August Mack Newsletter | February, 2019

Healthcare Facilities: Do You Ever Worry About Meeting JCAHO and EPA Compliance Requirements?
by Paula Morgan

Hospitals and healthcare facilities who plan to pursue or maintain Joint Commission on Accreditation of Healthcare Organizations (JCAHO) must complete unscheduled on-site surveys that include an environment of care session that focuses on six areas including life safety and environmental compliance. In addition to the JCAHO survey, healthcare facilities must comply with federal environmental regulations set by the Environmental Protection Agency (EPA). Healthcare facilities include laboratories, nursing care facilities, home care services, and hospitals.

Since 2002, the EPA has initiated increased enforcement efforts towards hospitals and healthcare facilities emphasizing medical facilities responsibilities to comply with environmental laws and regulations. Hospitals and healthcare facilities may be subject to specific regulations such as the Clean Air Act (CAA), Clean Water Act (CWA), Resource Conservation and Recovery Act (RCRA), and Superfund Amendments and Reauthorization Act (SARA) based on facility size and generator status. The most common violations for healthcare facilities include improper hazardous waste storage, handling, and disposal, lack of permits for wastewater discharges, and lack of Spill Prevention Control and Countermeasure (SPCC) plans. Healthcare facilities receive additional scrutiny from the regulatory agencies for hazardous waste non-compliance due to the presence of medical, pharmaceutical, and controlled substances onsite.

 Inspections completed by JCAHO and the EPA go hand-in-hand; to ensure facilities are meeting their environmental obligations the following questions should be considered:

  • Who is responsible for ensuring all hospital operations are in compliance with EPA and JCAHO standards?
  • Where are environmental, health and safety documents such as permits, plans, and records kept?
  • Are all licenses, manifests, safety data sheets (SDSs) required by law in an accessible area?
  • Does the facility conduct environmental compliance self-audits?
  • If self-audits are conducted, is there a system in place to ensure prompt correction of violations and prevent future violations?

For more information on how environmental compliance applies to healthcare facilities, sign up to attend our webinar on March 13, 2019

Paula Morgan is the eCAP® Account Specialist for August Mack Environmental, Inc. in the Lancaster, Pennsylvania office. She works closely with facilities to ensure compliance with federal, state, and local requirements. Paula earned a Master’s of Public Health degree in Environmental Health from West Chester University of Pennsylvania. Paula can be reached at 717.399.9587 ext. 225 or via email at

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