Questions and answers from ASHE members

QUESTION: Is it permissible to use lockable pull stations in an inpatient behavioral health unit in a health care occupancy?

Yes, if all staff have keys to activate the pull station.

QUESTION: Are ambulatory care facilities required to do an annual test and balance of the HVAC?

There is not a specific standard requirement to routinely test and balance an HVAC system. The requirement is that “the ventilation system provides appropriate pressure relationships, air-exchange rates, filtration efficiencies, temperature and humidity” in critical care areas, and “provides required pressure relationships, temperature, and humidity” in noncritical care areas (2018 TJC Standard EC.02.05.01 EP 15 & 16). It is up to the facility how often they must test in order to meet these requirements. These apply to ambulatory health care occupancies (AHCOs) as well as health care occupancies. I would guess that your AHCO would be a combination of critical and noncritical areas, but you should consult the documents referenced in these EPs to categorize areas in your AHCO.

QUESTION: Does the Centers for Medicare & Medicaid Services (CMS) have any impact on when states will be required to move to the 2012 Life Safety Code?

This will vary by jurisdiction since CMS will not require states to move to the 2012 edition. Some states will adopt the 2012 edition, in part, because of the CMS adoption. Other states adopted the 2012 before CMS and already have or are in the process of updating to newer editions. Make sure to coordinate with your authority having jurisdiction. HFM

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