CMS SOM App. U, Tag R229

facility if the dispensers are installed in a manner that adequately protects against

inappropriate access.

Interpretive Guidelines: §403.744(a)(4)

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

areas and egress corridors. 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, RNHCIs must take appropriate precautions to secure ABHR dispensers from

inappropriate access. This means RNHCIs 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.

Survey Procedures:

• Determine whether the RNHCI maintains the ABHR dispensers in accordance

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

that the RNHCI has adopted policies and procedures to ensure that the dispensers

are maintained.