Isolation Rooms

What is the required testing frequency for TB Isolation Rooms?

TJC standards do not specify. They leave it up to the organization to determine the frequencies or intervals for inspecting, testing and maintaining the various utility systems and components. You may want to check with your state department of health to see if they have any recommended or required testing frequencies. You might also want to check with the CDC as as your infection control practitioners.

Standard EC.02.05.01

The organization manages risks associated with its utility systems.

EP3. The hospital identifies in writing inspection and maintenance activities for all operating components of utility systems on the inventory. (See also EC.02.05.05, EPs 3 - 5 and EC.02.05.09, EP 1)

Note: Hospitals may use different approaches to maintenance. For example, activities such as predictive maintenance, reliability-centered maintenance, interval-based inspections, corrective maintenance, or metered maintenance may be selected to ensure dependable performance.

EP4. The hospital identifies in writing the intervals for inspecting, testing, and maintaining all operating components of the utility systems on the inventory, based on criteria such as manufacturers' recommendations, risk levels, or hospital experience. (See also EC.02.05.05, EPs 3-5)

EP6. In areas designed to control airborne contaminants (such as biological agents, gases, fumes, dust), the ventilation system provides appropriate pressure relationships, air-exchange rates, and filtration efficiencies.

Note: Areas designed for control of airborne contaminants include spaces such as operating rooms, special procedure rooms, delivery rooms for patients diagnosed or suspected of having airborne communicable diseases (for example, pulmonary or laryngeal tuberculosis), patients in "protective environment" rooms (for example, those receiving bone marrow transplants), laboratories, pharmacies, and sterile supply rooms.

For further information, see Guidelines for Design and Construction of Hospitals and Health Care Facilities, 2006 edition, published by The American Institute of Architects.

Standard EC.02.05.05

The [organization] inspects, tests, and maintains utility systems.

Note: At times, maintenance is performed by an external service. In these cases, organizations are not required to possess maintenance documentation, but must have access to such documentation during survey and as needed.

EP3. The hospital inspects, tests, and maintains the following: Life support utility system components on the inventory. These activities are documented. (See also EC.02.05.01, EPs 2-4)

EP4. The hospital inspects, tests, and maintains the following: Infection control utility system components on the inventory. These activities are documented. (See also EC.02.05.01, EPs 2-4)

EP5. The hospital inspects, tests, and maintains the following: Non-life support utility system components on the inventory. These activities are documented. (See also EC.02.05.01, EPs 2-4)