Bio-Hazard Waste Holding Room

Q: Our facility has a soiled utility room near the main laundry that also holds bagged, sealed, boxed, then sealed again bio-hazardous wasted awaiting removal by the contractor. Is this room required to have a dedicated air exhaust ventilation system to the outside of the building?

A: Yes… I believe it is required to have a dedicated air exhaust system to the outdoors. This is a requirement based on multiple entities. According to the FGI Guidelines, a soiled holing room is required to have the following:

  • Negative air pressure
  • 2 ACH minimum for outside air
  • 10 ACH minimum total
  • Room must exhaust directly to outdoors
  • No room unit ventilator air recirculation

In addition, according to the OSHA Bloodborne Pathogen standard 1910.1030(e)(4), if the storage area is also a HIV and HBV production area, then the room is required to have a dedicated exhaust system. So, it appears to me that the room is required to have a system that exhausts the air directly to the outdoors.

Disposal of Alcohol Prep Pads

Q: What is the proper method to store and dispose of waste alcohol prep pads? Are they considered hazardous waste?

A: The quantities of liquid alcohol in the preps would be considered incidental (or minimal) and not subject to the NFPA 30 (1996 edition) requirements for flammable liquid storage. However, even with incidental quantities, a written plan must be established on how your organization will address the disposal of the alcohol prep pads (which are flammable liquids) and how you will respond to a fire involving said flammable liquids. An evaluation is required on how the use and application of the incidental amounts of flammable liquids would pose a risk to safety to the occupants. Then a written action plan addressing those risks is required as well. Now pull those two actions together into a formal risk assessment and a written management plan on the proper use and disposal of the alcohol preps and the response to a fire that you would expect from your staff. As always, run the evaluation and written plan past the Safety Committee for their review and approval. It would also be a great idea to include the local AHJ on the evaluation and written plan to determine if they have any other suggestions or comments. They always want to know where flammable liquids are used or stored in an organization. You are required to have a written inventory of all hazardous materials and waste that is regulated. One can make the argument that the alcohol preps are regulated. Therefore, these alcohol preps would have to be included in the written inventory of hazardous materials and waste.

Spill Containment System

A friend of mine sent me this picture (to the left) of multiple barrels of chemicals that were crowded onto the spill containment system. Now granted, this may not be your typical Life Safety Code issue, but it is an issue that I do see in hospitals from time to time.

The question was raised is this a violation? And if so, what does it violate? Just looking at the picture, one can conclude that if a leak were to occur, the spill containment system may not catch it all, as the barrels hang over the edges. So, for starters, I can see a Joint Commission surveyor citing the hospital under EC.02.02.01, EP 5 which requires the hospital to minimize risks with storing hazardous materials.

Another concern, is compliance with EPA requirements in regards to CFR 264.175, on spill containment. This is reprinted here for your review:

 264.175 – Containment.
(a) Container storage areas must have a containment system that is designed and operated in accordance with paragraph (b) of this section, except as otherwise provided by paragraph (c) of this section.
(b) A containment system must be designed and operated as follows:
(1) A base must underlie the containers which is free of cracks or gaps and is sufficiently impervious to contain leaks, spills, and accumulated precipitation until the collected material is detected and removed;
(2) The base must be sloped or the containment system must be otherwise designed and operated to drain and remove liquids resulting from leaks, spills, or precipitation, unless the containers are elevated or are otherwise protected from contact with accumulated liquids;
(3) The containment system must have sufficient capacity to contain 10% of the volume of containers or the volume of the largest container, whichever is greater. Containers that do not contain free liquids need not be considered in this determination;
(4) Run-on into the containment system must be prevented unless the collection system has sufficient excess capacity in addition to that required in paragraph (b)(3) of this section to contain any run-on which might enter the system; and
(5) Spilled or leaked waste and accumulated precipitation must be removed from the sump or collection area in as timely a manner as is necessary to prevent overflow of the collection system.
[CFR Comment: If the collected material is a hazardous waste under part 261 of this Chapter, it must be managed as a hazardous waste in accordance with all applicable requirements of parts 262 through 266 of this chapter. If the collected material is discharged through a point source to waters of the United States, it is subject to the requirements of section 402 of the Clean Water Act, as amended.]
(c) Storage areas that store containers holding only wastes that do not contain free liquids need not have a containment system defined by paragraph (b) of this section, except as provided by paragraph (d) of this section or provided that:
(1) The storage area is sloped or is otherwise designed and operated to drain and remove liquid resulting from precipitation, or
(2) The containers are elevated or are otherwise protected from contact with accumulated liquid.
(d) Storage areas that store containers holding the wastes listed below that do not contain free liquids must have a containment system defined by paragraph (b) of this section:                                                                                                                                                           (1) FO20, FO21, FO22, FO23, FO26, and FO27.

So, the spill containment system only has to have a capacity of 10% volume of all the containers stored, or the total volume of the largest container. It appears in the picture that the spill containment system may very well meet that requirement. But CFR 264.175 also requires the base to contain leaks and spills, which the picture indicates that may not happen if the barrels are hanging over the edge of the containment system.

Take a look around your facility to see if you have this problem. It’s better that you find it first, before a surveyor or an inspector.