Q: The Centers for Medicare & Medicaid Services (CMS) standard §482.41(c)(4) states in their Interpretative Guidelines that hospitals must comply with the Facilities Guidelines Institute (FGI) for ventilation in anesthetizing locations. The Joint Commission standard EC.02.06.05, EP 1 requires compliance with the same FGI standards on ventilation. Our operating rooms were designed more than 20 years ago when the AIA guidelines at the time had less air changes per hour than what the new 2010 FGI guidelines require. Am I supposed to modify my current ventilation equipment in order to comply with the new 2010 FGI guidelines for air changes per hour?
A: This short answer is No; you do not have to modify your existing air handler to meet the new 2010 FGI guidelines on air changes per hour, unless you alter, renovate or remodel the rooms the ventilation equipment serves. The Interpretative Guidelines for the CMS standards are not part of the enforceable standards, and are considered references. CMS does not expect compliance with the new FGI guidelines on existing equipment; only on new construction. Also, CMS states “acceptable standards such as from the Association of Operating Room Nurses (AORN) or the FGI should be incorporated into hospital policy.” This means, the FGI guidelines are not the only standard you should consider when designing new construction or renovated areas.
In regards to the Joint Commission standard EC.02.06.05, EP 1, it clearly states in the standard: “When planning for new, altered, or renovated space…” This means the FGI guidelines only apply to new construction, and not to existing conditions. And the FGI guidelines are only one of a set of criteria that the organizations may choose to comply with. The others are state rules and regulations or other reputable standards and guidelines that provide equivalent design criteria.