Explanation: This template letter was approved by James P. Loveland, P.E., Program Manager, Engineering Services Section of the Minnesota Department of Health for use by Minnesota licensed hospitals. Date of approval: July 9, 2013.
Questions about this template may be directed to Ben Peltier, Vice President Legal Services, Minnesota Hospital Association at (651) 603-3513 or .
Instructions: (1) Remove Explanation and Instructions, (2) insert relevant text in place of [BOLD] language, and (3) send to address specified.
[DATE]
Mr. James P. Loveland, P.E.
Program Manager
Engineering Services Section
P.O. Box 64900
St. Paul, Minnesota 55164-0900
Re:Variance or Waiver Request
2012 Minnesota Statute 144.6535
Dear Mr. Loveland:
In accordance with Minnesota Statute §144.6535, [NAME OF HOSPITAL] hereby requests a waiver for Minnesota Statute §144.55, subdivision 3. Minnesota Statute §144.55, subdivision 3 requires, for purposes of licensure of a hospital, compliance with the hospital certification regulations promulgated pursuant to Title XVIII of the Social Security Act, United States Code, title 42, section 1395, et seq (“Federal Regulations”). These Federal Regulations require compliance with National Fire Protection Association (NFPA) Standard 101 (Life Safety Code, 2000 edition). In Chapter 2, the Life Safety Code (00) lists NFPA Standard 99 (Health Care Facilities, 1999 edition “NFPA 99 (99)”) as a mandatory reference. NFPA 99 (99), 5-4.1.1 requires that the mechanical ventilation system supplying anesthetizing locations have a capability of controlling the relative humidity at a level of 35 percent or greater.
On April 19, 2013, the Centers for Medicare and Medicaid Services (CMS) published a memorandum (“CMS S&C-13-25-LSC & ASC”) advising State Survey Agencies that CMS was issuing a categorical Life Safety Code waiver regarding the minimum acceptable level of relative humidity in an anesthetizing location. CMS now accepts a minimum level of relative humidity of 20% rather than the 35% required in NFPA 99 (99), 5-4.1.1.
Based on the guidance from CMS relative to federal certification, this hospital facility is requesting this waiver of licensure requirements to permit a minimum relative humidity of 20% in all anesthetizing locations.
Rationale
CMS S & C: 13-25-LSC & ASC was issued by CMS in response to concerns expressed by health care institutions relating to infrastructure maintenance related to maintaining the higher level of relative humidity. Review by the American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE), based upon input from health care institutions, indicates that maintaining the minimum 35 percent relative humidity level is unduly burdensome. Maintaining relative humidity at this higher level may result in:
1.Degradation of HVAC systems due to high relative humidity in supply, return, and exhaust air,
2.Degradation of exterior wall and roof assemblies due to higher levels of relative humidity present within the building envelope, and
3.Degradation of building fenestration due to condensation.
Based upon the ASHRAE review, there have been no indications that reducing the relative humidity to a level or 20 percent or greater does not provide adequate humidity levels for patient health and safety, while reducing relative humidity to a level of 20 percent or greater serves in alleviating unreasonable hardship on the infrastructure of the health care facility.
Documentation
As required by CMS S & C: 13-25-LSC & ASC, this hospital facility will maintain written documentation that this waiver has been granted. This hospital facility also will monitor relative humidity in anesthetizing locations to ensure that it remains at or above 20 percent.
Duration
We request that this waiver remain in effect until voluntarily withdrawn by this hospital facility, or until such time that a revision is necessary based on more up-to-date design standards. If you have any questions concerning this request, please contact [INSERT NAME OF KNOWLEDGEABLE STAFF] at [INSERT PHONE NUMBER].
Please consider our request for a waiver relating to the requirements of Section 5-4.1.1 of the 1999 edition of NFPA 99. Please contact us if we may be of further assistance.
Sincerely,
[Author Name, Credentials]
[Title]
cc: Commissioner Dr. Edward Ehlinger