Q: My understanding is we should be following the 2010 FGI Guidelines because that’s what is recognized by the 2012 LSC that was adopted by CMS. But I have read where CMS and Joint Commission would allow hospitals to comply with the most recent edition of the FGI Guidelines, which is the 2014 edition. To confuse the issue further, our state has adopted the 2010 FGI Guidelines. What this boils down to is Table 7-1 on ventilation and if we should follow the 2010 edition or a newer one. Is my understanding correct or are we to follow the latest FGI guideline?
A: For most hospitals, compliance with the FGI Guidelines is more of a suggestion, than a requirement. The FGI Guidelines are not standards, but are guidelines on how to design your facility. According to the Interpretive Guidelines for CMS Condition of Participation §482.41(c)(4), it is clear that the design of the hospital must be made in accordance with a select standard or guideline. CMS allows you to choose which standard or guideline you follow, and provides suggestions for temperature and ventilation as directed by AORN, FGI, CDC and the like. It is also expected that you would follow state or local regulations as well, even if they are more restrictive than the national regulations.
Once designed and constructed, the temperature and ventilation requirements do not change in your facility when a newer edition of a standard or guideline is adopted. If you designed your ORs to the 2010 edition of the FGI Guidelines, then you only have to comply with the requirements of the 2010 edition for the life of the building, or until you conduct major renovation. Your facility does not have to retroactively comply with newer editions of the FGI Guidelines.
If your state has adopted the 2010 edition of the FGI Guidelines, and they require compliance with that edition, then that is the edition you comply with, even though CMS would allow compliance with the 2014 edition. The state’s requirements are more restrictive than CMS’.
As far as I can see, the 2012 Life Safety Code does NOT reference any edition of the FGI Guidelines, but NFPA 99-2012 does reference the 2008 ASRAE 170 publication on ventilation, which is the basis for Table 7-1 in the FGI Guidelines.