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A March 25, 2005, interim final rule on alcohol-based handrubs (ABHRs) does not require facilities to install dispensers, but it does mandate correct installation if the dispensers are used.

CMS Installation Requirements for Alcohol Hand-Gel Dispensers

CMS Installation Requirements for Alcohol Hand-Gel Dispensers

A March 25, 2005, interim final rule on alcohol-based handrubs (ABHRs) does not require facilities to install dispensers, but it does mandate correct installation if the dispensers are used.1 The following are the key requirements for ABHR dispenser installation cited by the Centers for Medicaid & Medicare Services:

  • Where dispensers are installed in a corridor, the corridor shall have a minimum width of 6 ft. (1.8m).
  • The maximum individual dispenser fluid capacity shall be:
    • 0.3 gallons (1.2 liters) for dispensers in rooms, corridors, and areas open to corridors.
    • 0.5 gallons (2.0 liters) for dispensers in suites of rooms.
  • The dispensers shall have a minimum horizontal spacing of 4 ft. (1.2m) from each other.
  • Not more than an aggregate 10 gallons (37.8 liters) of ABHR solution shall be in use in a single smoke compartment outside of a storage cabinet.
  • Storage of quantities greater than 5 gallons (18.9 liters) in a single smoke compartment shall meet the requirements of NFPA 30, Flammable and Combustible Liquids Code.
  • The dispensers shall not be installed over or directly adjacent to an ignition source.
  • In locations with carpeted floor coverings, dispensers installed directly over carpeted surfaces shall be permitted only in sprinklered smoke compartments.
  • The dispensers shall be installed in a manner that minimizes leaks and spills that could lead to falls. While this regulation does not require a specific method for minimizing leaks and spills, facilities may decide to install additional hardware to ensure compliance with this regulation. Additional hardware, such as a device below the dispenser to catch drips, could increase purchasing and installation costs. In addition to any extra steps such as additional hardware installation, facilities should follow all manufacturer maintenance recommendations for ABHR dispensers.
  • The dispensers shall be installed in a manner that adequately protects against access by vulnerable populations, such as residents in psychiatric units. There are certain patient or resident populations, such as residents of dementia wards, who may misuse ABHR solutions, which are both toxic and flammable. As a toxic substance, ABHR solutions are very dangerous if they are ingested, placed in the eyes, or otherwise misused. As a flammable substance, ABHR solutions could be used to start fires that endanger the lives of patients and destroy property.

Reference

  1. Centers for Medicare & Medicaid Services. Fire safety requirements for certain health care facilities; amendment. Interim final rule. 70 Fed Reg 15,229-15,239 (Mar. 25, 2005).