Improper Storage of Alcohol-Based Hand Rub
Summary
During a Life Safety Code survey, it was observed that alcohol-based hand rub (ABHR) was improperly stored in the facility's basement. Specifically, 73 liters (equivalent to 19.28 gallons) of ABHR were stored in the Supplies storage room on open shelving, which is located across from the Boiler room. This storage method did not comply with the 2012 edition of the National Fire Protection Association (NFPA) 30: Flammable and Combustible Liquids Code, which requires that quantities greater than 10 gallons be stored in a flammable liquids storage cabinet. During an interview, the Maintenance Supervisor admitted to storing the ABHR in the Supplies room and was unaware of the regulations regarding the storage of ABHR in quantities exceeding 10 gallons.
Plan Of Correction
Plan of Correction: Approved February 26, 2025 The excess (greater than 10 gallons) volume of alcohol-based hand sanitizer noted during the survey has been removed and redistributed to meet life safety code standards. An audit of other housekeeping storage areas has been completed to identify any other areas that had quantities beyond those allowed by regulation. No other areas were identified to be in violation of this life safety code standards. A review of the facility's storage procedures has been completed to assure proper storage of alcohol-based hand sanitizers. The facility will also reduce on-site inventory of hand sanitizer to avoid the potential for excess storage in potentially hazardous areas. All maintenance and housekeeping staff will receive education and in-servicing on this new policy and procedure. Random audits of housekeeping storage areas will be completed weekly, for six months, to assure ongoing compliance. These audit results will be placed on the agenda of the Quality Assurance Performance Improvement committee to determine if continued monitoring is warranted or if corrective actions are completed. The Director of Maintenance will be responsible for ongoing compliance with these corrective measures.
Penalty
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