CMS Further Updates 1135 Waivers

Last week, we posted a blog discussing a CMS Waiver allowing modification for testing intervals for certain physical environments requirements in health care and ambulatory health care occupancies. That blog can be found here.

On May 11, CMS amended several other requirements that were not included in the previous waivers. The requirements now included in the waivers include the following:

  • Alcohol-based Hand-Rub (ABHR) Dispensers: [CMS] are waiving the prescriptive requirements for the placement of alcohol based hand rub (ABHR) dispensers for use by staff and others due to the need for the increased use of ABHR in infection control. However, ABHRs contain ethyl alcohol, which is considered a flammable liquid, and there are restrictions on the storage and location of the containers. This includes restricting access by certain patient/resident population to prevent accidental ingestion. Due to the increased fire risk for bulk containers (over five gallons) those will still need to be stored in a protected hazardous materials area.

Please note that this allowance strictly relates to the locations of ABHR dispensers to be used by patients, staff, and visitors due to the added levels of infection control that hospitals and other facilities are implementing. As stated, bulk storage containers are still required to be within the maximum allowable code quantities. Due to the increased use of alcohol based hand rub, many facilities are increasing their storage quantities or even mixing their own utilizing ethanol. Great caution should be taken with the storage and/or dispensing of flammable liquids. Applicable fire codes contain regulations pertaining to the protection of these hazards which should be consulted if adjustments to storage quantities or the introduction of new processes are occurring.

  • Fire Drills: Due to the inadvisability of quarterly fire drills that move and mass staff together, CMS will instead permit a documented orientation training program related to the current fire plan, which considers current facility conditions. The training will instruct employees, including existing, new or temporary employees, on their current duties, life safety procedures and the fire protection devices in their assigned area.
  • Temporary Construction: CMS is waiving requirements that would otherwise not permit temporary walls and barriers between patients.

It is recommended that these provisions are only used for relief where necessary and all instances are documented accordingly when used. If you or your facility have any questions regarding these added provisions to the 1135 Waivers, please do not hesitate to contact us.