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Keyes Life Safety

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ABHR Dispenser Test

by Brad Keyes, CHSP, on Aug 12, 2020 1:00:05 AM

Q: NFPA 101, 2012, requires that in health care occupancies, alcohol-based hand-rub dispensers "shall be tested in accordance with the manufacturer's care and use instruction each time a new refill is installed." The major manufacturer that my institution uses only publishes cleaning and use instructions, not testing information. I have contacted them as well and was referred to the use and cleaning instructions. Is there an expectation that these units be tested, and these tests are documented every time they are reloaded? Can I be cited for not maintaining documentation on these 'tests'?

A: Yes, you can be cited for not having documentation that you conducted this ‘test’, but I have not heard of any healthcare AHJ citing organizations for this. To be fully compliant with section (11)(f) of the 2012 LSC, you would need to instruct your staff to perform a quick ‘test’ of the dispenser in accordance with the manufacturer’s care and use instructions. It does not say anything about a manufacturer’s test procedures or instructions, but the ‘care and use instructions’.

You say you already have the manufacturer’s care and use instructions; use that as your base to follow in instructing your staff. Devise a login which each staff member who changes a refill a cartridge in the dispenser conducts the ‘test’ in accordance with the manufacturer’s care and use instructions. Then have the individual log it on the sheet and keep that in the nearby janitor’s closet. Is it a pain? Yes, it can be, but that is what the 2012 LSC requires.

Topics:Alcohol Based Hand Rub Dispensers

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