CMS SOM App. L, Tag Q-0105

(4) An ASC may place alcohol-based hand rub dispensers in its facility if the

dispensers are installed in a manner that adequately protects against inappropriate

access.

Interpretive Guidelines: §416.44(b)(4)

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

Healthcare-acquired and surgical site 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 the use of ABHRs

under certain conditions in patient care areas 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, individual

with intellectual disabilities, etc.). In order to avoid dangerous situations, ASCs must

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

means ASCs could 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.

While an ASC has flexibility in deciding how best to secure ABHR dispensers, it must do

so in a manner that protects against inappropriate access.

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

dispensers do not leak contents. ASCs 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.

See the interpretive guidelines for §416.42 related to use of alcohol-based skin

preparations in anesthetizing locations.

Survey Procedures: §416.44(b)(4)

• Verify ABHR dispensers are installed in a manner that protects against

inappropriate access.

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

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

the ASC has adopted policies and procedures to ensure that the dispensers are

maintained.