News and Views for Healthcare Accreditation Professionals

Archive for March, 2012

CMS requires “operating room” conditions for all rooms that perform “surgery”

CMS has a very liberal definition of what “surgery” is in the COP.  Basically any skin disruption is included.  This would naturally include procedures such as PEG tubes, pacemaker implants, cardiac cath procedures, and some wound care centers.  Also included would be areas that perform circumcisions and vasectomies.  As such, CMS has cited several hospitals because they do not establish operating room conditions:


1.  Positive pressure differential for all procedure rooms and operating rooms.

2.  Air Exchanges (ACH) at 15 per hour with 3 being external air.

3.  Humidity logged (recorded) and maintained at 35-60%.

4.  Temperature is also looked at but this is much less of a problem than the first three.


Unfortunately the citations are written as “imminent threat” causing the need for rapid corrective action.