Document wgLMQx3Vr47gwxZJ53GogNZad

RCRA Inspection Report 1) Inspector and Author of Report Paula A. Whiting Environmental Engineer whiting.paula@epa.gov (706) 355-8625 U.S. Environmental Protection Agency, Region 4 61 Forsyth Street, SW Atlanta, Georgia 30303 2) Facility Information Veteran Affairs Medical Center - Franklin R. Sousley Campus 2250 Leestown Road Lexington, Kentucky 40511 Fayette County EPA ID: KYD074072596 NAICS: 621511 - Medical Laboratories 62211 - General Medical and Surgical Hospitals 3) Responsible Official Mary Murray Acting Safety Chief Veteran Affairs Medical Center Franklin R. Sousley Campus MaryL.Murray@va.gov 4) Inspection Participants Mary Murray, Veteran Affairs Medical Center Amy McCracken, Kentucky Department for Environmental Protection (KYDEP) Novelle Smith, US EPA Region 4 Atlanta Paula Whiting, US EPA Region 4 Atlanta 5) Date and Time of Inspection February 13, 2025 @ 1:00 PM EST 6) Applicable Regulations1 Resource Conservation and Recovery Act (RCRA) Sections 3002, 3005 and 3007 (42 U.S.C. 6922, 6925 and 6927), and the regulations promulgated pursuant thereto at 40 Code of Federal Regulations (C.F.R.) Parts 260-270, 273 and 279. 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. Kentucky Revised Statutes Title XVIII, Chapter 224, Subchapter 46-Hazardous Waste et seq. (2006), and Title 401 of the Kentucky Administrative Regulations Pursuant to KRS 224.1-010(12) [40 C.F.R. 260.10], a generator of greater than 100 kilograms (220 lbs.) but less than 1,000 kilograms (2,200 lbs.) of hazardous waste in a calendar month is a Small Quantity Generator (SQG). Pursuant to 401 KAR 39:080, Section 1(1) [40 C.F.R. 262.16)], SQG may accumulate hazardous waste on-site for 180 days or less without a permit or without having interim status, as required by KRS 224.46-520 [Section 3005 of RCRA, 42 U.S.C. 6925], provided that the generator complies with the conditions listed in 401 KAR 39:080, Section 1(1) [40 C.F.R. 262.16] (hereinafter referred to as the "SQG Permit Exemption"). Pursuant to 401 KAR 39:080, Section 1(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 KRS 224.46-520 3005 of RCRA, 42 U.S.C. 6925], and without complying with 401 KAR 39:080, Section 1(1) [40 C.F.R. 262.16(b) or 262.17(a)], except as required in 401 KAR 39:080, Section 1(1) [40 C.F.R. 262.15(a)(7) and (8)], provided that the generator complies with the satellite accumulation area conditions listed in 401 KAR 39:080, Section 1(1) [40 C.F.R. 262.15] (hereinafter referred to as the "SAA Permit Exemption"). Pursuant to 401 KAR 39:080, Section 3(1) [40 C.F.R. 273.9], a small quantity handler of universal waste (SQHUW) is a universal waste handler who does not accumulate 5,000 kilograms or more of universal waste (batteries, pesticides, mercury-containing equipment, 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 (CEI) to determine whether the Veteran Affairs Medical Center - Franklin R. Sousley Campus (EPA ID Number: KYD074072596) was in compliance with the applicable requirements of RCRA and the corresponding KYDEP regulations. This was an EPA lead inspection. 8) Facility Description The Lexington Veterans Affairs Medical Center, established in 1931, is a fully accredited, twocampus, tertiary care medical center with an operating bed complement of 199 hospital beds with about 500 employees. Health care services are offered at six locations in Kentucky. Facilities include the two Lexington campuses and four community clinics in Berea, Hazard, Morehead, and Somerset. Acute medical, neurological, surgical and psychiatric inpatient services are provided at the Troy Bowling Campus, located adjacent to the University of Kentucky Medical Center. Other available services include: emergency care, medical-surgical units, acute psychiatry, ICU, progressive care unit, (includes Cardiac Cath Lab) ambulatory surgery, EPA-RCRA CEI Report January 14, 2025, LSASD Project ID: 25-0049 Page 2 of 7 Veteran Affairs Medical Center Franklin R. Sousley Campus EPA ID: KYD074072596 operating room (OR)/ post-anesthesia care unit (PACU), hemodialysis, medicine specialty clinics, surgery specialty clinics, and outpatient primary and specialty care. The Franklin R. Sousley Campus, located five miles from Cooper Drive, offers inpatient PostTraumatic Stress Disorder (PTSD) treatment, nursing home care, hospice and respite services, home based primary care, prosthestics and orthotics, geriatrics, optometry, mental health, and substance abuse treatment as well as primary care and women health. The Sousley Campus is 45 acres and has 8-10 employees handling hazardous waste. Veteran Affairs Medical Center - Franklin R. Sousley Campus' most recent Hazardous Waste Generator Notification (EPA Form 8700-12) dated August 16, 2023 characterized the facility as a Small Quantity Generator (SQG) of hazardous waste. Veteran Affairs Medical Center - Franklin R. Sousley Campus may generate D and F code hazardous waste streams, hazardous waste pharmaceuticals, spent aerosol cans, used solvent, used oil, universal lamps and batteries, paint waste and other wastes. 9) Previous Inspection History KYDEP has conducted eight RCRA CEIs at the subject facility between 1991 and 2024 and found 25 violations during those inspections. On March 6, 2024, KYDEP conducted the most recent RCRA CEI at the subject facility and found no apparent violations of the RCRA's requirements. 10) Findings On January 14, 2025, EPA inspectors Paula Whiting and Novelle Smith accompanied by KYDEP inspector Amy McCracken arrived at Veteran Affairs Medical Center - Franklin R. Sousley Campus at approximately 1:00 p.m. EST. The inspectors entered the facility and were escorted to a conference room. Mary Murray, Acting Safety Chief, immediately received the inspectors. Mary Murray and the inspectors were joined by Phil Bryan and Lindsay Watts, and various staff members of the Lexington Veteran Affairs Medical Center, for the opening conference. The inspectors introduced themselves, showed their credentials to Mary Murray, 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 the EPA. The company did not assert a business confidentiality claim. EPA-RCRA CEI Report January 14, 2025, LSASD Project ID: 25-0049 Page 3 of 7 Veteran Affairs Medical Center Franklin R. Sousley Campus EPA ID: KYD074072596 Mary Murray 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 the facility representative led the inspectors on a tour of the facility operations. Below is a description of the observations made during the inspection. 11) Inspection Observations During the opening conference, the inspectors were informed that Mr. Leonard Preston, former Safety Chief, had left in November 2024 and Mrs. Murray was now covering her position and this position. At the time of the inspection, Mr. Preston was contacted to verify the location of the hazardous waste pharmaceuticals and the universal waste storage. 180-Day Central Accumulation Area (CAA) Sousley Campus manages a hazardous waste CAA inside a standalone chemical storage shed (Pictures 1-3). The area was identified with a sign which read "dangerous." The storage shed was not marked as a "hazardous waste storage." In addition, the blue emergency contact sign was outdated, faded and illegible. Sousley Campus also manages ignitable waste in this CAA. The inspectors did not observe "No Smoking" signs on the exterior walls of the storage shed, however though the signs are not required, the EPA recommends adding "No Smoking" signs for safety. The CAA is equipped with an internal communications or alarm system capable of providing immediate emergency instruction to facility personnel; it is equipped with a device capable of summoning emergency assistance from local police departments, fire departments, or state or local emergency response teams; it is equipped with portable fire extinguishers, fire control equipment, spill control equipment, and decontamination equipment; and it is equipped with water to supply water hose streams, or foam producing equipment, or automatic sprinklers, or water spray system. Pursuant to 401 KAR 39:080, Section 1(1) [40 C.F.R. 262.16(b)(9)(ii)], which is a condition of the SQG Permit Exemption, a generator is required to post next to telephones, or in areas directly involved in the generation and accumulation of hazardous waste, the name and phone number of the emergency coordinator, the location of fire extinguishers and spill control material, and the phone number of the fire department (unless the facility has a direct alarm). At the time of the inspection, the inspectors did not observe any hazardous waste stored in the shed. Mrs. Murray stated a recent pickup of hazardous waste pharmaceuticals had occurred. Mrs. Murray also stated that most of the hazardous waste generated occurred at the University of Kentucky Troy Bowling Campus, and all pharmaceutical waste was generated at the Troy Bowling Campus instead of the Sousley Campus. Maintenance Shop The inspectors toured the maintenance and sign shop. The inspectors observed aerosol cans stored in the flammable cabinets and asked how the spent cans were disposed of. A shop employee stated that they were discarded in the trash, but Mrs. Murray stated that the spent EPA-RCRA CEI Report January 14, 2025, LSASD Project ID: 25-0049 Page 4 of 7 Veteran Affairs Medical Center Franklin R. Sousley Campus EPA ID: KYD074072596 cans were collected for disposal. At the time of the inspection, the inspectors did not observe any designated containers for spent aerosol can collection. Area of Concern: Hazardous waste aerosol cans are managed as universal waste per 40 C.F.R. 273. It is the facility's responsibility to determine whether the contents of the aerosol can may contain a hazardous waste characteristic prior to discarding and/or disposing of the cans. Building 3 - Old Fleet Garage Building 3 houses an old garage that at the time of the inspection did not appear in use. The inspectors did observe a 15-gallon used oil container with a red funnel (Picture 4). The container was labeled. An eyewash and shower were also observed in the area. Nothing else was stored in this area. Building 72 - Universal Waste Management Sousley Campus manages universal waste lamps and batteries in a standalone storage building (Pictures 5-17). The most recent shipment of universal waste lamps and batteries was sent to Cleanlites Recycling (EPA ID: MIR000016402) in Jackson, Michigan on August 22, 2024. The inspectors observed the following inside Building 72: Fourteen 4-foot cardboard boxes of universal waste lamps, one of the boxes was not secured, not labeled, and not dated, Four small boxes of universal waste lamps, Four uncontained, unlabeled, and undated 8-foot spent fluorescent lamps laying on the floor, Six 4-foot cardboard boxes and one 2-foot cardboard box of universal waste lamps inside a tan storage locker, 26 white 5-gallon containers of universal waste batteries, Six large red spent lead acid batteries (slabs), 16 boxes of small slabs, and One box of spent rechargeable radio batteries that were not dated or labeled. The oldest date observed was February 5, 2024, on a 4-foot cardboard box of universal waste lamps. The container was inside the tan storage locker. Pursuant 401 KAR 39:080, Section 3(1) [40 C.F.R. 273.13(d)], 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 401 KAR 39:080, Section 3(1) [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 WasteLamp(s)," or "Waste Lamp(s)," or "Used Lamps." Pursuant to 401 KAR 39:080, Section 3(1) [40 C.F.R. 273.14(a)], a SQHUW must label or mark each Universal Waste battery or container or tank in which the batteries are contained clearly EPA-RCRA CEI Report January 14, 2025, LSASD Project ID: 25-0049 Page 5 of 7 Veteran Affairs Medical Center Franklin R. Sousley Campus EPA ID: KYD074072596 with one of the following phrases: "Universal Waste - Battery(ies)," or "Waste Battery(ies)," or "Used Battery(ies)." Pursuant to 401 KAR 39:080, Section 3(1) [40 C.F.R. 273.15(a) and (c)], a SQHUW may accumulate universal waste no longer than one year and must to be able to demonstrate the length of time that the universal waste has accumulated from the date that it became a waste or was received. Pursuant to 401 KAR 39:080, Section 1(1) [40 C.F.R. 262.16(b)(9)(iii)], which is a condition of the SQG Permit Exemption, a generator is required to ensure that all employees are familiar with proper waste handling and emergency procedures. 12) Records Review Training The inspectors reviewed the training records of Michael Favor, the employee handling the hazardous waste at Sousley Campus. Mr. Favor received the Earth Smart Environmental Solution, LLC RCRA Refresher Training in August 2022. Mr. Favor receives training every three years; however, no certificates were available to document his training record. His written test where he passed the course were provided. The inspectors expressed concern with condition of signage for the CAA, Building 72 and the lack of universal waste aerosol can collection by the facility. The inspectors stated that training received was not consistent with the hazardous waste management occurring at the facility. Per 40 C.F.R. 262.16(b)(9)(iii), a SQG generator is required to ensure that all employees are familiar with proper waste handling and emergency procedures. In addition, no weekly inspections were being conducted for the CAA or the universal waste storage shed. Weekly Inspection Records The inspectors reviewed Sousley Campus' available records of inspections of the hazardous waste central accumulation area from 2020-2024 and Building 72 the universal waste storage shed. The inspection log includes a checklist of record observations about leaking containers and for deterioration of containers caused by corrosion or other factors. The records include the date and time of the inspection and the name, signature and initials of the employee conducting the inspection. Employees did not routinely record inspection observations and subsequent follow-up actions on the inspection log. In addition, no weekly inspections were conducted after November 19, 2024, for either the CAA or Building 72 the universal waste storage shed. Pursuant to 401 KAR 39:080, Section 1(1) [40 C.F.R. 262.16(b)(2)(iv)], which is a condition of the SQG Permit Exemption, a generator is required to, at least weekly, inspect central accumulation areas looking for leaking containers and for deterioration of containers caused by corrosion or other factors. 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 March 20, 2024. EPA-RCRA CEI Report January 14, 2025, LSASD Project ID: 25-0049 Page 6 of 7 Veteran Affairs Medical Center Franklin R. Sousley Campus EPA ID: KYD074072596 Hazardous waste manifest records show that hazardous waste pharmaceuticals are routinely shipped to Drug and Lab Disposal Inc. (EPA ID: MID092947928), and universal wastes to Cleanlites Recycling (EPA ID: MID000016402) and the most recent shipment was made on January 30, 2025. The return of the final designated facility copy was pending. 13) Closing Conference The inspectors conducted the exit meeting around 3:00 PM with Mrs. Murray and Mr. Bryan. During this meeting, the inspectors stated their preliminary conclusions of the inspection. Veteran Affairs Medical Center - Franklin R. Sousley Campus agreed to provide any corrections via email. On March 18, 2025, Mrs. McCracken conducted a follow up inspection with Mrs. Murray. During the follow up inspection, Mrs. McCracken observed new signs on Building 72 the universal waste storage shed and the inside of the shed was organized and separated by waste type. The 180day CAA had an updated emergency contact sign and a No Smoking sign. Mrs. McCracken also provided pictures of the CAA's fire suppression system. 14) List of Attachments Attachment A - Photo Log: Veteran Affairs Medical Center - Franklin R. Sousley Campus 14) Signed PAULA WHITING Paula A. Whiting Environmental Engineer Digitally signed by PAULA WHITING Date: 2025.04.17 09:54:34 -04'00' 16) Concurrence ARACELI CHAVEZ Araceli Chavez Chief RCRA Enforcement Section Digitally signed by ARACELI CHAVEZ Date: 2025.04.17 13:34:51 -04'00' EPA-RCRA CEI Report January 14, 2025, LSASD Project ID: 25-0049 Page 7 of 7 Veteran Affairs Medical Center Franklin R. Sousley Campus EPA ID: KYD074072596 Attachment 1 - Photo Log 17 Photos taken on: February 13, 2025 Photos taken by: Paula A Whiting Photos taken with: Olympus Tough EPA Property Tag: SC7374 Picture 1 - 180 Day CAA Picture 4 - Building 3 Old Garage Used Oil Container Picture 2 - 180 Day CAA Picture 5 - Building 72 Universal Waste Storage Picture 3 - 180 Day CAA - empty EPA-RCRA CEI Report January 14, 2025, LSASD Project ID: 25-0049 Picture 6 - Building 72 Universal Waste Page 1 of 3 Veteran Affairs Medical Center Franklin R. Sousley Campus EPA ID: KYD074072596 Picture 7 - Building 72 Universal Waste Lamps Picture 10 - Building 72 Universal Waste inspection log Picture 8 - Building 72 Universal Waste Lamps Picture 11 - Building 72 Universal Waste lamps uncontained, not dated, not labeled Picture 9 - Building 72 Universal Waste Lamps - expired date Picture 12 - Building 72 Universal Waste lamps uncontained, not dated, not labeled EPA-RCRA CEI Report January 14, 2025, LSASD Project ID: 25-0049 Page 2 of 3 Veteran Affairs Medical Center Franklin R. Sousley Campus EPA ID: KYD074072596 Picture 13 - Building 72 Universal Waste Lamps and Batteries Picture 16 - Building 72 Universal Waste Lamps and Batteries Picture 14 - Building 72 Universal Waste Lamps and Batteries Picture 17 - Building 72 Universal Waste Lamps and Batteries Picture 15 - Building 72 Universal Waste Lamps and Batteries EPA-RCRA CEI Report January 14, 2025, LSASD Project ID: 25-0049 Page 3 of 3 Veteran Affairs Medical Center Franklin R. Sousley Campus EPA ID: KYD074072596