Document ppv37BLqXJyZQVQNdpzeVxVxa
RCRA Inspection Report
1) Inspector and Author of Report Alan Newman Environmental Engineer Phone: 404-562-8589 newman.alan@epa.gov
2) Facility Information Veterans Administration Medical Center - Nashville Campus 1310 24th Avenue South Nashville, Tennessee 37212 Davidson County
U.S. Environmental Protection Agency, Region 4 Enforcement and Compliance Assurance Division Chemical Safety and Land Enforcement Branch RCRA Enforcement Section 61 Forsyth Street, S.W. Atlanta, Georgia 30303
EPA ID#: TN4360012948 NAICS #: 62211 General Medical and
Surgical Hospitals
3) Responsible Officials
Jake Silvensky Safety Manager jake.slivensky@va.gov
4) Inspection Participants
Philip Daniels, VAMC Jacob Houk, VAMC Carmen Wilmer, VAMC Jake Slivensky, VAMC Thomas Johnson, VAMC Hector Gutierrez, VAMC Heather Bawcom, VAMC Heather Reimold, VAMC Brandon Richardson, VAMC Janet Cancilla, VAMC Richard Hicks, VAMC Tracey Watson, VAMC Mark Miller, VAMC Theresa Hefty, VAMC Mary Lister, VAMC Jen Spann, VAMC Cory Frappier, VAMC Laura Dixon, VAMC Emily Adams, VAMC Brandi Malinoff, VAMC Paula Rorsh, VAMC Margaret Compton, VAMC
Mike Horsley, TDEC Rachel Freeman, TDEC Al Majors, TDEC Alan Newman, EPA Region 4
5) Date of Inspection
March 5, 2024, 9:00 am - 4:45 pm; March 7, 2024, 8:30 am - 1:00 pm.
6) Applicable Regulations1
Resource Conservation and Recovery Act (RCRA) Sections 3002 (42 U.S. Code - Annotated U.S.C.A. 6925 and 6927), and 40 Code of Federal Regulation (C.F.R.) Parts 260 - 270, 273, 278, & 279; Tennessee Hazardous Waste Management Act of 1977, Tennessee Code Annotated (Tenn. Code Ann.) 68-212-101 et seq., and Chapter 0400-12-01 of the Rules and Regulations of the State of Tennessee (Tenn. Comp. R. & Regs.)
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.01(2)(a) [40 C.F.R. 260.10], a large quantity generator (LQG) of hazardous waste is a generator who generates greater than or equal to 1,000 kilograms (2,200 pounds) of non-acute hazardous waste in a calendar month.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.03(1)(f)1. [40 C.F.R. 262.15(a)], a generator may accumulate as much as 55 gallons of non-acute hazardous waste in containers at or near any point of generation where wastes initially accumulate, which is under the control of the operator of the process generating the waste, without a permit or without having interim status, as required by Tenn. Comp. R. & Regs. 0400-12-01-.03(1)(f)1. [Section 3005 of RCRA, 42 U.S.C. 6925], and without complying with Tenn. Comp. R. & Regs. 0400-12-01-.03(1)(g)2. or 0400-12-01-.03(1)(h)1. [40 C.F.R. 262.16(b) or 262.17(a)], except as required in Tenn. Comp. R. & Regs. 0400-12-01-.03(1)(f)1.(vii and viii) [40 C.F.R. 262.15(a)(7) and (8)], provided that the generator complies with the satellite accumulation area (SAA) conditions listed in Ten Tenn. Comp. R. & Regs. 0400-12-01-.03(1)(f)1. [40 C.F.R. 262.15(a)] (hereinafter referred to as the "SAA Permit Exemption").
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.03(1)(h) [40 C.F.R. 262.17], an LQG may accumulate hazardous waste on-site for 90 days or less without a permit or without having interim status, as required by Section 68-212-108 of the THWMA, Tenn. Code Ann. 68-212108 [Section 3005 of RCRA, 42 U.S.C. 6925], provided that the generator complies with the conditions listed in Tenn. Comp. R. & Regs. 0400-12-01-.03(1)(h) [40 C.F.R. 262.17] (hereinafter referred to as the "LQG Permit Exemption").
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.12(1)(i) [40 C.F.R. 273.9], a small quantity handler of universal waste (SQHUW) is a universal waste handler who does not accumulate
1 As the State's authorized hazardous waste program operates in lieu of the federal RCRA program, the citations of those authorized provisions will be to the authorized State program. However, for ease of reference, the federal citations will follow in brackets.
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5,000 kilograms or more of universal waste (batteries, pesticides, mercury-containing equipment, fluorescent lamps, or aerosol cans, calculated collectively) at any time.
7) Purpose of Inspection
The purpose of this inspection was to conduct an unannounced compliance evaluation inspection to determine VAMC-Nashville compliance with the applicable requirements of RCRA and the corresponding Tennessee regulations. This was an EPA lead inspection.
8) Facility Description
The Veterans Administration Medical Center Nashville (VAMC-Nashville) is a large quantity generator of hazardous waste, a small quantity hander of universal waste lamps and batteries, and a health care facility for hazardous waste pharmaceuticals. VAMC-Nashville is one of two main campuses in the VA Tennessee Valley Healthcare System (TVHS) in middle Tennessee. In this region the TVHS is comprised of the Nashville campus, the Alvin C. York Medical Centers (Murfreesboro), and several outpatient clinics. VAMC-Nashville campus offers primary, secondary, and tertiary care to veterans living in middle Tennessee and Kentucky. The TVHS is affiliated with Vanderbilt University School of Medicine and Meharry Medical College, with active residency programs in all major medical and surgical specialties and sub-specialties.
VAMC-Nashville most recently notified of their hazardous waste activity on February 24, 2023.
The hazardous waste generated at the facility includes: Waste Stream Number/Name Description
Waste Stream #1 (WS #1) - Xylene (F003/F005) Waste Stream #7 (WS #7) - Lab pack waste (D001/D002/ D011/F003 /U062/U122) Waste Stream #9 (WS #9) Pharmaceutical Waste (D001/P012/U010/U058/U059)
Waste Stream #10 (WS #10) Mixed alcohol waste (D001/D002/F003) Waste Stream #11 (WS #11) - Still bottoms (F003)
Used waste or expired xylene Spent lab chemicals or chemicals with an expired shelf life Waste from medical and clinical procedures and expired or damaged pharmaceuticals Waste from laboratory and research procedures
Distillation waste from recycling of xylene
Amount generated in 2022 (pounds) 0 3,804 2,327
2,511
0
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9) Previous Inspection History
TDEC has conducted two RCRA CEIs at the subject facility between 2015 and 2024 and found seven violations during those inspections. On August 11, 2021, TDEC conducted the most recent RCRA CEI at the subject facility and found no apparent violations of RCRA's requirements.
10) Opening Conference
On March 5, 2024, EPA inspector Alan Newman, accompanied by TDEC inspectors Al Majors, Rachael Freeman, and Mike Horsely arrived at VAMC-Nashville at approximately 9:00 am. Philip Daniel, Industrial Hygienist, immediately received the inspectors. Philip Daniel, and the inspectors were joined by Jake Slivensky, Carmen Wilmer, and Jacob Houk, for the opening conference via phone. The inspectors introduced themselves, showed their credentials to Philip Daniel, and explained the purpose of the visit.
The inspectors described the anticipated use of a digital camera during the inspection and provided a request for records. The EPA inspector explained that the Small Business Regulatory Enforcement Fairness Act's classification of a "small business" is generally set by the Small Business Administration using the business' SIC/NAICS code and annual receipts or number of employees. A copy of the EPA's information sheet for small businesses can be found at https://www.epa.gov/sites/production/files/2017-06/documents/smallbusinessinfo.pdf. The EPA inspector also discussed the company's ability, pursuant to 40 C.F.R. 2.203, to assert a business confidentiality claim for information submitted to EPA. The company did not assert a business confidentiality claim aside from patient records.
Philip Daniel, Jake Slivensky, and Carmen Wilmer provided an overview of the facility's history and current operations during the opening conference. The inspection participants also discussed health and safety protocols and required personal protective equipment before Facility representative led the inspectors on a tour of the Facility operations.
11) Inspection Observations
VAMC-Nashville personnel escorted the inspection team to various locations where waste could be generated and accumulated including SAAs, Central Accumulation Areas (CAAs), and a universal waste storage closet.
4 North/Mental health (Room A-467)
VAMC-Nashville was accumulating non-creditable hazardous waste pharmaceuticals in two containers in this area on the day of the inspection: one 8-galllon yellow plastic container for "Chemotherapy Medications that need disposing" with a flip top lid that was storing general trash and a 2-gallon white plastic container that was empty (Photograph 1). There was no hazardous waste present in this area on the day of the inspection. In this area the inspection team noted the first of many Cactus Smart Sink System units (Photograph 2). This unit securely
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captures partially administered or unused controlled substances and renders them nonretrievable and unusable. VAMC-Nashville utilizes these units throughout the facility.
Podiatry (Room C468)
The inspection team noted non-creditable hazardous waste pharmaceuticals in one 8-gallon black container with a slide lid. This container was labeled as "Pharm Waste" on a yellow Hazardous waste label (Photograph 3). The regulation states that this container should be labeled as "Hazardous Waste Pharmaceuticals." VAMC-Nashville did not appear be using any method to demonstrate the length of time that the non-creditable hazardous waste pharmaceuticals have been accumulating, starting from the date it first becomes a waste (Photograph 4).
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.09(16)(c)5. [40 C.F.R. 266.502(e)], healthcare facilities must label or clearly mark each container of non-creditable hazardous waste pharmaceuticals with the phrase "Hazardous Waste Pharmaceuticals."
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.09(16)(c)6.(ii) [40 C.F.R. 266.502(f)(2)], a healthcare facility that accumulates non-creditable hazardous waste pharmaceuticals on-site must demonstrate the length of time that the non-creditable hazardous waste pharmaceuticals have been accumulating, starting from the date it first becomes a waste. A healthcare facility may make this demonstration by any of the following methods:
(I) Marking or labeling the container of non-creditable hazardous waste pharmaceuticals with the date that the non-creditable hazardous waste pharmaceuticals became a waste;
(II) Maintaining an inventory system that identifies the date the non-creditable hazardous waste pharmaceuticals being accumulated first became a waste; or
(III)Placing the non-creditable hazardous waste pharmaceuticals in a specific area and identifying the earliest date that any of the non-creditable hazardous waste pharmaceuticals in the area became a waste.
3 North (Room A-312)
There were two 8-gallon black plastic containers accumulating non-creditable hazardous waste pharmaceuticals: one had two pills on the lid and the other had nine small containers on top of the slide lid (Photographs 5-7). VAMC-Nashville failed to place these pharmaceutical wastes into a container. One of these two containers was labeled as "Pharm Waste" on a yellow hazardous waste label. There was one 2-gallon black plastic container that was labeled as "Hazardous Waste Disposal" (Photographs 8-10)." The regulation states that these containers should be labeled as "Hazardous Waste Pharmaceuticals." VAMC-Nashville was operating one of the Cactus Smart Sink System units in this area. VAMC-Nashville did not appear be using any method to demonstrate the length of time that the non-creditable hazardous waste pharmaceuticals have been accumulating.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.09(16)(c)4.(i)[40 C.F.R. 266.502(d)(1)], a healthcare facility must place non-creditable hazardous waste pharmaceuticals in a container
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that is structurally sound, compatible with its contents, and that lacks evidence of leakage, spillage, or damage that could cause leakage under reasonably foreseeable conditions.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.09(16)(c)5 [40 C.F.R. 266.502(e)], healthcare facilities must label or clearly mark each container of non-creditable hazardous waste pharmaceuticals with the phrase "Hazardous Waste Pharmaceuticals."
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.09(16)(c)6.(ii) [40 C.F.R. 266.502(f)(2)], a healthcare facility that accumulates non-creditable hazardous waste pharmaceuticals on-site must demonstrate the length of time that the non-creditable hazardous waste pharmaceuticals have been accumulating, starting from the date it first becomes a waste. A healthcare facility may make this demonstration by any of the following methods:
(I) Marking or labeling the container of non-creditable hazardous waste pharmaceuticals with the date that the non-creditable hazardous waste pharmaceuticals became a waste;
(II) Maintaining an inventory system that identifies the date the non-creditable hazardous waste pharmaceuticals being accumulated first became a waste; or
(III)Placing the non-creditable hazardous waste pharmaceuticals in a specific area and identifying the earliest date that any of the non-creditable hazardous waste pharmaceuticals in the area became a waste.
2 North (Room 2A211)
VAMC-Nashville was accumulating non-creditable hazardous waste pharmaceuticals in one open 8-gallon black plastic container in this area. The inspection team also noted some waste which was on the floor beside the accumulation container (Photographs 11-12). Workers in the area placed these wastes inside the container during the inspection. The container was labeled with the words "Pharm Waste" and "Hazardous Waste". It was not labeled with the words "Hazardous Waste Pharmaceuticals." Containers of non-creditable hazardous waste pharmaceuticals is required to be closed when in storage. VAMC-Nashville did not appear be using any method to demonstrate the length of time that the non-creditable hazardous waste pharmaceuticals have been accumulating. VAMC-Nashville was operating one of the Cactus Smart Sink System units in this area.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.09(16)(c)4.(iii) [40 C.F.R. 266.502(d)(3)], a healthcare facility must keep containers of non-creditable hazardous waste pharmaceuticals closed and secured in a manner that prevents unauthorized access to its contents.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.09(16)(c)5 [40 C.F.R. 266.502(e)], healthcare facilities must label or clearly mark each container of non-creditable hazardous waste pharmaceuticals with the phrase "Hazardous Waste Pharmaceuticals."
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.09(16)(c)4.(i)[40 C.F.R. 266.502(d)(1)], a healthcare facility must place non-creditable hazardous waste pharmaceuticals in a container
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that is structurally sound, compatible with its contents, and that lacks evidence of leakage, spillage, or damage that could cause leakage under reasonably foreseeable conditions.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.09(16)(c)6.(ii) [40 C.F.R. 266.502(f)(2)], a healthcare facility that accumulates non-creditable hazardous waste pharmaceuticals on-site must demonstrate the length of time that the non-creditable hazardous waste pharmaceuticals have been accumulating, starting from the date it first becomes a waste. A healthcare facility may make this demonstration by any of the following methods:
(I) Marking or labeling the container of non-creditable hazardous waste pharmaceuticals with the date that the non-creditable hazardous waste pharmaceuticals became a waste;
(II) Maintaining an inventory system that identifies the date the non-creditable hazardous waste pharmaceuticals being accumulated first became a waste; or
(III)Placing the non-creditable hazardous waste pharmaceuticals in a specific area and identifying the earliest date that any of the non-creditable hazardous waste pharmaceuticals in the area became a waste.
2G (Room G-253)
VAMC-Nashville was accumulating non-creditable hazardous waste pharmaceuticals in one 8gallon black plastic container in this area. The container was labeled with the words "Pharm Waste" and "Hazardous Waste" (Photograph 13). It was not labeled with the words "Hazardous Waste Pharmaceuticals." There was also a 3-gallon container of compressed gas cylinders that was determined to be non-hazardous waste. This waste is common throughout the facility. There were two 2-gallon brown containers for accumulation of spent batteries (Photographs 14-15). On the day of the inspection these containers were storing solely alkaline batteries.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.09(16)(c)5 [40 C.F.R. 266.502(e)], healthcare facilities must label or clearly mark each container of non-creditable hazardous waste pharmaceuticals with the phrase "Hazardous Waste Pharmaceuticals."
MTU (Room G-232B)
VAMC-Nashville was not storing any waste in Room G-232B.
MICU (Room G-214R)
There were two black plastic containers accumulating non-creditable hazardous waste pharmaceuticals: one open 8-gallon container was labeled as "Pharm Waste" on a yellow hazardous waste label and the one 2-gallon container that was labeled as "Hazardous Waste Disposal" (Photographs 16-18). The regulation states that these containers should be labeled as "Hazardous Waste Pharmaceuticals." Containers of non-creditable hazardous waste pharmaceuticals should be closed when in storage. VAMC-Nashville was operating one of the Cactus Smart Sink System units in this area. VAMC-Nashville did not appear be using any
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method to demonstrate the length of time that the non-creditable hazardous waste pharmaceuticals have been accumulating. VAMC-Nashville was accumulating universal waste batteries in a brown plastic container in this area. The container was labeled as universal waste batteries. There was no indication of how long these batteries had been stored in this container.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.09(16)(c)5 [40 C.F.R. 266.502(e)], healthcare facilities must label or clearly mark each container of non-creditable hazardous waste pharmaceuticals with the phrase "Hazardous Waste Pharmaceuticals."
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.09(16)(c)4.(iii) [40 C.F.R. 266.502(d)(3)], a healthcare facility must keep containers of non-creditable hazardous waste pharmaceuticals closed and secured in a manner that prevents unauthorized access to its contents.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.09(16)(c)6.(ii) [40 C.F.R. 266.502(f)(2)], a healthcare facility that accumulates non-creditable hazardous waste pharmaceuticals on-site must demonstrate the length of time that the non-creditable hazardous waste pharmaceuticals have been accumulating, starting from the date it first becomes a waste. A healthcare facility may make this demonstration by any of the following methods:
(I) Marking or labeling the container of non-creditable hazardous waste pharmaceuticals with the date that the non-creditable hazardous waste pharmaceuticals became a waste;
(II) Maintaining an inventory system that identifies the date the non-creditable hazardous waste pharmaceuticals being accumulated first became a waste; or
(III)Placing the non-creditable hazardous waste pharmaceuticals in a specific area and identifying the earliest date that any of the non-creditable hazardous waste pharmaceuticals in the area became a waste.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.12(2)(f)1 [40 C.F.R. 273.15(c)], a small quantity handler of universal waste who accumulates universal waste must be able to demonstrate the length of time that the universal waste has been accumulated from the date it becomes a waste or is received. The handler may make this demonstration by:
(i) Placing the universal waste in a container and marking or labeling the container with the earliest date that any universal waste in the container became a waste or was received;
(ii) Marking or labeling each individual item of universal waste (e.g., each battery or thermostat) with the date it became a waste or was received;
(iii) Maintaining an inventory system on-site that identifies the date each universal waste became a waste or was received;
(iv) Maintaining an inventory system on-site that identifies the earliest date that any universal waste in a group of universal waste items or a group of containers of universal waste became a waste or was received;
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(v) Placing the universal waste in a specific accumulation area and identifying the earliest date that any universal waste in the area became a waste or was received; or
(vi) Any other method which clearly demonstrates the length of time that the universal waste has been accumulated from the date it becomes a waste or is received.
Pharmacy
VAMC-Nashville was accumulating trace chemotherapy waste (non-hazardous) in an 18-gallon plastic container. Adjacent to this accumulating container were two black plastic containers which typically are used to accumulate non-creditable hazardous waste pharmaceuticals: one open 18-gallon container and one 8-gallon container (Photographs 19-20). None of these containers were topped with lids nor were they labeled as to their contents. The black containers were empty on the day of the inspection.
HD Room 1 - Compounding area
In a clean room viewed through a plexiglass barrier, the inspection team noted that VAMCNashville was accumulating non-creditable hazardous waste pharmaceuticals and trace chemotherapy waste in three containers at a workstation (one black and one yellow 18-gallon containers and one black 2-gallon container) (Photograph 21). The worker was actively adding waste to these three open containers. These containers were not labeled as to their contents and there was no indication of how long these wastes had been accumulating.
In an adjacent area, VAMC-Nashville was storing multiple containers of non-creditable hazardous waste pharmaceuticals in 18-gallon and 8-gallon containers (Photographs 22-27). One of these containers was not labeled as to its contents and several were not labeled with an accumulation start date which was a common practice in this area. These containers were closed and in good condition.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.09(16)(c)5 [40 C.F.R. 266.502(e)], healthcare facilities must label or clearly mark each container of non-creditable hazardous waste pharmaceuticals with the phrase "Hazardous Waste Pharmaceuticals."
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.09(16)(c)6.(ii) [40 C.F.R. 266.502(f)(2)], a healthcare facility that accumulates non-creditable hazardous waste pharmaceuticals on-site must demonstrate the length of time that the non-creditable hazardous waste pharmaceuticals have been accumulating, starting from the date it first becomes a waste. A healthcare facility may make this demonstration by any of the following methods:
(I) Marking or labeling the container of non-creditable hazardous waste pharmaceuticals with the date that the non-creditable hazardous waste pharmaceuticals became a waste;
(II) Maintaining an inventory system that identifies the date the non-creditable hazardous waste pharmaceuticals being accumulated first became a waste; or
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(III)Placing the non-creditable hazardous waste pharmaceuticals in a specific area and identifying the earliest date that any of the non-creditable hazardous waste pharmaceuticals in the area became a waste.
Emergency Department / Medication (Room A-107C)
There were two black plastic containers accumulating non-creditable hazardous waste pharmaceuticals: one open 8-gallon container was not labeled as to its contents and one 2gallon container that was labeled as "Pharmaceutical Waste" on a yellow hazardous waste label (Photographs 28-30). VAMC-Nashville was also accumulating compressed gas inhaler canisters and trace chemotherapy waste in this area (both non-hazardous waste). There was no indication as to how long these black containers had been accumulating waste. The regulation states that these containers should be labeled as "Hazardous Waste Pharmaceuticals." VAMCNashville was operating one of the Cactus Smart Sink System units in this area.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.09(16)(c)4.(iii) [40 C.F.R. 266.502(d)(3)], a healthcare facility must keep containers of non-creditable hazardous waste pharmaceuticals closed and secured in a manner that prevents unauthorized access to its contents.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.09(16)(c)5 [40 C.F.R. 266.502(e)], healthcare facilities must label or clearly mark each container of non-creditable hazardous waste pharmaceuticals with the phrase "Hazardous Waste Pharmaceuticals."
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.09(16)(c)6.(ii) [40 C.F.R. 266.502(f)(2)], a healthcare facility that accumulates non-creditable hazardous waste pharmaceuticals on-site must demonstrate the length of time that the non-creditable hazardous waste pharmaceuticals have been accumulating, starting from the date it first becomes a waste. A healthcare facility may make this demonstration by any of the following methods:
(I) Marking or labeling the container of non-creditable hazardous waste pharmaceuticals with the date that the non-creditable hazardous waste pharmaceuticals became a waste;
(II) Maintaining an inventory system that identifies the date the non-creditable hazardous waste pharmaceuticals being accumulated first became a waste; or
(III)Placing the non-creditable hazardous waste pharmaceuticals in a specific area and identifying the earliest date that any of the non-creditable hazardous waste pharmaceuticals in the area became a waste.
Pod D (Room D-120A)
VAMC-Nashville was accumulating non-creditable hazardous waste pharmaceuticals in one 8gallon container in this area (Photograph 31). This container was labeled as "Flu and TDAP vials and Pharm Waste" on a yellow hazardous waste label and was marked with an accumulation start date of 11/30/2023. The regulation states that these containers should be labeled as "Hazardous Waste Pharmaceuticals."
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Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.09(16)(c)5 [40 C.F.R. 266.502(e)], healthcare facilities must label or clearly mark each container of non-creditable hazardous waste pharmaceuticals with the phrase "Hazardous Waste Pharmaceuticals."
Pod A (Room F-115)
VAMC-Nashville was accumulating non-creditable hazardous waste pharmaceuticals in one 8gallon container in this area (Photograph 32). This container was labeled as "Flu and TDAP vials and Pharm Waste" on a yellow hazardous waste label. Facility personnel stated that this container had only been in place for the last two months.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.09(16)(c)5 [40 C.F.R. 266.502(e)], healthcare facilities must label or clearly mark each container of non-creditable hazardous waste pharmaceuticals with the phrase "Hazardous Waste Pharmaceuticals."
Pod C (Room F-130)
VAMC-Nashville was accumulating non-creditable hazardous waste pharmaceuticals in one 8gallon container in this area. The container was labeled with the words "Pharm Waste." Facility personnel stated that this was a recent addition to the area.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.09(16)(c)5 [40 C.F.R. 266.502(e)], healthcare facilities must label or clearly mark each container of non-creditable hazardous waste pharmaceuticals with the phrase "Hazardous Waste Pharmaceuticals."
PACU (Room G-56C)
VAMC-Nashville was storing one brown container of batteries which was labeled as universal waste batteries. On the day of the inspection there were only alkaline batteries being stored in this container. VAMC-Nashville was operating one of the Cactus Smart Sink System units in this area.
SICU (Room C-07A)
There were two black plastic containers accumulating non-creditable hazardous waste pharmaceuticals: one 8-gallon container was labeled as "Pharm Waste" on a yellow hazardous waste label and the one 2-gallon container that was labeled as "Hazardous Waste Disposal" (Photograph 33). The 2-gallon container was labeled with an accumulation start date of December 2, 2023; the 8-gallon container was not labeled with an accumulation start date. VAMC-Nashville was operating one of the Cactus Smart Sink System units in this area. VAMCNashville was storing one brown container of batteries which was labeled as universal waste batteries. On the day of the inspection there were only alkaline batteries being stored in this container.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.09(16)(c)5 [40 C.F.R. 266.502(e)], healthcare facilities must label or clearly mark each container of non-creditable hazardous waste pharmaceuticals with the phrase "Hazardous Waste Pharmaceuticals."
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Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.09(16)(c)6.(ii) [40 C.F.R. 266.502(f)(2)], a healthcare facility that accumulates non-creditable hazardous waste pharmaceuticals on-site must demonstrate the length of time that the non-creditable hazardous waste pharmaceuticals have been accumulating, starting from the date it first becomes a waste. A healthcare facility may make this demonstration by any of the following methods:
(I) Marking or labeling the container of non-creditable hazardous waste pharmaceuticals with the date that the non-creditable hazardous waste pharmaceuticals became a waste;
(II) Maintaining an inventory system that identifies the date the non-creditable hazardous waste pharmaceuticals being accumulated first became a waste; or
(III)Placing the non-creditable hazardous waste pharmaceuticals in a specific area and identifying the earliest date that any of the non-creditable hazardous waste pharmaceuticals in the area became a waste.
Exterior Central Accumulation Area (CAA)
VAMC-Nashville was storing multiple wastes in the stand-alone metal building. The CAA is equipped with a secondary containment floor, an eyewash station, and a fire extinguisher is mounted on the inside wall adjacent to the entrance.
The waste being storing in this building included (Photographs 34-43):
Two 18-gallon, ten 8-gallon, and eight 2-gallon containers of hazardous waste pharmaceuticals with an oldest accumulation start date (ASD) of 1/30/2024 (photographs 34-35). These containers were labeled as "Pharm Waste" or "P-listed Pharm Waste" instead of "Hazardous Waste Pharmaceuticals";
Ten cardboard containers of Ni Metal Halide Batteries (Photograph 35); these containers were not individually labeled and there was no demonstration of the length of time that the universal waste has been accumulated; one similar container was labeled as "Used Batteries NiMH 1/17/24";
Four 5-gallon black plastic containers of Li-ion universal waste batteries and two 5gallon black plastic containers of NiCad and NiMH universal waste batteries (Photographs 35-38); VAMC-Nashville did not demonstrate the length of time that the universal waste has been accumulated;
Six lead-acid batteries were being accumulated; four were placed into a plastic gray bin that was labeled as "Used Batteries" bin and the other two were on the shelf adjacent to the bin (Photographs 37-38); there was no demonstration of the length of time that the universal waste has been accumulated and two of the batteries were not labeled or in a bin that was labeled;
One brown 2-gallon container labeled as "Universal Waste Batteries" and indicated that it was only for accumulating Lithium batteries (Photographs 37-38); there was no demonstration of the length of time that the universal waste has been accumulated;
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Seven 2-foot universal waste lamps in open-ended cardboard sleeves and one without the sleeve in an open gray bin that was labeled "Hg bulbs" with an ASD of 2/1/2024 (Photograph 40); these lamps were not containerized or labeled;
Four 4-foot closed cardboard containers of universal waste lamps sharing one universal waste label which was marked as UV bulbs Hg and an ASD of 2/1/2024 (Photograph 39); each container is required to be labeled; and
Two 15-gallon containers of waste formalin with an oldest ASD of 1/30/2024 (Photographs 41-43).
The inspection team also noted some debris in the secondary containment area. It is recommended that the debris be removed and periodically checked for additional accumulated debris.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.09(16)(c)5 [40 C.F.R. 266.502(e)], healthcare facilities must label or clearly mark each container of non-creditable hazardous waste pharmaceuticals with the phrase "Hazardous Waste Pharmaceuticals."
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.12(2) [40 C.F.R. 273.13(d)(1)], a SQHUW must manage universal waste lamps in a way that prevents releases of any universal waste or component of a universal waste to the environment.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.12(2)(e)1. [40 C.F.R. 273.14(a)], a SQHUW must label or mark each universal waste battery, or a container in which the batteries are contained, must be labeled or marked clearly with any one of the following phrases: "Universal Waste - Battery(ies)" or "Waste Battery(ies)" or "Used Battery(ies)."
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.12(2)(e)5. [40 C.F.R. 273.14(e)], a SQHUW must label or mark each lamp or container of lamps clearly with one of the following phrases: "Universal Waste-Lamp(s)," or "Waste Lamp(s)," or "Used Lamps."
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.12(2)(f)3. [40 C.F.R. 273.15(c)], a small quantity handler of universal waste who accumulates universal waste must be able to demonstrate the length of time that the universal waste has been accumulated from the date it becomes a waste or is received. The handler may make this demonstration by:
(i) Placing the universal waste in a container and marking or labeling the container with the earliest date that any universal waste in the container became a waste or was received;
(ii) Marking or labeling each individual item of universal waste (e.g., each battery or thermostat) with the date it became a waste or was received;
(iii) Maintaining an inventory system on-site that identifies the date each universal waste became a waste or was received;
(iv) Maintaining an inventory system on-site that identifies the earliest date that any universal waste in a group of universal waste items or a group of containers of universal waste became a waste or was received;
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(v) Placing the universal waste in a specific accumulation area and identifying the earliest date that any universal waste in the area became a waste or was received; or
(vi) Any other method which clearly demonstrates the length of time that the universal waste has been accumulated from the date it becomes a waste or is received.
Garage Storage Closet for Universal Waste Lamps
On the second floor of a parking garage near the Exterior CAA, VAMC-Nashville was storing universal waste lamps (Photographs 44-49). There were three 4-foot and one 8-foot containers of universal waste lamps stored in this location at the time of the inspection. These containers were in good condition, closed, and labeled as to their contents and with the accumulation start dates. The oldest accumulation start date was on the 8-foot container which was July 1, 2022, which is over one year. Small quantity handlers of universal waste are limited to one year for storage of universal waste.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.12(2)(f)1 [40 C.F.R. 273.15(a)], a small quantity handler of universal waste may accumulate universal waste for no longer than one year from the date the universal waste is generated, or received from another handler, unless the requirements of part 2 of this subparagraph are met.
Laboratory
VAMC-Nashville was accumulating laboratory generated hazardous waste in a large metal flammable cabinet. There were two 30-gallon black metal accumulation containers in the cabinet on the day of the inspection. One container was closed, in good condition, labeled and was stacked with nine 4-liter containers. Facility personnel stated that these stacked wastes were generated and placed on this container within the last week. VAMC-Nashville had not determined if these stacked wastes were hazardous waste. The other black accumulation container was equipped with a drainage funnel through one of the bung holes on top of the container (Photograph 50). This container was open and unlabeled with the words "Hazardous Waste" or with the indication of the hazard. The inspection team noted that the floor of the flammable cabinet was stained pink (Photograph 50).
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.03(1)(b) [40 C.F.R. 262.11], a person who generates a solid waste, as defined in Tenn. Comp. R. & Regs. 0400-12-01-.02(1)(b) [40 C.F.R. 261.2], must make an accurate determination as to whether that waste is a hazardous waste in order to ensure wastes are properly managed according to applicable RCRA regulations articulated in Tenn. Comp. R. & Regs. 0400-12-01-.03(1)(b) [40 C.F.R. 262.11].
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.03(1)(f)1.(iv) [40 C.F.R. 262.15(a)(4)], which is a condition of the SAA Permit Exemption, a generator is required to keep containers of hazardous waste closed at all times during accumulation, except when adding, removing, or consolidating waste; or when temporary venting of a container is necessary for the proper operation of equipment, or to prevent dangerous situations, such as build-up of extreme pressure.
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Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.03(1)(f)1.(v) [40 C.F.R. 262.15(a)(5)], which is a condition of the SAA Permit Exemption, a generator is required to mark or label its containers (I) The words "Hazardous Waste" and (II) with an indication of the hazards of the contents.
Laboratory Surgical Pathology Grossing Room
VAMC-Nashville was generating formalin waste in this area. A 15-gallon poly container used to accumulate the waste was closed, in good condition, and labeled (Photograph 51). Adjacent to the formalin waste, a gray tray storing four 4-liter containers three of which were empty (Photograph 52). The partially full container was open and not labeled with the words "Hazardous Waste" or with the indication of the hazard. The facility was also storing alkaline batteries in a container labeled as universal waste.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.03(1)(f)1.(iv) [40 C.F.R. 262.15(a)(4)], which is a condition of the SAA Permit Exemption, a generator is required to keep containers of hazardous waste closed at all times during accumulation, except when adding, removing, or consolidating waste; or when temporary venting of a container is necessary for the proper operation of equipment, or to prevent dangerous situations, such as build-up of extreme pressure.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.03(1)(f)1.(v) [40 C.F.R. 262.15(a)(5)], which is a condition of the SAA Permit Exemption, a generator is required to mark or label its containers (I) The words "Hazardous Waste" and (II) with an indication of the hazards of the contents.
Histology Laboratory
VAMC-Nashville was generating waste bluing and waste clarifer in the Histology laboratory. Facility personnel were accumulating this waste in 1-gallon containers in a labeled gray bin (Photograph 53). These 1-gallon containers were not labeled with the words "Hazardous Waste" or with an indication of the hazard. The inspection team noted one empty 5-gallon container used to transfer waste. The label on this container was faded and it was recommended that this labeled be replaced (Photograph 54).
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.03(1)(f)1.(v) [40 C.F.R. 262.15(a)(5)], which is a condition of the SAA Permit Exemption, a generator is required to mark or label its containers (I) The words "Hazardous Waste" and (II) with an indication of the hazards of the contents.
ACRE Building/3rd Floor (Room F-3C2)
No hazardous waste was present at the time of the inspection.
ACRE Building/3rd Floor (Room F-432)
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VAMC-Nashville operates a CAA for the research waste locations on floors 3, 4 and 5 of the ACRE Research Tower. At the time of the inspection, only one 1-gallon container of corrosive Qiazol waste (WS#7) was accumulating (Photograph 55). The container had been set in a tray that was labeled with the words "Hazardous Waste." The container was closed and labeled with the words "Hazardous Waste" as well as an indication of the hazard of the waste (corrosive). The accumulation start date of March 7, 2024, was written on the container label. The inspection team noted an eyewash station and spill response equipment in this area.
VAMC-Nashville operated multiple SAAs on the fourth floor (Photographs 56-64). In Room F407, Bay 1/Bench B, the inspection team noted one 1-gallon container of hazardous waste methanal (WS#10). This container was closed and in good condition however it was not labeled with the words "Hazardous Waste" nor did it have an indication of the hazard of the container contents. VAMC-Nashville staff corrected the deficiency during the inspection and moved the container to the 3rd floor CAA. The inspection team noted, on Bay 3/Bench E and F of Room F407, a 5-gallon container of Ethidium Bromide gel (WS#7) accumulating, which was in a closed container, labeled with the words "Hazardous Waste" and with the indication of the hazard of the contents. On Bay 4/Bench G of Room F407, the inspection team noted a 1-gallon container of hazardous waste Ethidium Bromide Gel (WS#7). The container was labeled with the words "Hazardous Waste" but was not labeled with an indication of the hazard of the contents. VAMC-Nashville staff labeled the container during the inspection. Additionally, on Bay 5/Bench I, VAMC-Nashville was storing a container of hazardous waste Ethidium Bromide (WS#7) that was labeled with the words "Hazardous Waste" but not with the indication of the hazard of the contents. Facility staff corrected the deficiency during the inspection.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.03(1)(f)1.(v) [40 C.F.R. 262.15(a)(5)], which is a condition of the SAA Permit Exemption, a generator is required to mark or label its containers (I) The words "Hazardous Waste" and (II) with an indication of the hazards of the contents.
12) Records Review
Contingency Plan and Quick Reference Guide (QRG):
The actions that facility personnel should take in response to an emergency are described in the facility's Emergency Operations Plan, which was last updated in 2019.
The plan describes actions facility personnel must take in response to fires, explosions, or any unplanned sudden or non-sudden release of hazardous waste or hazardous waste constituents to air, soil, or surface water at the facility.
The plan describes arrangements agreed to with the local police department, fire department, other emergency response teams, emergency response contractors, equipment suppliers, local hospitals, or the Local Emergency Planning Committee.
The plan does not list the current names and emergency telephone numbers for persons identified as emergency coordinators.
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Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.03(12)(i)(4) [40 C.F.R. 262.261(d)], the plan must include a list names and emergency telephone numbers of all persons qualified to act as emergency coordinator and the list must be kept up to date.
The plan includes a list of all emergency equipment at the facility. The list includes fire extinguishing systems, spill control equipment, communications and alarm systems, and decontamination equipment. The list appears up to date. The plan includes the location and a physical description of each item on the list, and a brief outline of its capabilities.
The plan includes an evacuation plan for personnel. This plan describes signal(s) to be used to begin evacuation, evacuation routes, and alternate evacuation routes.
There was no documentation that a copy of the Emergency Operations Plan (and its QRG) was submitted to the local emergency responders. The QRG does not include all of the following elements including the types/names of hazardous waste in layman's terms and the associated hazard associated with each hazardous waste present at any one time; the estimated maximum amount of each hazardous waste that may be present at any one time; the identification of any hazardous wastes where exposure would require unique or special treatment by medical or hospital staff; a map of the facility showing where hazardous wastes are generated, accumulated and treated and routes for accessing these wastes; a street map of the facility in relation to surrounding businesses, schools and residential areas; the locations of water supply; the identification of on-site notification systems; and the name of the emergency coordinator(s) and emergency telephone number(s).
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.03(1)(h)1(iv) [40 C.F.R. 262.17(a)(6)], which incorporates [Tenn. Comp. R. & Regs. 0400-12-01-.03(12)(j)3 [40 C.F.R. 262.262(c)], and is a condition of the LQG Permit Exemption, generators must update, if necessary, their quick reference guides, whenever the contingency plan is amended and submit these documents to the local emergency responders identified in part 1 of this subparagraph or, as appropriate, the Local Emergency Planning Committee. The quick reference guide must include the following elements:
(i) The types/names of hazardous wastes in layman's terms and the associated hazard associated with each hazardous waste present at any one time (e.g., toxic paint wastes, spent ignitable solvent, corrosive acid);
(ii) The estimated maximum amount of each hazardous waste that may be present at any one time;
(iii) The identification of any hazardous wastes where exposure would require unique or special treatment by medical or hospital staff;
(iv) A map of the facility showing where hazardous wastes are generated, accumulated, and treated, and routes for accessing these wastes;
(v) A street map of the facility in relation to surrounding businesses, schools, and residential areas to understand how best to get to the facility and also evacuate citizens and workers;
(vi) The locations of water supply (e.g., fire hydrant and its flow rate);
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(vii)
The identification of on-site notification systems (e.g., a fire alarm that rings off
site, smoke alarms); and
(viii)
The name of the emergency coordinator(s) and 7/24-hour emergency
telephone number(s) or, in the case of a facility where an emergency coordinator is
continuously on duty, the emergency telephone number for the emergency
coordinator.
Training Records:
The inspectors reviewed facility job descriptions and employee names that were provided for multiple job titles. These records were not up to date. Each description did not include the requisite skill, education, or other qualifications, and duties of facility personnel assigned to that position.
VAMC-Nashville provided a written description of the type and amount of both introductory and continuing training to be given to each person filling the positions listed above. The inspectors reviewed records of employee hazardous waste training completed in 2023. Jacob Houk, Philip Daniel, and Carmen Wilmer had not received annual RCRA training.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.03(1)(h)1.(vii)(III) [40 C.F.R. 262.17(a)(7)(iii)], facility personnel must take part in an annual review of the initial training required in item (I) of this subpart.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.03(1)(h)1.(vii)(IV) [40 C.F.R. 262.17(a)(7)(iv)], the large quantity generator must maintain the following documents and records at the facility:
(A) The job title for each position at the facility related to hazardous waste management, and the name of the employee filling each job;
(B) A written job description for each position listed under paragraph (a)(7)(iv)(A) of this section. This description may be consistent in its degree of specificity with descriptions for other similar positions in the same company location or bargaining unit, but must include the requisite skill, education, or other qualifications, and duties of facility personnel assigned to each position;
(C) A written description of the type and amount of both introductory and continuing training that will be given to each person filling a position listed under paragraph (a)(7)(iv)(A) of this section;
(D) Records that document that the training or job experience, required under paragraphs (a)(7)(i), (ii), and (iii) of this section, has been given to, and completed by, facility personnel.
Waste Manifest and Land Disposal Restriction (LDR) Records:
The inspectors reviewed available hazardous waste manifest records and land disposal restriction forms for shipments of hazardous waste sent since 2021. The inspection team noted
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that shipments of non-creditable hazardous waste pharmaceuticals did not reflect the healthcare facility requirement to indicate "PHARMS" or "PHARM" on Item 13 of EPA Form 8700-22 for their shipments.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.09(16)(i)1.(ii)(II) [40 C.F.R. 266.508(a)(2)(ii)], a healthcare facility must ship non-creditable hazardous waste pharmaceuticals off-site to a designated facility (such as a permitted or interim status treatment, storage, or disposal facility) in compliance with the manifest requirements of paragraph (3) of Rule 0400-12-01-.03 [40 CFR part 262 subpart B], except that: a healthcare facility shipping non-creditable hazardous waste pharmaceuticals must write the word "PHARMS" or "PHRM" in Item 13 of EPA Form 8700-22.
Weekly Inspection Records:
The inspectors reviewed VAMC-Nashville's available records of inspections of the hazardous waste central accumulation area (CAA) since 2021. The inspection log includes a checklist to record observations about leaking containers and for deterioration of containers caused by corrosion or other factors. The records for the Exterior CAA included the date and time of the inspection and the name, signature and initials of the employee conducting the inspection. The records for the ACRE Building/3rd Floor (Room F-432) CAA included the date of the inspection and the name, signature and initials of the employee conducting the inspection. The inspection logs from May 4, 2022, through October 12, 2023, did not include the time of the inspection. Employees do not routinely record inspection observations; there was no space to record inspection finding notes on the inspection form. The inspection team recommended the form be revised to include a space for observations.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.03(1)(h)1.(i)(V)II. [40 C.F.R. 262.17(a)(1)(v)], a large quantity generator must record inspections required by subitem I of this item in an inspection log or summary. The large quantity generator must keep these records for at least three years from the date of inspection. At a minimum, these records must include the date and time of the inspection, the name of the inspector, a notation of the observations made, and the date and nature of any repairs or other remedial actions.
The inspection team reviewed the annual reports from 2021, 2022, and 2023. The 2023 annual report detailed multiple waste streams numbered #4. Additionally, the HN-ESA form did not indication universal waste activity for 2023. The waste stream report for waste stream #3 identified the report year as 2022. These items require correction.
The annual reports for 2021 and 2022 were reviewed and it was noted that there was no indication of universal waste activity reflected in either year. Small and large quantity generators are responsible for maintaining an up-to-date notification file.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.03(2)(d)1.(ii) [40 C.F.R. 262.18(d)], small and large quantity generators shall be responsible for maintaining an up-to-date notification file by reviewing the most current notification information on file with the Commissioner, as made available by the Commissioner with the annual report, correcting inaccurate data or
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supplying all the information needed to ensure the Commissioner is maintaining an accurate notification file. The updated or corrected information shall be returned to the Commissioner by March 1st following the receipt of the notification information on file or as instructed otherwise by the Commissioner.
13) Closing Conference
The inspectors conducted the exit meeting at 12:00 pm on March 7, 2024, with Philip Daniels, Carmen Wilmer, Jake Slivensky, Alexisa Humphrey, Terri (Lisa) Torregano, and Dana Hastings. During this meeting, the inspectors stated their preliminary conclusions of the inspection.
14) Summary of Observations
During the inspection, observations were made concerning the following RCRA requirements: Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.03(1)(b) [40 C.F.R. 262.11], a person who generates a solid waste, as defined in Tenn. Comp. R. & Regs. 0400-12-01.02(1)(b) [40 C.F.R. 261.2], must make an accurate determination as to whether that waste is a hazardous waste in order to ensure wastes are properly managed according to applicable RCRA regulations articulated in Tenn. Comp. R. & Regs. 0400-12-01.03(1)(b) [40 C.F.R. 262.11].
VAMC - Nashville failed to make a hazardous waste determination for waste located in the laboratory.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.03(1)(f)1.(iv) [40 C.F.R. 262.15(a)(4)], which is a condition of the SAA Permit Exemption, a generator is required to keep containers of hazardous waste closed at all times during accumulation, except when adding, removing, or consolidating waste; or when temporary venting of a container is necessary for the proper operation of equipment, or to prevent dangerous situations, such as build-up of extreme pressure.
VAMC - Nashville failed to keep SAA containers closed in the following locations: the laboratory and the laboratory surgical pathology grossing room.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.03(1)(f)1.(v) [40 C.F.R. 262.15(a)(5)], which is a condition of the SAA Permit Exemption, a generator is required to mark or label its containers (I) The words "Hazardous Waste" and (II) with an indication of the hazards of the contents. VAMC - Nashville failed to label SAA containers in the following locations: the laboratory, laboratory surgical pathology grossing room, histology laboratory, ACRE Building 4th Floor at multiple areas in Room F407.
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Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.03(1)(h)1.(i)(V)II. [40 C.F.R. 262.17(a)(1)(v)], a large quantity generator must record inspections required by subitem I of this item in an inspection log or summary. The large quantity generator must keep these records for at least three years from the date of inspection. At a minimum, these records must include the date and time of the inspection, the name of the inspector, a notation of the observations made, and the date and nature of any repairs or other remedial actions.
VAMC - Nashville failed to include the time of the inspection on the weekly inspection logs conducted at the CAA in the ACRE building.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.03(1)(h)1(iv) [40 C.F.R. 262.17(a)(6)], which incorporates [Tenn. Comp. R. & Regs. 0400-12-01-.03(12)(j)3 [40 C.F.R. 262.262(c)], and is a condition of the LQG Permit Exemption, generators must update, if necessary, their quick reference guides, whenever the contingency plan is amended and submit these documents to the local emergency responders identified in part 1 of this subparagraph or, as appropriate, the Local Emergency Planning Committee. The quick reference guide must include the following elements: a. The types/names of hazardous wastes in layman's terms and the associated hazard associated with each hazardous waste present at any one time (e.g., toxic paint wastes, spent ignitable solvent, corrosive acid); b. The estimated maximum amount of each hazardous waste that may be present at any one time; c. The identification of any hazardous wastes where exposure would require unique or special treatment by medical or hospital staff; d. A map of the facility showing where hazardous wastes are generated, accumulated, and treated, and routes for accessing these wastes; e. A street map of the facility in relation to surrounding businesses, schools, and residential areas to understand how best to get to the facility and also evacuate citizens and workers; f. The locations of water supply (e.g., fire hydrant and its flow rate); g. The identification of on-site notification systems (e.g., a fire alarm that rings off site, smoke alarms); and h. The name of the emergency coordinator(s) and 7/24-hour emergency telephone number(s) or, in the case of a facility where an emergency coordinator is continuously on duty, the emergency telephone number for the emergency coordinator.
VAMC - Nashville failed to transmit the contingency plan and QRG to the local emergency responders or include all elements in their QRG.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.03(1)(h)1.(vii)(III) [40 C.F.R. 262.17(a)(7)(iii)], facility personnel must take part in an annual review of the initial training required in item (I) of this subpart.
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VAMC - Nashville failed to ensure three employees had taken their annual training reviews.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.03(1)(h)1.(vii)(IV) [40 C.F.R. 262.17(a)(7)(iv)], the large quantity generator must maintain the following documents and records at the facility:
(A) The job title for each position at the facility related to hazardous waste management, and the name of the employee filling each job;
(B) A written job description for each position listed under paragraph (a)(7)(iv)(A) of this section. This description may be consistent in its degree of specificity with descriptions for other similar positions in the same company location or bargaining unit, but must include the requisite skill, education, or other qualifications, and duties of facility personnel assigned to each position;
(C) A written description of the type and amount of both introductory and continuing training that will be given to each person filling a position listed under paragraph (a)(7)(iv)(A) of this section;
(D) Records that document that the training or job experience, required under paragraphs (a)(7)(i), (ii), and (iii) of this section, has been given to, and completed by, facility personnel.
VAMC - Nashville failed to maintain up to date records with job titles and job descriptions among other training records.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.03(2)(d)1.(ii) [40 C.F.R. 262.18(d)], small and large quantity generators shall be responsible for maintaining an up-to-date notification file by reviewing the most current notification information on file with the Commissioner, as made available by the Commissioner with the annual report, correcting inaccurate data or supplying all the information needed to ensure the Commissioner is maintaining an accurate notification file. The updated or corrected information shall be returned to the Commissioner by March 1st following the receipt of the notification information on file or as instructed otherwise by the Commissioner.
VAMC - Nashville failed to maintain accurate annual report data.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.09(16)(c)4.(i) [40 C.F.R. 266.502(d)(1)], a healthcare facility must place non-creditable hazardous waste pharmaceuticals in a container that is structurally sound, compatible with its contents, and that lacks evidence of leakage, spillage, or damage that could cause leakage under reasonably foreseeable conditions.
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VAMC - Nashville failed to containerize waste in 3 North (Room A-312) and 2 North (Room 2A211).
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.09(16)(c)4.(iii) [40 C.F.R. 266.502(d)(3)], a healthcare facility must keep containers of non-creditable hazardous waste pharmaceuticals closed and secured in a manner that prevents unauthorized access to its contents.
VAMC - Nashville failed to close containers of hazardous waste pharmaceuticals in the following locations: containerize waste in 2 North (Room 2A211), MICU (Room G-214R), and Emergency Department/Medication (Room A-107C).
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.09(16)(c)5. [40 C.F.R. 266.502(e)], healthcare facilities must label or clearly mark each container of non-creditable hazardous waste pharmaceuticals with the phrase "Hazardous Waste Pharmaceuticals."
VAMC - Nashville failed to label containers of non-credible hazardous waste pharmaceuticals in the following locations: Podiatry (Room C468), 3 North (Room A312), 2 North (Room 2A211), 2G (Room G-253), MICU (Room G-214R), HD Room 1 - Compounding Area, Emergency Department/Medication (Room A-107C), Pod D (Room D-120A), Pod A (Room F-115), Pod C (Room F-130), SICU (Room C-07A), and the Exterior CAA.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.09(16)(c)6.(ii) [40 C.F.R. 266.502(f)(2)], a healthcare facility that accumulates non-creditable hazardous waste pharmaceuticals on-site must demonstrate the length of time that the non-creditable hazardous waste pharmaceuticals have been accumulating, starting from the date it first becomes a waste. A healthcare facility may make this demonstration by any of the following methods: o Marking or labeling the container of non-creditable hazardous waste pharmaceuticals with the date that the non-creditable hazardous waste pharmaceuticals became a waste; o Maintaining an inventory system that identifies the date the non-creditable hazardous waste pharmaceuticals being accumulated first became a waste; or o Placing the non-creditable hazardous waste pharmaceuticals in a specific area and identifying the earliest date that any of the non-creditable hazardous waste pharmaceuticals in the area became a waste.
VAMC - Nashville failed to demonstrate accumulation time for containers of noncredible hazardous waste pharmaceuticals in the following locations: Podiatry (Room C468), 3 North (Room A-312), 2 North (Room 2A211), MICU (Room G-214R), HD Room 1
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Veterans Administration Medical Center Nashville Campus EPA ID# TN4360012948
Compounding Area, Emergency Department/Medication (Room A-107C), and SICU (Room C-07A).
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.09(16)(i)1.(ii)(II) [40 C.F.R. 266.508(a)(2)(ii)], a healthcare facility must ship non-creditable hazardous waste pharmaceuticals off-site to a designated facility (such as a permitted or interim status treatment, storage, or disposal facility) in compliance with the manifest requirements of paragraph (3) of Rule 0400-12-01-.03 [40 CFR part 262 subpart B], except that: a healthcare facility shipping non-creditable hazardous waste pharmaceuticals must write the word "PHARMS" or "PHRM" in Item 13 of EPA Form 8700-22.
VAMC - Nashville failed to use "PHARMS" or "PHRM" in Item 13 of EPA Form 8700-22 when shipping non-creditable hazardous waste pharmaceuticals off-site.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.12(2) [40 C.F.R. 273.13(d)(1)], a SQHUW must manage universal waste lamps in a way that prevents releases of any universal waste or component of a universal waste to the environment.
VAMC - Nashville failed to close containers of universal waste lamps in the Exterior CAA.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.12(2)(e)1. [40 C.F.R. 273.14(a)], a SQHUW must label or mark each universal waste battery, or a container in which the batteries are contained, must be labeled or marked clearly with any one of the following phrases: "Universal Waste - Battery(ies)" or "Waste Battery(ies)" or "Used Battery(ies)."
VAMC - Nashville failed to label universal waste batteries in the Exterior CAA.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.12(2)(e)5. [40 C.F.R. 273.14(e)], a SQHUW must label or mark each lamp or container of lamps clearly with one of the following phrases: "Universal Waste-Lamp(s)," or "Waste Lamp(s)," or "Used Lamps."
VAMC - Nashville failed to label universal waste lamps in the Exterior CAA.
Pursuant to Tenn. Comp. R. & Regs. 0400-12-01-.12(2)(f)1 [40 C.F.R. 273.15(c)], a small quantity handler of universal waste who accumulates universal waste must be able to demonstrate the length of time that the universal waste has been accumulated from the date it becomes a waste or is received. The handler may make this demonstration by: a. Placing the universal waste in a container and marking or labeling the container with the earliest date that any universal waste in the container became a waste or was received; b. Marking or labeling each individual item of universal waste (e.g., each battery or thermostat) with the date it became a waste or was received; c. Maintaining an inventory system on-site that identifies the date each universal waste became a waste or was received;
EPA-RCRA CEI Report March 5 and 7, 2024
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Veterans Administration Medical Center Nashville Campus EPA ID# TN4360012948
d. Maintaining an inventory system on-site that identifies the earliest date that any universal waste in a group of universal waste items or a group of containers of universal waste became a waste or was received;
e. Placing the universal waste in a specific accumulation area and identifying the earliest date that any universal waste in the area became a waste or was received; or
f. Any other method which clearly demonstrates the length of time that the universal waste has been accumulated from the date it becomes a waste or is received.
VAMC - Nashville failed to demonstrate accumulation time for universal waste in these locations: MICU (Room G-214R), the Exterior CAA, and the Garage Storage Closet.
15) List of Attachments
Attachment 1 - Photo Log: 64 photographs taken by either Alan Newman or Al Majors.
16) Signed
ALAN NEWMAN Date: 2024.08.26 15:59:43 -04'00' Digitally signed by ALAN NEWMAN
Alan Newman Environmental Engineer
17) Concurrence
ARACELI CHAVEZ Date: 2024.08.26 16:34:06 -04'00' Digitally signed by ARACELI CHAVEZ
Araceli B. Chavez, Chief RCRA Enforcement Section
EPA-RCRA CEI Report March 5 and 7, 2024
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Veterans Administration Medical Center Nashville Campus EPA ID# TN4360012948
Appendix 1
Photograph Log:
Photos taken March 5 and 7, 2024 Photos taken by Alan Newman and Al Majors
RCRA CEI Report - Appendix 1- Photograph Log EPA ID No.: TN4360012948 March 5 and 7, 2024
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Photograph 3: Podiatry (Room C468)
Photograph 1: 4 North/mental health (Room A467).
Photograph 4: Podiatry (Room C468)
Photograph 2: 4 North/mental health (Room A467) Cactus Unit.
Photograph 5: 3 North (Room A-312).
RCRA CEI Report - Appendix 1- Photograph Log EPA ID No.: TN4360012948 March 5 and 7, 2024
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Photograph 6: 3 North (Room A-312).
Photograph 8: 3 North (Room A-312).
Photograph 7: 3 North (Room A-312).
RCRA CEI Report - Appendix 1- Photograph Log EPA ID No.: TN4360012948 March 5 and 7, 2024
Photograph 9: 3 North (Room A-312).
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Photograph 12: 2 North (Room 2A211).
Photograph 10: 3 North (Room A-312).
Photograph 13: 2G (Room G-253).
Photograph 11: 2 North (Room 2A211).
Photograph 14: 2G (Room G-253).
RCRA CEI Report - Appendix 1- Photograph Log EPA ID No.: TN4360012948 March 5 and 7, 2024
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Photograph 15: 2G (Room G-253).
Photograph 16: MICU (Room G-214R).
Photograph 17: MICU (Room G-214R).
RCRA CEI Report - Appendix 1- Photograph Log EPA ID No.: TN4360012948 March 5 and 7, 2024
Photograph 18: MICU (Room G-214R).
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Photograph 19: Pharmacy.
Photograph 21: HD Room 1 - Compounding area.
Photograph 20: Pharmacy.
RCRA CEI Report - Appendix 1- Photograph Log EPA ID No.: TN4360012948 March 5 and 7, 2024
Photograph 22: HD Room 1 - Compounding area.
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Photograph 25: HD Room 1 - Compounding area.
Photograph 23: HD Room 1 - Compounding area.
Photograph 26: HD Room 1 - Compounding area.
Photograph 24: HD Room 1 - Compounding area.
RCRA CEI Report - Appendix 1- Photograph Log EPA ID No.: TN4360012948 March 5 and 7, 2024
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29: Emergency Department / Medication (Room A-107C).
Photograph 27: HD Room 1 - Compounding area.
Photograph 30: Emergency Department / Medication (Room A-107C).
Photograph 28: Emergency Department / Medication (Room A-107C).
RCRA CEI Report - Appendix 1- Photograph Log EPA ID No.: TN4360012948 March 5 and 7, 2024
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Photograph 31: Pod D (Room D-120A).
Photograph 33: SICU Room C-07A.
Photograph 32: Pod A (Room F-115).
RCRA CEI Report - Appendix 1- Photograph Log EPA ID No.: TN4360012948 March 5 and 7, 2024
Photograph 34: CAA waste pharmaceuticals.
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Photograph 35: CAA waste pharmaceuticals and batteries.
Photograph 37: CAA waste batteries.
Photograph 36: CAA waste batteries.
RCRA CEI Report - Appendix 1- Photograph Log EPA ID No.: TN4360012948 March 5 and 7, 2024
Photograph 38: CAA waste batteries.
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Photograph 39: CAA waste universal lamps.
Photograph 42: CAA waste formalin.
Photograph 40: CAA waste universal lamps.
Photograph 43: CAA waste formalin.
Photograph 41: CAA waste formalin.
RCRA CEI Report - Appendix 1- Photograph Log EPA ID No.: TN4360012948 March 5 and 7, 2024
Photograph 44: Garage Storage Closet for Universal Waste Lamps.
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Photograph 45: Garage Storage Closet for Universal Waste Lamps.
Photograph 48: Garage Storage Closet for Universal Waste Lamps.
Photograph 46: Garage Storage Closet for Universal Waste Lamps.
Photograph 49: Garage Storage Closet for Universal Waste Lamps.
Photograph 47: Garage Storage Closet for Universal Waste Lamps.
RCRA CEI Report - Appendix 1- Photograph Log EPA ID No.: TN4360012948 March 5 and 7, 2024
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Photograph 50: Laboratory SAA.
Photograph 52: Laboratory Surgical Pathology Grossing Room.
Photograph 51: Laboratory Surgical Pathology Grossing Room.
Photograph 53: Histology Laboratory.
RCRA CEI Report - Appendix 1- Photograph Log EPA ID No.: TN4360012948 March 5 and 7, 2024
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Photograph 54: Histology Laboratory. Photograph 56: ACRE Building Room F407 SAA.
Photograph 55: ACRE Building Room F-432 CAA .
RCRA CEI Report - Appendix 1- Photograph Log EPA ID No.: TN4360012948 March 5 and 7, 2024
Photograph 57: ACRE Building Room F407 SAA.
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Photograph 58: ACRE Building Room F407 SAA.
Photograph 60: ACRE Building Room F407 SAA.
Photograph 59: ACRE Building Room F407 SAA.
Photograph 61: ACRE Building Room F407 SAA.
RCRA CEI Report - Appendix 1- Photograph Log EPA ID No.: TN4360012948 March 5 and 7, 2024
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Photograph 62: ACRE Building Room F407 SAA.
Photograph 64: ACRE Building Room F407 SAA.
Photograph 63: ACRE Building Room F407 SAA.
RCRA CEI Report - Appendix 1- Photograph Log EPA ID No.: TN4360012948 March 5 and 7, 2024
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