Your HEPA HVAC system stands between patients and airborne infections. Research shows contaminated air-conditioning systems create an 8.59 times higher probability of hospital-acquired infections—yet most facilities discover filtration failures only during Joint Commission surveys or infection outbreaks. This inspection checklist covers every critical checkpoint required by ASHRAE 170 and Joint Commission EC.02.05.01. Healthcare facilities ready to automate this process can schedule a demo to see digital inspection workflows that ensure nothing gets missed.
Healthcare Compliance Checklist
HEPA HVAC System Inspection Checklist
Complete inspection protocol for infection control compliance
Joint Commission Aligned
ASHRAE 170 Compliant
CDC Guidelines
99.97%
HEPA particle removal at 0.3μm
88%
Pathogen reduction achievable
722K
Annual U.S. hospital HAIs
Quick Reference: Inspection Frequency
Daily
Pressure differentials, Temp/humidity logs
Monthly
Visual filter inspection, Sensor calibration
Quarterly
Air change rate measurement
Annual
HEPA challenge test (DOP/PAO), Full TAB
Complete Inspection Checklist
Healthcare facilities using digital inspection platforms—try one free complete these checks faster, maintain audit-ready documentation and automatically flag out-of-range values before they become compliance issues.
Digitize This Checklist for Your Team
Stop managing compliance with paper forms. Assign inspections, track completion, receive automatic alerts for missed checks, and generate survey-ready reports instantly.
Space-Specific Requirements
Different healthcare spaces have different ASHRAE 170 requirements. Use this reference when setting up your inspection program—sign up free for each area in your facility.
Critical
Operating Rooms
Min Air Changes
20 ACH
Pressure
Positive
Filtration
HEPA Terminal
Humidity
30-60% RH
Critical
Protective Environment
Min Air Changes
12 ACH
Pressure
+0.01" WC
Filtration
HEPA Supply
Humidity
30-60% RH
High Priority
Airborne Infection Isolation
Min Air Changes
12 ACH
Pressure
-0.01" WC
Filtration
HEPA Exhaust
Exhaust
Direct/HEPA
Standard
ICU / Critical Care
Min Air Changes
6 ACH
Pressure
Positive
Filtration
MERV-14+
Humidity
30-60% RH
Expert Guidance
"HVAC systems work to decrease risk through the principles of ventilation, filtration, and flow. Disruptions or inadequate HVAC systems can increase risk of pathogen transmission through the air. Infection preventionists need to develop collaborative relationships with facilities and engineering teams—the IP brings clinical and disease transmission expertise; the facilities team brings built environment expertise."
— Infection Control Today, Healthcare HVAC Guidelines
Documented Outbreak Evidence
86% of SARS-CoV-1 outbreak studies demonstrated HVAC system involvement through epidemiological data or infection modeling. Proper maintenance prevents these connections.
Condensate Risk Factor
Cooling coils produce moisture that becomes a microorganism growth source. Drain pan inspection is critical—contaminated condensate directly affects air quality.
Documentation Requirements
Surveyors expect comprehensive records demonstrating systematic inspection programs. Start your free trial to centralize inspection records and instantly retrieve historical readings when needed.
Daily Pressure Logs
Timestamped readings for all critical areas with technician signatures
Challenge Test Certificates
Annual DOP/PAO results with leak scan documentation
TAB Reports
Air change rate measurements and balancing verification
Work Order History
Corrective actions taken for out-of-range readings
Ready to Automate Your HEPA Inspections?
Healthcare facilities nationwide trust OXmaint to manage inspection workflows, maintain compliance documentation, and protect patients through systematic air quality verification.
Frequently Asked Questions
What is HEPA challenge testing and how often is it required?
HEPA challenge testing (DOP or PAO testing) verifies that installed filters achieve their rated 99.97% efficiency at 0.3 microns. The test introduces an aerosol upstream and measures downstream penetration to detect leaks in filter media, frame seals, and housing gaskets. Required upon installation and annually thereafter, with additional testing after filter replacement or construction activities.
What pressure differential is required for isolation rooms?
Airborne Infection Isolation (AII) rooms require minimum negative pressure of -0.01" WC relative to corridors. Protective Environment (PE) rooms require minimum positive pressure of +0.01" WC. Both must be monitored continuously with visual indicators or alarms, and daily documentation is required.
How do I know when HEPA filters need replacement?
Monitor differential pressure continuously. When pressure drop reaches manufacturer's end-of-life threshold (typically 1.5-2x initial), replacement is indicated. Visual inspection revealing moisture damage, tears, or discoloration warrants immediate replacement regardless of pressure readings.
What documentation do Joint Commission surveyors expect?
Surveyors reviewing EC.02.05.01 expect daily pressure logs for critical areas, temperature/humidity records, HEPA challenge test certificates (within 12 months), air change rate measurements, work orders showing corrective actions, and calibration records. Documentation should demonstrate systematic inspection rather than reactive responses.
Can isolation room air be recirculated through general HVAC?
Yes, if it passes through HEPA filtration first. ASHRAE 170 permits recirculation from AII rooms provided air passes through a challenge-tested HEPA filter before mixing with return air. Direct exhaust to outdoors remains preferred when feasible.
