CMS - Relative Humidity (RH): Waiver of Life Safety Code (LSC) Requirements for Anesthetizing Locations

On April 19, 2013 CMS Center for Clinical Standards and Quality Survey and Certification group released S&C Letter 13-25-LSC and ASC.   The topic of this letter was CMS issuing a categorical waiver to allow relative humidity (RH) of ≥ 20 percent in anesthetizing locations.  The summary is a follows:

• RH of ≥ 20 percent permitted in anesthetizing locations:  CMS is issuing a categorical Life Safety Code (LSC) waiver permitting new and existing ventilation systems supplying hospital and critical access hospitals (CAH) anesthetizing locations to operate with a RH of ≥ 20 percent, instead of ≥ 35 percent.  CMS is also recommending that RH not exceed 60 percent in these locations.

• These changes are consistent with the 2012 edition of NFPA 99 and 2010 FGI guidelines, both of whom adopted the American Society for Heating, Refrigeration and Air Conditioning Engineers (ASHRAE) standard 170-2008, Ventilation of Health Care Facilities.  Addendum D of the ASHRAE standard requires RH in anesthetizing locations to be maintained between 20 - 60 percent.

•  Waiver does not apply if:
• More stringent RH levels are required under State or local laws and regulations; or
• The reduction of RH would negatively affect ventilation system performance

• Hospitals and CAHs must elect to use the categorical waiver:
• Individual waiver applications are not required, but facilities are expected to have written documentation that they have elected to use the waiver.
• At the entrance conference for any survey assessing LSC compliance, a facility that has elected to use this waiver must notify the survey team
• The absence of such evidence provided at the start of the survey means that the facility may be issued a citation if not in conformance with the 2000 LSC edition. 

• Ongoing Requirements:
• Facilities must monitor RH in anesthetizing locations and take corrective actions when needed to ensure RH remains at or above 20 percent.

• ASCs:  ASCs are not subject to all of the same LSC requirements as hospitals, but are required, consistent with 42 CFR 416.44(a)(1), to maintain RH in operating rooms in accordance with nationally accepted guidelines.

Link to the S&C Letter:  http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-25.pdf