Document O34zZd00M5OkKb3bJRMvK4Yqp

Compliance Evaluation Inspection Report St. Albans VA Medical Center St. Albans, New York September 19, 2022 Written by: X Digitally signed by RONALD LOCKWOOD DN: c=US, o=U.S. Government, ou=Environmental Protection Agency, cn=RONALD LOCKWOOD, 0.9.2342.19200300.100.1.1=68001003650913 Date: 2022.10.19 08:30:58 -04'00' Adobe Acrobat Reader version: 2022.003.20258 Enforcement Officer ECAD-CAPSB-CAS USEPA R2 Approved by: KATHLEEN MALONE- X BOGUSKY Digitally signed by KATHLEEN MALONE-BOGUSKY Date: 2022.10.19 08:40:17 -04'00' Chief - Compliance Assurance Section ECAD-CAPSB-CAS USEPA R2 1 VA St. Albans CEI Report September 19, 2023 This page has intentionally been left blank 2 VA St. Albans CEI Report September 19, 2023 COMPLIANCE EVALUATION INSPECTION REPORT U.S. Environmental Protection Agency, Region 2 Enforcement and Compliance Assurance Division 290 Broadway, 21st floor New York, New York 10007-1866 Locational Information Facility Name: St. Albans VA Medical Center Facility Address: 179-00 Linden Boulevard, Queens, NY 11424-1468 Latitude & Longitude: 40.692303, -73.768173 ICIS & other Program ID Codes as appropriate FRS: 110019335557 ICIS: 3601302622 RCRA ID: NY8360032082 Sector Information Federal Facility: Yes SIC: 8062 (General Medical and Surgical Hospitals) NAICS: 622110 (General Medical and Surgical Hospitals) Environmental Sensitivity Information Potential Flood-Prone Area: No (See Appendix B: FEMA Flood Map) Sole Source Aquifer: Yes (See Appendix C: Sole Source Aquifer Map) Potential EJ Concerns: Yes (See Appendix D: EJ SCREEN) Inspection Information Date of Inspection: September 19, 2022 Inspector(s): Ronald Lockwood Facility Representative(s): Name Title James McCarthy Supervisory Environmental Engineer, GEMS Coordinator Jose Flores Chief Engineer Phone (718) 836-6600 ext: 4560 (718) 836-6600 Corrections/Updates for EPA Databases: None to report. Email James.McCarthy2@va.gov Jose.Flores@va.gov 3 VA St. Albans CEI Report September 19, 2023 Table of Contents 1. INTRODUCTION..................................................................................................................... 5 2. FACILITY TOUR .................................................................................................................... 5 3. RECORD REVIEW.................................................................................................................. 6 4. REGULATORY CONCERNS ................................................................................................ 7 5. ENVIRONMENTAL ASSISTANCE ...................................................................................... 8 APPENDICES:.............................................................................................................................. 9 A: Photographs.................................................................................................................. 9 B: FEMA Flood Map ........................................................................................................ 9 C: Sole Source Aquifer Map ............................................................................................ 9 D: EJ Screen ...................................................................................................................... 9 4 VA St. Albans CEI Report September 19, 2023 1. INTRODUCTION The Region 2 office of the Environmental Protection Agency (EPA) inspected the St. Albans Veterans Affairs (VA) Medical Center to evaluate compliance with the Resource Conservation and Recovery Act (RCRA) because EPA wanted to confirm the facility's designation as an active small quantity generator (SQG) of hazardous wastes in EPA's databases. The VA New York Harbor Healthcare System (NYHHS) provides primary and specialty health care services to veterans living in the five boroughs of New York City. As part of that system, the St. Albans VA Medical Center in Jamaica, Queens includes an extended-care center that provides long- and short-term nursing and rehabilitation services. The extended care center has 231 beds: 181 nursing home beds; and 50 psychosocial domiciliary program beds for homeless veterans or veterans with multiple and severe medical conditions, mental illness, addiction, or psychosocial deficits, who require high-quality residential and clinical rehabilitation and treatment services. I arrived at 11:52 AM, went to the Information Desk and asked to speak to the Green Environmental Management System (GEMS) Coordinator/Supervisory Environmental Engineer, Mr. James McCarthy. I had contacted Mr. McCarthy earlier that morning and informed him I would be at the St. Albans facility, as he is the GEMS Coordinator for the VA NYHHS' Brooklyn and Manhattan campuses as well. Mr. McCarthy arrived shortly thereafter and escorted me to a small conference room in the office of the facility's Chief Engineer, Mr. Jose Flores. At which point, I presented EPA credentials and my business card to Mr. McCarthy and Mr. Flores; offered in- and out-briefings; and explained that I was there to conduct a RCRA hazardous waste inspection, which would include looking at the central hazardous waste storage areas (CHWSA), any satellite accumulation areas (SAAs), and the universal waste storage areas (UWSA), and reviewing the facility's hazardous waste manifests, weekly inspection checklists, and training records for the past three years. I also mentioned that if there were any information that they considered to be confidential business information, now would be the appropriate time to make the claim. All that was requested was for me to not take any photographs of hospital staff or patients. Mr. McCarthy, Mr. Flores and I then began the facility walkthrough. 2. FACILITY TOUR The facility has two CHWSAs (one in the Engineering Service Building/Garage and another outside of the Pharmacy Laboratory (Room A-146)), and one UWSA room in the basement (Room E-78). Universal Waste Storage Area The first room of the tour was Room E-78 located in the Main Building basement where the universal wastes are stored. In the room were three cylindrical cardboard storage boxes filled with spent fluorescent bulbs. Two of the boxes were fully closed but one had the cover askew. Also, only one of the storage boxes was labeled "Universal Waste" and dated 5/10/22 (Photo 001). There was signage for both universal waste handling and hazardous waste handling (for broken bulbs) posted (Photo 002). 5 VA St. Albans CEI Report September 19, 2023 Pharmacy Central Hazardous Waste Storage Area The next area inspected was Room A-146, the CHWSA located directly across from the Pharmacy on the first floor. This CHWSA is used to store unused pharmaceuticals from both the Pharmacy and the rooms of the patients/tenants for the purposes of sorting them for either credit or manifesting off-site as hazardous waste. Inside the room there was a fire extinguisher with a monthly inspection record, and an emergency landline phone with emergency contact numbers. Hazardous wastes are stored in the room in a locked cage/cabinet clearly labeled with the words "Hazardous Waste Satellite Accumulation Area (SAA)" and with 24-hour emergency contact information (Photo 003). Inside the cage/cabinet there were three 5-gallon pails and a small open paper bag (Photo 004). Of the three 5-gallon pails, the first pail was closed and had a hazardous waste label identifying its contents as "Inhalers - Flammable Gas (D001)" but not dated (Photo 005); the second pail was also closed and had a hazardous waste label identifying its contents as "Insulin and Other Flammable Toxics" and also not dated (Photo 006); and the third pail was open and unlabeled (Photo 007). Inside the third unlabeled 5-gallon pail there were numerous mixed unsorted items, including inhalers (Photo 008). As for the paper bag, inside there were also numerous unsorted items, including inhalers (Photo 009). Note: Once the Pharmacy CHWSA was inspected, Mr. Flores left Mr. McCarthy and I to go about his daily routine. Engineering Service Building/Garage Central Hazardous Waste Storage Area The last area inspected was the CHWSA located outside of the main building in the Engineering Service Building/Garage. The hazardous wastes are stored in the rear of the Engineering Service Building/Garage in a locked caged (approx. 30 X 20 ft) area with signage on the gate door identifying it as the hazardous waste storage area and describing the kinds of wastes stored there as well as the quantity and time limits for each RCRA generator type. At the back of the caged area there were six 55-gallon drums and one 30-gallon drum of product liquids placed on plastic spill pallets; one 55-gallon drum of used motor oil labeled "Used Oil" on a spill pallet (Photo 010); and one partially filled 55-gallon drum of waste aerosols (D001) labeled `Hazardous Waste" atop a plastic spill pallet. The latter had a note that the date will be written in when the drum is full (Photo 011). Also, inside the caged area there were fire extinguishers and spill kits, and right outside of the caged area was an emergency phone, additional fire extinguishers and an eyewash station. At the front of the Engineering Service Building/Garage there was a room with full showers and another eye-wash station. 3. RECORD REVIEW Manifests I reviewed three years of the facility's manifest records for both hazardous wastes and universal wastes and noted that there was no signature from the designated treatment, storage, and disposal facility (TSDF) for manifest #001501966, which was dated 6/5/2019. After the inspection, on 9/21/2022, Mr. McCarthy provided a copy of manifest #001501966 that had the signature of the designated TSDF. Mr. McCarthy stated the signed copy had fallen out in the manifest folder and should have been with the others. I totaled the hazardous waste manifest amounts from 2019 to date (see table below). All the 6 VA St. Albans CEI Report September 19, 2023 wastes manifested were nonacute hazardous wastes and no P-wastes were listed on any of the manifests. Hence, based on this data, I determined that the facility was a very small quantity generator (VSQG) from 2019 to 2021 but in the last year temporarily became a small quantity generator (SQG) given that over the 7 month period from December 2021 to June 2022 the facility generated 1968 pounds because of a one-time cleanout of hazardous wastes that included expired sanitizers purchased for use during the pandemic and thus, averaged 281 lbs a month, which is over the 220 lbs SQG threshold but way below the 2200 lb large quantity generator threshold. The facility appears to have dropped down again to a VSQG since June 2022. See Section 5 below concerning pending changes to the New York State Department of Environmental Conservation (NYSDEC) hazardous waste requirements regarding episodic generation events. 2022 June 2022 - 1968 lbs March 2022 - 50 lbs 2021 November 2021 - 400 lbs 2020 September 2020 -1 lb April 2020 - 30 lbs 2019 June 2019 - 2 lb Training Records No training records were provided for review. Weekly Inspection Checklists No weekly inspection checklists were provided for review. Closing Meeting Now that the walkthrough and record review was completed, Mr. McCarthy and I returned to Mr. Flores' office (he was not in the office at the time) and I began the closing meeting. I pointed out the unlabeled mixed waste in both the open 5-gallon pail, and the paper bag in the SAA near the Pharmacy (Room A-146) and asked about the hazardous waste training procedures used to train staff who handle hazardous wastes. Mr. McCarthy stated all staff are trained and will address the issue. I mentioned the manifest missing the designated facility signature, which Mr. McCarthy also said he would address (and, as noted above, did so by sending me a copy of the signed manifest on 9/21/22). Finally, I told Mr. McCarthy I would review my notes and document the days' inspection in this CEI report, which would be sent to him when finalized. At which point, I concluded the inspection and left the facility 4. REGULATORY CONCERNS Based on observations made during the inspection and/or a review of records related to the inspection, the following regulatory concerns were identified: REGULATORY, STATUTORY OR PERMIT REFERENCE Pursuant to 6 NYCRR Part 372.2 (a)(8)(iii)(`d') & 3731.1 (d)(1)(iii)(`c')(`2') The date on which each period of FIELD OBSERVATION In the Pharmacy CHWSA, there were two 5-gal pails with hazardous wastes labels but with no dates, one open unlabeled and undated pail with unsorted hazardous and non-hazardous 7 VA St. Albans CEI Report September 19, 2023 REGULATORY, STATUTORY OR PERMIT REFERENCE FIELD OBSERVATION accumulation begins is clearly marked and visible for inspection on each container materials, and one open undated paper bag with unsorted hazardous and non-hazardous materials. Pursuant to 6 NYCRR Parts 374-3.2 (4)(i), a small quantity handler of universal waste must contain any lamp in containers or packages that are structurally sound, adequate to prevent breakage, and compatible with the contents of the lamps. Such containers and packages must remain closed and must lack evidence of leakage, spillage or damage that could cause leakage under reasonably foreseeable conditions. Pursuant to 6 NYCRR Parts 374-3.2 (e)(5), each lamp or a container or package in which such lamps are contained must be labeled or marked clearly with one of the following phrases: Universal Waste-Lamp(s), or Waste Lamp(s), or Used Lamp(s). Pursuant to 6 NYCRR Parts 372.2(a)8(iii)(`b') & 373-3.9 (d)(3), an SQG marks the containers in a CHWSA with the words "Hazardous Waste" and with other words that identify the contents of the containers. Pursuant to 6 NYCRR Parts 372.2(a)(8)(iii)(`b') & 3733.9(d)(1), a container holding hazardous waste in an CHWSA must always be closed during storage, except when it is necessary to add or remove waste Pursuant to 6 NYCRR Parts 372.2(a)(8)(iii)(`e')(`3'), a SQG must ensure that all employees are thoroughly familiar with proper waste handling and emergency procedures, relevant to their responsibilities during normal facility operations and emergencies In the Engineering Service Department/Garage CHWSA, there was one partially filled 55-gallon drum of waste aerosols (D001) labeled `Hazardous Waste" atop a plastic spill pallet but with no accumulation start date. Instead, there was a note that the date will be written in when the drum is full. There was a partially askew lid on one of the containers of universal waste. There was no labeling on two of the three universal waste containers. In the Pharmacy CHWSA, there was one open 5-gallon unlabeled pail of unsorted wastes and one unmarked open paper bag with unsorted wastes. In the Pharmacy CHWSA, there was one open 5-gallon unlabeled drum of unsorted wastes and an unmarked open paper bag with unsorted wastes. No training records were provided for review and the issue of the unsorted mixed waste in an open unlabeled pail and an unlabeled paper bag in the Pharmacy CHWSA raises concern on whether all employees are thoroughly familiar with proper waste handling. 5. ENVIRONMENTAL ASSISTANCE To increase the Federal community's understanding and compliance with applicable environmental requirements, EPA, along with other Federal agencies, sponsor Fed Center, the Federal government's home for comprehensive environmental stewardship and compliance assistance information for Federal facility managers and their agencies. Fed Center can be accessed via the worldwide web at https://www.fedcenter.gov/ Also, the NYSDEC is seeking comments on potential revisions to the New York State hazardous waste management regulations to adopt some of the major regulatory changes published by EPA since 2012, including EPA's Hazardous Waste Generator Improvements Rule that, among other things, includes procedures for episodic generation events such as the hazardous waste cleanout 8 VA St. Albans CEI Report September 19, 2023 at St. Albans in 2022 to allow hazardous waste generators to avoid increased burden of a higher generator status when generating episodic waste provided the episodic waste is properly managed. For more information on this pending change, go to: https://www.dec.ny.gov/regulations/117189.html APPENDICES: A: Photographs B: FEMA Flood Map C: Sole Source Aquifer Map D: EJ Screen 9 VA St. Albans CEI Report September 19, 2023 A: Photographs Photo 001 10 VA St. Albans CEI Report September 19, 2023 Photo 002 11 VA St. Albans CEI Report September 19, 2023 Photo 003 12 VA St. Albans CEI Report September 19, 2023 Photo 004 13 VA St. Albans CEI Report September 19, 2023 Photo 005 14 VA St. Albans CEI Report September 19, 2023 Photo 006 15 VA St. Albans CEI Report September 19, 2023 Photo 007 16 VA St. Albans CEI Report September 19, 2023 Photo 008 17 VA St. Albans CEI Report September 19, 2023 Photo 009 18 VA St. Albans CEI Report September 19, 2023 Photo 010 19 VA St. Albans CEI Report September 19, 2023 Photo 011 20 VA St. Albans CEI Report September 19, 2023 Appendix B: Federal Emergency Management Agency (FEMA) 100 Year Flood Zone and EPA's Region 2 Composite Flood Risk Layer Facility Name: St. Albans VA Medical Center The facility is not located within a FEMA 100-year flood zone area. The facility is not located within the "moderate, high, or extreme" zones of EPA's Region 2 Composite Flood Risk potential risk area. 21 VA St. Albans CEI Report September 19, 2023 Appendix C: Sole Source Aquifer Map Facility Name: The facility is located within a Sole Source Aquifer area. 22 VA St. Albans CEI Report September 19, 2023 EJScreen Report (Version 2.1) 1 mile Ring Centered at 40.692304,-73.768172, NEW YORK, EPA Region 2 Approximate Population: 64,142 Input Area (sq. miles): 3.14 VA St. Albans Selected Variables Environmental Justice Indexes EJ Index for Particulate Matter 2.5 EJ Index for Ozone EJ Index for Diesel Particulate Matter* EJ Index for Air Toxics Cancer Risk* EJ Index for Air Toxics Respiratory HI* EJ Index for Traffic Proximity EJ Index for Lead Paint EJ Index for Superfund Proximity EJ Index for RMP Facility Proximity EJ Index for Hazardous Waste Proximity EJ Index for Underground Storage Tanks EJ Index for Wastewater Discharge State Percentile 75 86 77 76 81 70 82 76 71 69 77 N/A USA Percentile 71 83 93 85 91 80 92 89 69 88 88 N/A This report shows the values for environmental and demographic indicators and EJSCREEN indexes. It shows environmental and demographic raw data (e.g., the estimated concentration of ozone in the air), and also shows what percentile each raw data value represents. These percentiles provide perspective on how the selected block group or buffer area compares to the entire state, EPA region, or nation. For example, if a given location is at the 95th percentile nationwide, this means that only 5 percent of the US population has a higher block group value than the average person in the location being analyzed. The years for which the data are available, and the methods used, vary across these indicators. Important caveats and uncertainties apply to this screening-level information, so it is essential to understand the limitations on appropriate interpretations and applications of these indicators. Please see EJSCREEN documentation for discussion of these issues before using reports. October 19, 2022 1/3 EJScreen Report (Version 2.1) 1 mile Ring Centered at 40.692304,-73.768172, NEW YORK, EPA Region 2 Approximate Population: 64,142 Input Area (sq. miles): 3.14 VA St. Albans Sites reporting to EPA Superfund NPL Hazardous Waste Treatment, Storage, and Disposal Facilities (TSDF) October 19, 2022 0 1 2/3 EJScreen Report (Version 2.1) 1 mile Ring Centered at 40.692304,-73.768172, NEW YORK, EPA Region 2 Approximate Population: 64,142 Input Area (sq. miles): 3.14 VA St. Albans Selected Variables Value State %ile in USA Avg. State Avg. %ile in USA Pollution and Sources Particulate Matter 2.5 (g/m3) 8.23 7.86 54 8.67 40 Ozone (ppb) 42.7 41.5 69 42.5 54 Diesel Particulate Matter* (g/m3) 0.758 0.637 60 0.294 95-100th Air Toxics Cancer Risk* (lifetime risk per million) 30 29 67 28 80-90th Air Toxics Respiratory HI* 0.5 0.39 75 0.36 95-100th Traffic Proximity (daily traffic count/distance to road) 400 870 51 760 62 Lead Paint (% Pre-1960 Housing) 0.71 0.54 62 0.27 86 Superfund Proximity (site count/km distance) 0.13 0.24 51 0.13 74 RMP Facility Proximity (facility count/km distance) 0.22 0.52 47 0.77 40 Hazardous Waste Proximity (facility count/km distance) 2.8 6 47 2.2 77 Underground Storage Tanks (count/km2) 10 7.7 70 3.9 89 Wastewater Discharge (toxicity-weighted concentration/m distance) DSoecmiooegcroanpohmiciIcnIdnidcaictaotrosrs Demographic Index People of Color N/A 61% 98% 4 N/A 35% 81 45% 92 12 N/A 35% 83 40% 95 Low Income 22% 29% 47 30% 41 Unemployment Rate Limited English Speaking Households Less Than High School Education 7% 3% 13% 6% 71 8% 58 13% 64 5% 71 5% 70 12% 66 Under Age 5 6% 6% 58 6% 55 Over Age 64 15% 17% 48 16% 49 *Diesel particular matter, air toxics cancer risk, and air toxics respiratory hazard index are from the EPA's Air Toxics Data Update, which is the Agency's ongoing, comprehensive evaluation of air toxics in the United States. This effort aims to prioritize air toxics, emission sources, and locations of interest for further study. It is important to remember that the air toxics data presented here provide broad estimates of health risks over geographic areas of the country, not definitive risks to specific individuals or locations. Cancer risks and hazard indices from the Air Toxics Data Update are reported to one significant figure and any additional significant figures here are due to rounding. More information on the Air Toxics Data Update can be found at: https://www.epa.gov/haps/airtoxics-data-update. For additional information, see: www.epa.gov/environmentaljustice EJScreen is a screening tool for pre-decisional use only. It can help identify areas that may warrant additional consideration, analysis, or outreach. It does not provide a basis for decision-making, but it may help identify potential areas of EJ concern. Users should keep in mind that screening tools are subject to substantial uncertainty in their demographic and environmental data, particularly when looking at small geographic areas. Important caveats and uncertainties apply to this screening-level information, so it is essential to understand the limitations on appropriate interpretations and applications of these indicators. Please see EJScreen documentation for discussion of these issues before using reports. This screening tool does not provide data on every environmental impact and demographic factor that may be relevant to a particular location. EJScreen outputs should be supplemented with additional information and local knowledge before taking any action to address potential EJ concerns. October 19, 2022 3/3