Risk Mitigation with Compliance

Calendars

Triumvirate Environmental Presents

Meet Your Moderator:

Sasha Laferte

Type your comments and questions in the questions pane on the right.

How to Interact Today

Meet Your PresenterMatthew Teeter, HEMEnvironmental Compliance Advisor

mteeter@triumvirate.com• 12 years of healthcare Health and

Safety experience • 9 Years of healthcare consulting

experience with Triumvirate

OverviewHow it helps with compliance

How to develop and implement

Case study.

You Might Be Thinking...

Why do I need a compliance calendar?

I have a great program.

Why developing a calendar can

assist you with compliance.

In FY 2010, EPA initiated 346 cases, and 289 defendants were charged. The guilty paid nearly $41 million in fines and restitution and were sentenced to 72 years in prison.

Violating Posting Requirements (failure to post OSHA poster, OSHA 300 Annual summary, citations, etc.) – maximum $7,000

The Cost of Non-Compliance

• OSHA• EPA• MADEP, RIDEM,

CTDEEP, NHDES, MEDEP, NYSDEC, NJDEP

• DPH• The Joint

Commission

• Centers for Medicare

& Medicaid Services• College of American

Pathologists (CAP)• MWRA• Local POTW• Corporate audits• Customer audits• Internal policy and

procedures

Ensure Compliance

Compliance calendars are a good idea for all facilities regardless of size.

Who at your facility is the best person to develop and implement the compliance calendar?

• Safety department• Facility Manager• EVS Director• Security Director• Risk Management• Committee approach – safety

committee

Team approach vs. One person

Who Can Benefit from a Compliance Calendar?

What can I track on my calendar?Calendars can be used for more than just reporting requirements. Can be used for other tasks such as:• Tracking training cycles• Document review dates• Program reviews• Routine inspections• Performance testing dates• IH sampling cycles• Chemical inventory dates• Wastewater sampling• Tank testing/inspections• Track hazardous and universal waste shipments• Payment of compliance assurance, renewal or

usage fees

• Catch basins• Fire extinguisher inspection• Pigeon guano• Exit sign• Emergency lighting• Emergency response drills• Eyewash, safety showers

Routine Maintenance Tracking

Here’s how to develop and implement a compliance calendar.

Step 1: Do a Program Assessment

• What regulations apply to me?

• Do regulations have reporting or tracking requirements?

• Are these requirements being met and who is completing them

Focus on potential time and cost savings

Step 2: Management approval and buy-in to

your program.

An environmental compliance assessment may be of help in determining what regulations

apply to your facility if there are unknowns.

Step 3: Start by listing out reporting requirements by month

• Agency that has the requirement

• Regulatory citation (if applicable)

• Responsibilities

When is it best to review/update compliance calendar?

- Biennial Hazardous Waste Reporting- Air reporting and permitting- Wastewater discharge

permits- SPCC plan – 5 year review

Commonly Missed Reporting Deadlines

OverviewHow it helps with compliance

How to develop and implement

Case study.

Hospital with multiple locations within Massachusetts.

Faced with keep track of numerous regulatory reporting requirements within these facilities across the state.

Prior to calendar implementation, hospital was disorganized with regulatory permitting and submittals which resulted in regulatory inspection fines.

High turnover in key positions and staff lack of regulatory knowledge as well as site historical knowledge led to non-compliance.

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Case Study

Triumvirate contracted to oversee Environmental Health and Safety department.

Complete a facility and paperwork audit to determine which regulations apply to institution. From here a team was comprised of facilities, EVS and security staff to meet regularly and review calendar and associated materials.

Currently program managed Triumvirate with assistance from hospital staff. • Routine team meetings to discuss progress with completing identified

calendar tasks as well as upcoming tasks. • Monthly reporting tasks are assigned to respective party for

completion. • Once task has been completed, completion date tracked on calendar.• Transparency with program for institution.

Case Study

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QUESTIONS?

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