By David Stymiest, PE, CHFM, CHSP, FASHE
The Centers for Medicare & Medicaid Services (CMS) issued a categorical Life Safety Code waiver permitting new and existing ventilation systems supplying hospital and critical access hospital (CAH) anesthetizing locations to operate with a relative humidity (RH) of ≥20%, instead of ≥35%. CMS is also recommending that RH not exceed 60% in these locations.
CMS issued the new Survey & Certification memorandum # S&C: 13-25-LSC & ASC on April 19, 2013. In its S&C memo, CMS referenced the recent code changes that adopted the lower requirements. Many hospitals are expected to welcome this change, and it was supported by ASHE.
Organizations will not need to apply for this waiver or wait until they are cited by CMS or by state validation surveyors representing CMS. However if organizations choose to take advantage of this waiver, they are required to document their decision to do so (such as within Safety Committee meeting minutes) before they start using it. Organizations are also required to advise every Life Safety Code survey team at the beginning of any survey of their prior decision to use the CMS waiver. CMS stated that lack of documentation of the prior decision to use the waiver may result in citations that would otherwise have been unnecessary.
The CMS waiver does not overrule more stringent state or local laws or regulations nor does it apply if the reduction of the relative humidity would negatively affect ventilation system performance.
According to CMS, organizations must still monitor relative humidity levels in anesthetizing locations and must take action when needed to ensure that RH levels remain at or above 20%. Specifically, the CMS S&C memo stated “Facilities must monitor RH levels in anesthetizing locations and be able to provide evidence that the RH levels are maintained at or above 20%. When outdoor humidity and internal moisture are not sufficient to achieve the minimum humidity level, then humidification must be provided by means of the hospital’s or CAH’s ventilation systems. In addition, facilities must provide evidence that timely corrective actions are performed successfully in instances when internal monitoring determines RH levels are below the permitted range.”
The categorical waiver contains 17 pages of details including updated State Operations Manual Appendices A, I, L and W. All organizations should obtain a copy of the letter and review it closely.
The URL for the CMS Survey and Certification Memo is:
http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-25.pdf
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