Since the beginning of 2019, the Centers for Medicare and Medicaid Services (CMS) released numerous memos to state survey agency directors. Two of these memorandums involve emergency power sources and temperature requirements. While healthcare facilities have known for some time of the new requirements, these recent updates have raised questions and concerns.
As stated by the CMS, it is up to each facility, based on its risk assessment, to determine the most appropriate alternative energy sources to maintain adequate temperature. However, with the February 1, 2019, update (Emergency Preparedness Appendix Z), some long-term care facilities are now required to maintain specific temperatures. It is no longer up to the facility based on its risk assessment. It now states temperatures will remain between 71 and 81 degrees Fahrenheit (page 23).
The second memorandum, released March 5, 2019 (Revisions to Appendix Q, Guidance on Immediate Jeopard), provides state agencies guidance determining key components of immediate jeopardy. One of the examples (page 22) states, “Allowing temperatures to raise or drop outside of 71 to 81 degrees significantly.” Now the question is, how does the AHJ surveyor define “significantly” and decide non-compliance?
In Healthcare, the answer is always “It Depends.” What year was the area designed and approved, and was it modified or upgraded? The TJC 2020 standards now reference under EC.02.06.05 EP 1 the 2018 FGI, which has the ASHRAE 170 (2017) document included. This requirement means any hospital designed in 2020 must consider the ASHRAE 170 (2017) when designing the new facility or area upgrade.
Remember that CMS adopted the 2012 LSC, and it references documents on July 5, 2016, which included NFPA 99 (2012 Edition), which references ASHRAE 170, Ventilation of Healthcare Facilities, 2008, included in the 2010 FGI that TJC also referenced under their standard EC.02.06.05 EP1. TJC later referenced the 2014 FGI under EC.02.06.05 EP 1, which referenced ASHRAE 170 (2013).
Regarding CMS, since they only officially adopted the 2012 NFPA 99 that references the ASHRAE 170 (2008) edition, CMS would probably require compliance with the ASHRAE 170 (2008), including today. So a facility designed since the adoption of the 2012 LSC would have been required by TJC to meet either the 2008 or 2013 ASHRAE 170 standard or if designed after January 2020, the 2017 ASHRAE 170.
For example, if designed and approved utilizing the 2014 FGI, including ASHRAE 170 (2013), the designers should have considered the requirements of the ASHRAE 170 (2008) for compliance with the CMS COPs.
Jerald D. Stewart Jr., CHFM, CHSP
Senior Healthcare Consultant
Stewart Regulatory Solutions, LLC