Questions and answers from ASHE members

The My ASHE Messenger column contains excerpts of topics from My ASHE, the member-only community for the American Society for Healthcare Engineering. To join the discussion, visit my.ashe.org.

I recall discussion that new dampers need to be tested one year after installation rather than after one year of occupancy. Is there a specific reference for this?

It’s the 2010 Edition of the National Fire Protection Association’s NFPA 80 19.4. An operational test must be completed once the fire damper is installed. Each fire damper must be tested and inspected one year after installation. After you hit the one-year mark, your fire dampers then must be tested and inspected every six years for hospitals.

Has anyone been cited by the Joint Commission or Centers for Medicare & Medicaid Services (CMS) for not having pressure monitors at their operating room (OR) entrances for checking the daily pressure relationship for buildings built prior to 2003?

The Joint Commission Environment of Care (EC) Standard states that “the basis for design compliance [of HVAC systems] is the Guidelines for Design and Construction of Health Care Facilities, based on the edition used at the time of design” (Joint Commission Standard EC.02.05.01 EP 5). So, unless that requirement existed in the Facility Guidelines Institute (FGI) Guidelines from around 2000 or so (when a 2003 building would presumably have been designed), I don’t see how anyone could be cited for violating this requirement, even though it’s in the currently enforced version. I have the 2001 edition, and pressure monitors are required only for airborne-infection isolation and protective environment rooms — not for ORs. While CMS doesn’t follow the Joint Commission standards, the FGI Guidelines, which include the American National Standards Institute/ASHRAE/American Society for Healthcare Engineering Standard 170, Ventilation of Health Care Facilities, have a grandfather clause that CMS should honor, stating that the Guidelines apply to newly constructed, installed or renovated systems — so, again, the current version of the standard should not be applied to a 2003 building.

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