated in its pharmaceutical rooms, wholesale room and the IV room. In the intensive care unit's pharmaceutical room, pharmaceutical waste was placed in black hazardous waste containers. On the day of inspection one black 8-gallon hazardous waste container labeled "Pharmaceutical Waste Only RCRA Hazardous Waste" (Photograph #1) was observed. In the wholesale room, pharmaceutical waste is sorted. Applicable expired or unsold medications are returned for credit. Pharmaceutical waste not returned for credit is seperated into hazardous waste containers based on compatibility. At the time of inspection there were two 2-gallon containers labeled "RCRA Hazardous Waste Pharmaceutical Aerosol/ Inhaler Waste"; one 2-gallon container labeled "Pharmaceutical Corrosive Waste"; and one 2-gallon container labeled "Pharmaceutical Oxidizer Waste" (Photograph #2). Plisted waste is periodically generated from the packaging of Warfarin. The packaging is placed in a sealed plastic bag and labeled as P-listed hazardous waste. Less than 2.2 lbs of P-listed hazardous waste were recorded to have been accumulated on site at the time of the inspection. In the IV room where pharmaceutical compounding occurs, the waste is placed in an 8-gallon container and labeled RCRA Hazardous Waste. At the time of inspection, 2 black 8-gallon containers were observed. Containers are collected from each room and transferred to the hazardous waste accumulation room. Page 3 of 11 Columbia Memorial Hospital NYD080481708 Inspection Date: December 19, 2024 The hospital stores its biohazardous and RCRA hazardous waste in its Hazardous Waste Central Accumulation Area. On the day of inspection, one 55-gallon plastic drum labeled as "RCRA Hazardous Waste Containing Waste Medicine, liquid, flammable, toxic N.O.S ( Ethanol, insulin)3(6.1).PGII" (Photograph # 3) was observed. The 55-gallon drum was in good condition, with waste codes: D001, D005, D007, D009, D010, D011, D022, D024, D026, U010, U188, U205, U236. The container was sealed and labeled with the accumulation start date December 12, 2024. A walkthrough of the hospital's laboratory was conducted. No RCRA hazardous waste was observed. All waste observed was medical/biohazardous waste. Both biohazardous waste and RCRA hazardous waste is managed by Advant-Edge Solutions. Advant-Edge Solutions removes biohazardous waste from the hazardous waste accumulation area weekly; they remove RCRA hazardous waste as needed. RCRA hazardous waste is shipped using Approved Storage & Waste Hauling II, Inc to Northland Environmental, which is located in Providence, Road Island. Records Review The Uniform Hazardous Waste Manifests, from January 1, 2024, to December 19, 2024, were reviewed; training documentation was also reviewed. A review of the hazardous waste manifests indicated that Columbia Memorial Hospital is a Small Quantity Generator of hazardous waste, with an estimated average of 180 kg generated per month. Hazardous waste safety training is provided two times a year to the employees that handle hazardous waste. Applicable employees, including the director of environmental services, have completed Department of Transportation (DOT) training. In addition, Columbia Memorial Hospital maintains a Hazmat management system plan to address the risks associated with hazardous material. Weekly inspections of the hazardous waste accumulation area are conducted, and records were maintained. Observations Inconsistencies and discrepancies were noted in the reviewed manifests. The preprinted information on the paper manifest forms was consistently crossed out. Additionally, the units reported for the quantity of hazardous waste shipped deviates between pounds and gallons. Inconsistencies in manifest documentation may lead to errors. For transported hazardous waste on May 23, 2024, manifest tracking number 026555324JJK, the manifest reports a shipment of 5 gallons of UN1950 Waste Aerosols; under special handling instructions and additional information, it is noted that only 2 gallons of UN1950 Waste Aerosols was shipped. Manifest 026555323JJK, signed by the transporter on June 27, 2024, does not have a date included with the generator's certification signature in item 15. According to 40 Page 4 of 11 Columbia Memorial Hospital NYD080481708 Inspection Date: December 19, 2024 CFR 262.27 Waste Minimization Certification, a generator who initiates a shipment of hazardous waste must certify the waste minimization statement. According to the EPA hazardous waste manifest instructions for the completion of form 8700-22, in Item 15 of the uniform hazardous waste manifest, the generator must read, sign, and date the waste minimization certification statement. Attachments Attachment 1: May 23, 2024, manifest tracking number 026555324JJK, the manifest reports a shipment of 5 gallons of UN1950 Waste Aerosols while description reports 2 gallons of UN1950 Waste Aerosols shipped Attachment 2: Manifest 026555323JJK, signed by the transporter on June 27, 2024, does not have a date included with the generator's certification signature in item 15 Photographs Photograph 1: 8-gallon satellite container of pharmaceutical waste located in ICU pharmaceutical room Photograph 2: RCRA hazardous waste categorized satellite containers located in wholesale room. Photograph 3: 8-gallon hazardous waste satellite containers located in IV room for pharmaceutical waste Photograph 4: The Hazardous Waste Central Accumulation Area observed 55-gallon plastic drum labeled as RCRA hazardous waste containing waste medicine, liquid, flammable, toxic N.O.S ( Ethanol, insulin)3(6.1).PGII Page 5 of 11 Columbia Memorial Hospital NYD080481708 Inspection Date: December 19, 2024 ATTACHMENTS Page 6 of 11 "UUBDINFOU.BZ NBOJGFTUUSBDLJOHOVNCFS++, UIFNBOJGFTUSFQPSUTBTIJQNFOUPGHBMMPOTPG 6/8BTUF"FSPTPMTXIJMFEFTDSJQUJPOSFQPSUTHBMMPOTPG6/8BTUF"FSPTPMTTIJQQFE t Please 0r rurl Form UNIFORM HAZARDOUS 1. WASTE MNIFEST Page Response JJK Address rxEgrHlil,1 fJ'Zt ig$t'S CoilaiomdH Hmilbl ?l PrpdAvq lhdran, l{Y 12531-28f1 7. Transporler fppdE t Sot0G I Wrsto Haffig ll hc ltR0rlt)23748? EPA o. and Address Phone: ffD?Er{S&at0 Na{dfurfllentd fr$l$ilvc Roldslca, Rlt2905 9a. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Clss, lD Number, HM and Packing Group (if anY)) f, ${321s. WASIE tEDrdllE t0'lD. Futl8tE" Toxlc xoe iEI}l01*sut$l r{.rFol 2. a rx{t950. ttTE AEno6d, zl OlrnrrruOC,rt+gg-- U.S. EPA lD Number Rltxl10lE8g52 10. Continers No. Type I' DF 11. Total Quantity 5 \ DF 5 12. Unit M./Vol. 6 13. Waste Codes Do2{ R1S G iF 4 @ qb \e IoBt{o3e#o{b oo\ )\r X \ ERG t3t+ 15. GENERATOR'S/OFTEROR'S CERTIFICATION: hereby dclars that th conlents of this consignment are fully and accurately described above by the pr0pef shipping name, ard ate classified, marked and labled/placarded, and ae all respects in proper condition for transport according to applicable ntemational and national govemmental regulations. tf export shipment and am the Exporter, certify that the contents of this consignment conform to the terms of the atteched EPAAcknowledgment of Consent, certify that the waste minimization statement identifid tn 40 CFR 262.27(al (if m a large quantity generator) 0r am small quantity generator) ts hue. packaged, Primary (Nme 3 J lmport to U.S, Export from U.S. Port of entry/exit: z, Date U.S.: 17 Acknowledgment of Receipt of Materlals o 1C Year 2.( Day 18. Discrepancy 18a. Discrepancy lndication Space f Quantty Type l-l Resiue Parlial Rejection |-l Futt Reection F AIlernte (or Generator) = Phone: cul Ikz 1S. Hazardous Waste Report Management Method Codes (i.e. codes for hazardous wste treatment, disposal, and for Htu Hlvt . cc) e ES fr e \ a 20.Designated t Owner or 0perator: Certification of receipt of hzrdous materals covered by th manifest I (Rev, 12-17) er U,S. EPA systems) as nded in llem 184 tq Lt{ DESIGNATED FACILITY T0 EPA's C.MANIFEST SYSTEM T 6ttt Attachment 2: Manifest 026555323JJK, signed by the transporter on June 27, 2024, does not have a date included with the generator's certification signature in item 15 Please 0r Form OMB No. 2050-0039 ID lof UNIFORM HAZARDOUS WASTE MANIFEST JJK Nme txr6st.tor 1 Cottrla ltrmalal Hpltal ?'l Propedw &dr,l$Y 1253-2827 Company ID lD Number Phne: Hn78163lrcrnO Itabtut Fwfomcnd 2754IEAv 9a, 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, lD Number' HM and Packing Group (il any)) 1. o r${s218. WATE }rEorcrlG rruD. FUm|AB.E ToXc N iEf }l{LJ.S'JLlNl k gatFGll r = (9 rfi tc0. usTE AERosds, xl ut{32.t9 tvAsIE fDICXNE, g)uD, TOXIC, N.O.S. ^f^F^, RtD010rH35? 10. Containers No. Type I 0r m f dE 1 1. Total Quanlity ff d 12. Unit Wt.|/ol. 13. Waste Codes Dnt Cla G fbelf- arurQ Flti G P01 6 qb ERo r3t+ \v. \"'' l* ,5 i{.r.q.o\ t 'oq usfo "it"i$ 15. GENERATOR'S/0FFER0R'S CERTIFICATION: I hereby deolare that lh mntonts ofthls conslgnmont are fully and marked and labaled/placrded, and aro ln all rospcts ln plopsr condltlon lor transport accordlng to appllcable internationaland described above by the proper shipplng name, rd ro classlfled, packaged' national govommntl regulallons. f export shlpmont and I m tho Prmry Exporter, I certlfo that lerms of lhe attached EPAAcknowledgmnt of Consenl. I crllfy that th waste qunllty gnerator) or (lfl am a small ls lrue, Namg lmporl to U.S. = Transpoer signalure (for exports only): , 17, TranspoterAcknowladgment of Reipt of Matelals t , oo- U' Tansporter 2 PrintediTyped Name =. 18. Discrepancy 18a. Discrepancy lndicalion Space r Quantity Export ltom U.S. Porl of entry/sxlt: Date leavinq U,S.: 'ryy / Type l-l Resdue I Partial Reection hJ() Facllity (or Generator) Phone: c ]U Ik=(t, 19. Hazardous Waste otr 20. Designated Facility Method Codos (1,e,, codes for hazardous waste treatment, dlsposal, and rocycling of of matedals covered by the manifest except ln ltom I Number ttlMonth Day Year tr Full Rejection : i ,r! . EPA Form 8700-22 (Rev 17) are obsolete. TED FACILITY TO EPA'S E.MANIFEST Columbia Memorial Hospital NYD080481708 Inspection Date: December 19, 2024 PHOTOGRAPHS Page 7 of 11 Columbia Memorial Hospital NYD080481708 Inspection Date: December 19, 2024 Photograph #1: 8-gallon satellite container of pharmaceutical waste located in ICU pharmaceutical room Page 8 of 11 Columbia Memorial Hospital NYD080481708 Inspection Date: December 19, 2024 Photograph #2: RCRA hazardous waste categorized satellite containers located in wholesale room. Page 9 of 11 Columbia Memorial Hospital NYD080481708 Inspection Date: December 19, 2024 Photograph 3: 8-gallon hazardous waste satellite containers located in IV room for pharmaceutical waste Page 10 of 11 Columbia Memorial Hospital NYD080481708 Inspection Date: December 19, 2024 Photograph 4: The Hazardous Waste Central Accumulation Area observed 55-gallon plastic drum labeled as RCRA hazardous waste containing waste medicine, liquid, flammable, toxic N.O.S ( Ethanol, insulin)3(6.1).PGII Page 11 of 11