Focus: Fire-Life Safety / Column


Regulations, Codes & Standards Q&A: Four-foot wrap around for ABHR dispensers

By Brad Keyes / Special to Healthcare Facilities Today
May 27, 2020

Q: In regard to the four-foot separation of alcohol-based hand rub (ABHR) dispensers and the wrap-around the door frame requirement. I would like to pose the following: As part of the fire-response procedures by staff, they are required to close all doors. Closing doors provides the required separation and, thus, would allow the installation of the dispenser in the patient room. What are your thoughts on that justification for allowing the installation of the dispenser in the room?

A: That justification will not pass muster with CMS. The reference on this particular issue is CMS Baltimore and they have made the interpretation that a wrap-around horizontal measurement of less than four feet through an open doorway is not acceptable … probably because the door can be left open.  

Brad Keyes, CHSP, is the owner of KEYES Life Safety Compliance, and his expertise is in the management of the Life Safety Program, including the Environment of Care and Emergency Management programs.

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Topic Area: Regulations, Codes & Standards


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