CMS Requirements on Ventilation Testing

Q: What does CMS require as far as frequency of testing of air changes per hour (ACH) in hospitals? I see where we are supposed to test and know what ACH is required, but I have not seen at what frequency we are to test. 

A: You raise a very interesting point. CMS seems to have a different philosophy when it comes to writing standards, than say, The Joint Commission, HFAP or DNV. CMS does not write into their standards as much detail or specifics as the accreditors do. CMS does rely heavily on their written Interpretive Guidelines and Survey Procedures that they include with their standards. At times, these Interpretive Guidelines and Survey Procedures have very useful and detailed information.

In regards to ventilation requirements, CMS standard §482.41(c)(4) says “There must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas”. That’s all it says in the standard, which is not much to go on. But their Interpretive Guidelines for this standard says: Acceptable standards such as from the Association of Operating Room Nurses (AORN) or the Facilities Guidelines Institute (FGI) should be incorporated into hospital policy.”

So, CMS is saying in their Interpretive Guidelines that the FGI Guidelines must be followed for ventilation requirements. But it is important to understand that the FGI Guidelines are not retroactive to existing conditions, but are used for the design of new construction or renovated areas. For existing conditions, you need to be compliant with the laws, regulations and FGI Guidelines (or AIA Guidelines, if the area is that old) that were in affect at the time the area was designed or renovated.

If your existing area can meet the current FGI Guidelines, then that is great and you’re in good shape. If your existing area cannot meet the current FGI Guidelines, then you need to determine what regulations or guidelines were in effect at the time the area was constructed. If you meet those ventilation requirements, and you can document that, then you’re in good shape.

Now, to answer your direct question: “What does CMS require as far as frequency of testing of air changes per hour (ACH) in hospitals?” The answer is…CMS does not specify how frequent you need to check the ACH rates, and neither does the FGI Guidelines appear to specify how frequently you need to check your ACH rates. But that does not mean you do not have to perform periodic checks. The answer is… You get to decide how often you check the ACH rates, but it better be based on reasonable assumptions. The state agency surveyors who will survey your hospital on behalf of CMS will have expectations on how often you check the ACH. I could offer suggestions, but ultimately you need to know and follow what your state agency inspectors expect. I suggest you contact them and discuss this issue with them to understand what their expectation will be.