CMS SOM App. A, Tag A-0716

dispensers are installed in a manner that adequately protects against inappropriate access.

Interpretive Guidelines, 482.41(b)(7):

Alcohol-based hand rub (ABHR) dispensers are a common infection control method.

Healthcare-acquired infections are of increasing concern, and many such infections are

transmitted because health care workers do not wash their hands or do so improperly or

inadequately. An important aspect of getting health care workers to use ABHR dispensers is their

accessibility. The American Hospital Association commissioned a study to determine the safest

method to place ABHR dispensers in corridors. As a result of this study, the LSC was amended

to permit their use under certain conditions in patient care rooms and egress corridors.

In addition, CMS requires that ABHR dispensers be installed in a manner that protects against

inappropriate access by persons who may not comprehend the associated risks of misusing

ABHR solutions, which are both toxic and flammable (e.g., children, individuals with intellectual

disabilities, psychiatric patients, etc.). In order to avoid dangerous situations, a facility must

take appropriate precautions to secure ABHR dispensers from inappropriate access. This means

facilities could choose not to install ABHR dispensers in locations where vulnerable populations

exist, or a facility may choose to install ABHR dispensers only in areas that can be easily and

frequently monitored, such as in view of a nurse’s station or areas that are continuously

monitored with a security camera, or not install them at all in other areas. It is up to the

hospital to decide how best to secure ABHR dispensers against inappropriate access.

Regular maintenance of ABHR dispensers is seen as a crucial step in making sure that dispensers

do not leak contents, which would allow inappropriate access. Hospitals are expected to

maintain ABHR dispensers in accordance with manufacturers’ guidelines. If the manufacturer

does not have specific maintenance requirements, the facility is expected to develop its own

policies and procedures to maintain all ABHR dispensers.

Survey Procedures §482.41(b)(7):

• Determine whether ABHR dispensers are adequately protected against inappropriate

access.

• Determine whether the hospital maintains the ABHR dispensers in accordance with the

manufacturer’s guidelines, or, if there are no manufacturer’s guidelines, that the hospital

has adopted policies and procedures to ensure that the dispensers are maintained.