Temperature and Humidity - Monitoring Requirements

What are the monitoring requirements for temperature and humidity?

Any examples are for illustrative purposes only.

The Joint Commission has no prescriptive requirement for daily monitoring or logging of temperature and relative humidity of a particular room type unless required by a controlling authority, such as the state health department or CMS, or by organizational policy. However, ASHRAE 170-2008, as referenced in NFPA 99-2012 must be complied with for new construction (designed after July 5, 2016). Existing spaces must be maintained as originally designed unless hazards to health and safety exist.

Rooms that are considered critical, like those where invasive procedures are performed or where sterile items are stored, are to be in constant compliance when being used for their intended purpose. Therefore some reliable strategy is to be implemented to insure continuous compliance, such as daily readings, real-time indicating devices in the space, alarming through a building automation system, etc. Room temperature and humidity monitoring can be accomplished remotely by a building automation system, as long as there is a means to effectively identify an adverse condition (like a person at the monitoring station, an alarming mechanism, a paging system, etc.).

Daily monitoring can also be accomplished at the room site, by the occupants, as long as there is a process to periodically check readings (like a temperature/humidity reading device within the space). Daily monitoring would be acceptable as long as the organization has assessed there to be a reasonable assurance that the snap-shot-in-time selected represents compliant humidity and temperature levels throughout the operational day. Non-continuous, periodically checked conditions are to be logged. All non-compliant conditions are to be documented with corrective actions described. If the room is not in-use and is placed in a non-compliant mode, like for energy conservation, then the room must be validated to be in compliance before a procedure begins; an energy conservation mode must maintain proper relative humidity levels. For other rooms assessed to be less critical, evidence of temperature and humidity levels may not be required, but are to be initially set-up properly when affected by new construction, alteration or renovation, and through methods such as regular environmental rounding, occupant feedback and through maintenance activities.
Last updated on April 07, 2020
Manual: Ambulatory
Chapter: Environment of Care EC

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