Staying Compliant with Alcohol-Based Hand Rub Dispensers - ABHR
Dustin Phillips, CFI
Fire & Life Safety Consultant for Hospitals, Nursing Homes, Ambulatory Surgery Centers, Assisted Living, and Dialysis Clinics
In healthcare facilities, hand hygiene is essential for infection control, and alcohol-based hand rub dispensers (ABHR) are a critical component. However, staying compliant with fire safety codes is just as important to avoid survey deficiencies and ensure the safety of both patients and staff. The National Fire Protection Association (NFPA) 101 Life Safety Code outlines specific requirements for the placement, use, and storage of ABHR dispensers. With the release of the 2024 edition of NFPA 101, there are important changes to take note of, particularly for non-healthcare settings, though healthcare facilities must continue to follow the same guidelines.
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Let’s walk through the key ABHR requirements and the recent updates so you can stay compliant and maintain safety in your facility.
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Dispenser Size and Placement
The size and location of hand rub dispensers have detailed requirements by NFPA 101. Under current rules for healthcare facilities:
- Dispensers in corridors or areas open to corridors must not exceed a fluid capacity of 1.2 liters (0.32 gallons).
- In rooms or suites separated from corridors, dispensers can be larger, with a maximum of 2 liters (0.53 gallons).
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For aerosol containers, ensure they are 18 ounces (0.51 kg) or less, and only Level 1 aerosols (the least flammable) are allowed.
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Spacing and Aggregate Quantity Limits
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To prevent fire hazards, ABHR dispensers must be spaced at least 48 inches (1220 mm) apart from each other horizontally. Additionally, the total amount of alcohol-based solution in use, outside of storage cabinets, cannot exceed 10 gallons (37.8 liters) per smoke or fire compartment or story of your facility.
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For facilities storing more than 5 gallons (18.9 liters) in one area, compliance with NFPA 30 (which governs flammable and combustible liquids) is required.
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Safe Installation Locations
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To reduce the risk of ignition, NFPA 101 outlines specific guidelines for where ABHR dispensers can be installed:
- Not directly above or to the side of an ignition source within a 1-inch distance.
- Not beneath an ignition source within 1-inch vertically.
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In areas with carpeted floors, ABHR dispensers are only allowed in spaces protected by automatic sprinkler systems.
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Alcohol Content and Dispensing Mechanisms
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To minimize fire risks, hand rub dispensers must contain no more than 95% alcohol by volume. Dispensers should release their contents only when activated, either manually or through touch-free activation. Automatic dispensers should activate only when an object is within 4-inches (100 mm) of the sensor to prevent accidental activation.
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Regular Testing and Maintenance
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It's important to regularly test and maintain your ABHR dispensers in line with the manufacturer's instructions, particularly when refilling. This ensures proper operation and prevents potential hazards.
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CMS Compliance and K-Tags - K325
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In addition to NFPA 101, facilities such as hospitals, nursing homes, and surgery centers need to stay compliant with CMS guidelines. When a facility is found deficient in meeting the ABHR requirements, CMS assigns K-Tags and specifically for ABHR dispenser deficiencies the K-Tag number is K325. This K-Tag number applies to hospitals, nursing homes, and surgery centers, and can be referenced on CMS Forms 2786R and 2786U. Understanding this K-Tag can help you prepare for surveys and prevent potential survey deficiencies.
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?New in NFPA 101 (2024) for Non-Healthcare Occupancies
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The 2024 edition of NFPA 101 introduces two major changes for non-healthcare settings, such as business, mercantile, educational, and assembly buildings:
1. Increased ABHR Quantities: The amount of ABHR solution allowed in fully sprinklered buildings has doubled from 10 gallons to 20 gallons.
2. Larger Dispenser Sizes:
?? - In corridors or areas open to corridors: Increased from 0.32 gallons to 0.53 gallons.
?? - In sprinklered corridors or areas open to corridors: The maximum dispenser size is now 1.06 gallons (previously 0.32 gallons).
?? - In rooms or suites of rooms: Dispensers have increased from 0.53 gallons to 1.06 gallons.
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Additionally, the 2024 edition introduces spill containment and maintenance requirements:
- Spill containment must be provided and kept clear of trash and other materials.
- Any spilled ABHR solution must be cleaned up immediately during refilling.
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These changes only apply to non-healthcare settings, while the current ABHR requirements continue for healthcare and ambulatory healthcare occupancies.
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Conclusion
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Maintaining compliance with NFPA 101 and CMS regulations regarding ABHR dispensers is essential for ensuring a safe and effective hand hygiene program in healthcare facilities. By adhering to guidelines on dispenser size, spacing, placement, and maintenance, and by staying informed about changes to the Life Safety Code, you can keep your facility both safe and compliant.
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For healthcare facilities, knowing about K-Tags will help ensure compliance during CMS surveys, while the 2024 updates expand flexibility in non-healthcare settings.
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