News and Views for Healthcare Accreditation Professionals

Archive for August, 2011

CMS: OR Humidity Rules!

CMS still holds hospitals to NFPA 99 (,, and for humidity limits in anesthetizing locations to: 35-60%. The more liberal ANSI recommendation of a lower limit of 20% is NOT CMS approved. Serious findings have been written by CMS when the humidity is out of range and surgery continues.

Addendum:  Recently it was made known that Joint Commission will survey the acceptable humidity range as 20%-65%, but caution hospitals that CMS will hold hospitals to the 35%-60% range per NFPA 99.

Nurses retrieving medication for doctors

This was recently cited:

As the Pyxis serves as “Pharmacy” in L&D, the nurse cannot take the drug from the Pyxis as described and “dispense” it to the physician as this is not in the nurses’ scope of practice per state law, therefore a violation of MM03.01.01 Element 6.


I have seen the third TJC survey report in a month that resulted in a 45 day conditional follow up survey. A CMS condition level citation was written. The problem was negative airflow in operating rooms that should be positive, and positive airflow in decontamination rooms that should be negative. They mean BUSINESS. It is expected that cases are canceled if the airflow is incorrect. Most hospitals only measure annually. Obviously the airflows should be measured almost on a daily basis.