Annual Testing & Balance of HVAC Systems

Q: Do you know if the ambulatory health care facilities are required to do an annual Test and Balance of the HVAC system?

A: No… I am not aware of that requirement. As far as I know, there is no standard for ambulatory healthcare occupancies (ASC) and healthcare occupancies (hospitals) to conduct annual TAB for their HVAC systems.

Now, having said that, the accreditation organizations and the CMS certification agencies do require you to demonstrate compliance with certain ASHRAE ventilation requirements in critical areas, such as operating rooms. But there is no actual standard that says you have to conduct annual TAB on the HVAC systems.

I suspect your accreditation organization and state agency who surveys on behalf of CMS will expect you to have documentation that your HVAC systems in your critical areas of the ambulatory healthcare occupancy is in compliance. An annual TAB report should be sufficient for that purpose.

Testing Elevator Fire-Fighters Service

Q: We have multiple hospitals that we provide fire-safety testing services to. With the new requirement for testing elevator fire-fighters emergency operations, we all have a different opinion about what needs to be done. I believe we need to test Phase I and Phase II. Some people believe its only Phase I and some believe its only Phase II that need to be tested. I even have one hospital that believes it’s only the emergency phone that needs to be tested. What is your opinion on this?

A: Well…. The hospital that believes only the phones need to be tested are not among the enlightened. They need to get a new understanding.

Section 9.4.6.2 of the 2012 Life Safety Code says all elevators equipped with firefighters’ emergency operations in accordance with section 9.4.3 (which references ASME A17.1 Safety Code for Elevators) shall be subject to a monthly operation with a written record. ASME A17.1 is the industry standard for Phase I and Phase II operations. Phase I is typically the recall portion, and Phase II is the in-cab operation of the fire fighters’ service. So, I would say both Phase I and Phase II must be operated monthly. Now, if the elevators are only equipped with Phase I, then of course you can’t test Phase II operations.