Ventilation standards: Navigating code conflicts
Life safety and facilities leaders may face confusion following new construction. Although many projects are built according to updated standards from the Facility Guidelines Institute (FGI) or the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE), surveys often continue to cite older references tied to the 2008 edition of ASHRAE 170 as referenced in NFPA 99-2012.
This disconnect stems from regulatory lag, according to Harold Blits, CHSP, senior consultant at Patton Healthcare Consulting. While hospitals may build under the FGI guidelines adopted by their state, or other regulations developed by their regulatory entity, it can create tension during deemed status surveys.
Blits advises hospitals to consider developing a ventilation management plan (VMP) once operational. He also references The Joint Commission’s (TJC) standard PE.01.01.01 EP 1 note 2, which allows facilities to utilize the most current edition of the FGI guidelines, or that which is adopted by the state regulations. When designing, ensure that the most restrictive of the standards or regulations are followed, be it those referenced in the 2008 edition as required by NFPA 99 or newer ASHRAE 170 standards as adopted by the state.
In responding to citations, organizations should clearly document:
- Adherence to current TJC standards
- Adoption of newer codes by a state’s authority having jurisdiction
- A structured operational transition through a developed VMP
“The VMP demonstrates to the surveyor that you are not ‘ignoring’ the rule, but managing it through a recognized, safe, and documented operational framework,” Blits says.
For accreditation and quality leaders, collaboration with facilities, infection prevention, and engineering teams is essential to ensure that survey-ready documentation aligns with both state and federal frameworks.
Editor’s note: This article was excerpted from our Inside Accreditation & Quality newsletter.