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Q: I know that our CMS deemed-status level of accreditation means that we must monitor the airflow in our ORs, sterile core and sterile processing rooms. Is there is a code or standard attached to this requirement? Also, we've discovered the air flow is off and are having trouble discerning whose job it is to correct this: The HVAC company or the air balance and testing company. Would you please advise?
A: Assuming you are a hospital, the CMS Conditions of Participation (CoP) 482.41(c)(4) says you must have proper ventilation and they recommend you use AORN or CDC, or FGI Guidelines in lieu of any state or local requirements. They also say you must maintain records that demonstrate you’ve achieved these results. They don’t say how often you must make entries in your records, but the frequency must be sufficient to prove you are maintaining the required ventilation parameters.
The Testing and Air Balance (TAB) technician does NOT correct ventilation errors. All he/she does is to test the system. You need a qualified HVAC service technician to do the changes to the system to achieve the correct ventilation rates.