New items for an existing Element of Performance

Please read the new requirements that the Joint Commission is implementing to help address mold and other ventilation hazards.

“The Joint Commission has added new content to Element of Performance (EP) 15 of Standard EC.02.05.01: The [organization] manages risks associated with its utility systems. Effective January 1, 2020, EP 15, for hospitals and critical access hospitals, is worded as follows (with new content underlined and in red):

In critical care areas designed to control airborne contaminants (such as biological agents, gases, fumes, dust), the ventilation system provides appropriate pressure relationships, air-exchange rates, filtration efficiencies, temperature, and humidity.

For new and existing health care facilities, or altered, renovated, or modernized portions of existing systems or individual components (constructed or plans approved on or after July 5, 2016), heating, cooling, and ventilation are in accordance with NFPA 99-2012, which includes 2008 ASHRAE 170, or state design requirements if more stringent.

Note 1: For hospitals that use Joint Commission accreditation for deemed status purposes: Existing facilities may elect to implement a Centers for Medicare & Medicaid Services (CMS) categorical waiver to reduce their relative humidity to 20% in operating rooms 3 EC News February 2020 Copyright 2020 The Joint Commission Environment of Care® News, February 2020, Volume 23, Issue 2 and other anesthetizing locations. Should the facility elect the waiver, it must be included in its Basic Building Information (BBI), and the facility’s equipment and supplies must be compatible with the humidity reduction. For further information on waiver and equivalency requests, see https://www.jointcommission.org /life_safety_code_information_resources/.

Note 2: For hospitals that use Joint Commission accreditation for deemed status purposes: Existing facilities may comply with the 2012 NFPA 99 ventilation requirements or the ventilation requirements in the edition of the NFPA code previously adopted by CMS at the time of installation (for example, 1999 NFPA 99).

A standard co-developed by the American National Standards Institute (ANSI), the American Society of Heating, Refrigerating and Air-Conditioning Engineers (ASHRAE), and the American Society for Health Care Engineering (ASHE), Ventilation of Health Care Facilities (ANSI/ASHRAE/ASHE Standard 170-2008) details the minimum efficiency reporting value (MERV) required for air filtration in various functional spaces. The MERV is a measurement scale of 1 to 20, with 17 or higher indicating high-efficiency particulate air (HEPA) filtration. The higher the MERV number, the smaller the size of contaminants that are filtered out. For critical care areas, at least two filter banks are needed to achieve the required MERV”.

See the EC News from Joint Commission for February 2020 for further details.

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