CMS Issues Categorical Waiver to Lower OR Humidity Requirement

Please see below and refer to the URL to obtain your own copy of the just-issued CMS categorical waiver regarding Operating Room minimum allowable relative humidity (RH).

CMS is lowering the humidity requirement for operating rooms from at least 35 percent to at least 20 percent.  In its S&C letter, CMS referenced the recent code changes that adopted the lower requirements.

You will not need to apply for this waiver or wait until you are cited, however if you choose to take advantage of this waiver (and I expect many hospitals will) you must document your decision to do so (such as within your Safety Committee meeting minutes) before you start using it.  You must also advise every Life Safety Code survey team at the beginning of any survey that you have made the prior decision to use the CMS waiver.  CMS stated that lack of documentation of your prior decision to use the waiver may result in your being cited against the 35 percent requirement.

The CMS waiver does not overrule more stringent state or local laws or regulations.

The CMS waiver does not apply if the reduction of the relative humidity would negatively affect ventilation system performance.

According to CMS, you 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 percent.

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

I suggest that you read the entire CMS S&C memo and share it with your staff.