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If there is an air pressure problem, ’it’s almost inevitable that a surveyor will find it’


July 1, 2018

Make a list of all areas that are required to have positive or negative air pressure and ensure those areas are checked regularly to avoid possible condition-level findings by CMS, The Joint Commission (TJC), or another authority having jurisdiction, say experts.

Rooms that are in older buildings or areas that might have a harder time maintaining the correct air pressure, meanwhile, should be checked every morning—particularly if you are expecting a survey, recommends Steven A. MacArthur, senior consultant for The Greeley Company, in Danvers, Massachusetts.

Get leadership involved early on if problems require new machinery or other physical fixes that may cost money. Condition-level findings can put your accreditation at risk and open your facility to even more scrutiny.

If there is a problem with room pressures, it’s almost inevitable that a surveyor will find it, says MacArthur. If you’re checking the problem area every morning and keep a record of it, you can at least show you’re paying attention.

“As far as survey readiness goes, you want to have a pretty decent-sized data set, particularly as it relates to areas that are not as reliable,” which tend to be found in older facilities, he notes.

Have the list of problem areas ready so you’ll know where to check pressure again as soon as the survey team arrives, he advises. “Invariably, if there is a problem identified during a survey, the question will be raised as to when was the last time the room [or rooms] in question had been checked for appropriate environmental conditions—and this can include temperature and humidity as well as pressures,” says MacArthur.

“If you can say that ‘everything was good when we checked it this morning,’ then you’ve got a greater likelihood of being able to correct any aberrant conditions quickly, which could be the difference between a standard-level deficiency and a condition-level deficiency,” he notes.

CMS, TJC checking soiled utility rooms
Since the beginning of 2016, CMS has cited more than 45 hospitals nationwide for problems with ventilation, light, and temperature controls. Often those citations are for incorrect air pressures in soiled utility rooms and operating rooms. Hospitals are reporting that TJC has also cited facilities for problems with soiled utility areas.

Under Medicare Condition of Participation §482.41(c)(4), “there must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas,” according to CMS’ State Operations Manual, Appendix A, under Tag A-0726.

Under Environment of Care standard EC.02.05.01, TJC requires hospitals to manage utility risks. Until recently, the main resource for information on air pressure, humidity, and ventilation that was referenced by TJC was the Facility Guidelines Institute’s “Guidelines for Design and Construction of Health Care Facilities,” mentioned in EC.02.05.01, EP 15, with an added note that you should rely on the edition in use at the time your building was designed, says MacArthur. (Elsewhere, TJC references the NFPA 99 Health Care Facilities Code, he notes.)

However, as of March 11, a revision to that standard adds EP 27 to note that HVAC conditions in areas where general anesthesia is in use should be maintained according to ANSI/ASHRAE Standard 170.

That resource, “Standard for Ventilation of Health Care Facilities,” is available through the American Society of Heating, Refrigeration & Air-Conditioning Engineers (ASHRAE).

In particular, says MacArthur, refer to the standard’s Table 7-1, Design Parameters, to find the recommended pressure relationships to adjacent areas (positive or negative), the maximum and minimum number of air exchanges, whether air should be exhausted directly outdoors, and recommended humidity and temperatures.

For instance, soiled utility rooms should have a negative air pressure and be vented directly outdoors, “to prevent contaminants from spewing out into cleaner areas,” says MacArthur. The standard does not speak to frequency of monitoring, so “check these areas as often as you need to in order to ensure proper operational pressures.”

Regular checks a first step
Review your policy for monitoring areas for proper negative and positive pressure, especially if you are preparing for survey, recommends Linda Brohman, BSN, RN, a Certified Joint Commission Professional (CJCP) and regulatory coordinator with a hospital in Illinois.

Identify the rooms that are to be monitored, and ensure the frequency is included in that policy.

During a previous survey, Brohman’s facility had evidence of maintenance checks, but on the day of survey, one of the rooms had incorrect airflow. “And we were cited,” she says. The hospital responded by developing a log for the identified areas and had the department check those areas each morning. Hospital policy and procedures were also updated.

Regular monitoring will let you know when there is a mechanical or other problem that needs to be addressed, says MacArthur.

“That’s not to say that a belt couldn’t break on an air handler or a damper gets closed because someone didn’t like air blowing on them, or a door in the space is propped open, changing the pressures,” he says. “But if you‘ve been keeping a close eye on things, then the fix should be fairly simple.”

If the fix is major, such as replacing the heating, ventilation, and air conditioning systems, you need to begin work on it as soon as possible.

“If you’ve been trying to get administration to sign off on a million-dollar upgrade to the HVAC system and that’s why you’ve got an issue [with air pressures]—and if that is the case, you better have a paper trail of those requests—then the organization is probably going to have to take their lumps because the finding will likely result in a condition-level finding,” says MacArthur.

That will require a 45-day re-survey, “which can give you a whole ‘nother chance to fail,” he warns.

Tips to handling a citation
If you do have a repair in process, be sure to document the work orders and be able to produce them if there is a problem on the day of survey. You might be able to “talk your way out of a finding,” says MacArthur, although that is becoming less likely.

One step is to show that you have done an infection control risk assessment or have taken steps to mitigate the problem, such as relocating what was in the space as you wait for a fix. Otherwise, you can attempt to make “a very convincing argument that you are appropriately managing the risks associated with the condition,” says MacArthur.

“At the end of the day, you have to be able to demonstrate that you are not putting occupants—patients, staff, visitors—at risk due to the identified condition.”

Editor’s note: A version of this story first appeared in Inside the Joint Commission, a DecisionHealth newsletter.

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