Environment of Care (EC) (Critical Access Hospitals / Critical Access Hospitals)
Controlling Airborne Contaminants - Documentation
Modify | April 11, 2016
What is the requirement for documentation of indoor air quality and ventilation maintenance?
The Joint Commission requires no specific documentation or forms to be filled out for indoor air quality and proper ventilation maintenance. Evidence of compliance with regard to the following criteria is required. Standard EC.02.05.01 EP 15 requires the hospital to maintain appropriate pressure relationships, air-exchange rates, and filtration efficiencies for the critical space types described in the EP Note. This includes implementing methods to validate continuous compliance for these three criteria at the space, and implementing methods to maintain the infrastructure equipment that achieve these three criteria. Methods are established by the criteria described in EC.02.05.01 EP 1 through 7; systems are designed appropriately, inventoried and assessed, and a maintenance strategy established/implemented based upon manufacturers' recommendation or an alternate equipment maintenance (AEM) strategy. Frequencies of maintenance and testing are determined by assessment of the particular circumstances of the installation. Examples of air pressure relationship management could include periodic testing (like tissue/smoke test with logged results), continuous indicators (like ball-in-tube, mounted mechanical or electronic manometer), remote building automation system monitoring, etc. Air exchange rate management could include periodic air balance tests, a building automation system with flow measurement capabilities, etc. Air filtration efficiencies are maintained by regular evaluation and replacement of air handling unit and other system filters that serve these critical spaces. Infrastructure equipment maintenance includes ventilation fan and distribution system maintenance (AHU, exhaust/return fan systems), control and indicator maintenance/calibration, and critical space structural integrity (doors, walls, etc.). The organization must document that the maintenance and testing activities implemented were performed on the schedule established. For other spaces assessed to be less critical, evidence of continuous compliant ventilation, 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. [EC.02.05.01]
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