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Compliance News Volume XIII, Issue III

| David Stymiest

The Centers for Medicare & Medicaid Services (CMS) issued a categorical Life Safety Code waiver permitting new and existing ventilation systems supplying hospital and critical access hospital (CAH) anesthetizing locations to operate with a relative humidity (RH) of ≥20%, instead of ≥35%. CMS is also recommending that RH not exceed 60% in these locations.

CMS issued the new Survey & Certification memorandum # S&C: 13-25-LSC & ASC on April 19, 2013. In its S&C memo, CMS referenced the recent code changes that adopted the lower requirements. Many hospitals are expected to welcome this change, and it was supported by ASHE.

Organizations will not need to apply for this waiver or wait until they are cited by CMS or by state validation surveyors representing CMS. However if organizations choose to take advantage of this waiver, they are required to document their decision to do so (such as within Safety Committee meeting minutes) before they start using it. Organizations are also required to advise every Life Safety Code survey team at the beginning of any survey of their prior decision to use the CMS waiver. CMS stated that lack of documentation of the prior decision to use the waiver may result in citations that would otherwise have been unnecessary.

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