Attention All Hospitals and Critical Access Hospitals:
During OSFM next inspection performed on behalf of Centers for Medicare/Medicaid annual survey there is going to be one change that will be added to our inspection documentation review that our inspectors will be asking for you to present for review.
This will be the review humidity maintenance records for anesthetizing locations to ensure, if monitoring determined humidity levels. Hospitals must maintain relative humidity (RH) levels at 35 percent or greater in each anesthetizing location, unless the hospital elects to use the CMS categorical waiver, which permits it to maintain a RH of at least 20 percent. Hospitals must maintain records that demonstrate they have achieved the required levels. Although not required, CMS recommends that hospitals maintain the upper range of RH at 60 percent or less.
Hospital and critical access hospital anesthetizing locations in which clinical procedures are performed are required to maintain relative humidity. According to NFPA 99, anesthetizing locations are defined as “Any area of a facility that has been designated to be used for the administration of nonflammable inhalation anesthetic agents in the course of examination or treatment, including the use of such agents for relative analgesia.” NFPA 99 defines relative analgesia as “A state of sedation and partial block of pain perception produced in a patient by the inhalation of concentrations of nitrous oxide insufficient to produce loss of consciousness (conscious sedation).” (Note that this definition is applicable only for LSC purposes and does not supercede other guidance we have issued for other purposes concerning anesthesia and analgesia.)
OSFM inspection staff will be asking to see the following documentation to be provided during the inspection documentation review:
- Verify that each anesthetizing location has temperature control mechanisms.
- Review the records for anesthetizing locations temperature and humidity to ensure levels are maintained.
- Review temperature and humidity maintenance records for anesthetizing locations to ensure, if monitoring determined temperature or humidity levels were not within acceptable parameters, the corrective actions were performed in a timely manner to achieve acceptable levels.
If you should have any questions please feel free to contact Office of the State Fire Marshal or visit the CMS website for further instructions.