NURSING HOMES AND AIR CONDITIONING

You asked (1) whether Connecticut requires nursing homes to have air conditioning; (2) if it does not, why not; and (3) what other states require air conditioning.

Connecticut law does not require air conditioning for nursing homes. In 2003, the legislature required the Department of Public Health (DPH) to make recommendations for maximum and minimum temperatures. Minimums have been in regulations for a long time. But it seems that DPH did not recommend maximum temperatures. Instead, it issued other general recommendations and guidelines nursing homes should take in hot weather, which it reissues just before summer every year.

Reasons for not requiring air conditioning include the cost and difficulty of installing it in older buildings, many older people's dislike of air conditioning, and the fact that Connecticut has fewer hot days every summer than southern states.

Federal regulations do not require air conditioning, but they require nursing homes to provide a safe, functional, sanitary, and comfortable environment for the residents, staff and the public. They also require comfortable and safe temperature levels and specifically require newer facilities initially certified after October 1, 1990 to maintain a

temperature range of 71 to 81 degrees Fahrenheit. These federal rules also generally apply to Connecticut, except that the federal guidance provided to DPH personnel conducting nursing home inspections allow temperatures even in newer homes in the most northern states to exceed 81 degrees during rare, brief episodes of unseasonably hot weather.

We have identified four states that specifically require air conditioning in all nursing homes and set specific maximum temperature requirements (New Jersey, Arkansas, Florida, and New Mexico). We also found three states that require it for newer homes (Kansas, Maryland, and Washington).

The New England states do not require air conditioning for all nursing homes or in all patient rooms, but Rhode Island requires those that do not have air conditioning in every patient room to provide air conditioning in at least one common room and Massachusetts requires every facility to have air conditioning in common rooms that can keep the temperature at a maximum of 75 degrees (but not in residents' rooms).

New York requires “comfortable and safe” temperature levels. Vermont does the same and specifies a minimum of 71 degrees, but not a maximum.

Illinois currently has no requirement that all nursing homes have air conditioning, but the city of Chicago has an ordinance requiring it and an Illinois lawmaker is preparing a proposal to require it statewide.

We found no national comprehensive survey of air conditioning requirements. Most of the relevant excerpts from other states' laws or regulations shown below were provided to us by Bernadette Wright, a researcher at AARP. There may be other states with such requirements, but we have so far not identified them. Donna Folkemer, a researcher at the National Conference of State Legislatures, provided the references to the federal regulations.

Connecticut law does not require air conditioning for nursing homes. And the only specific reference to temperature in regulations requires that “all areas used by patients shall have temperatures of not less than 75 degrees Fahrenheit. All other occupied areas shall have temperatures of not less than 75 degrees Fahrenheit.” (Public Health Code § 19-13-D8t (d)(4)).

State legislation passed in 2003 required the Department of Public Health to “adopt recommendations for minimum and maximum temperatures for areas within nursing homes and rest homes. Such recommendations may be based upon standards set by national public or private entities after research into appropriate temperature settings to ensure the health and safety of the residents of such homes. The department shall make such recommendations available to nursing homes and rest homes and to the public, and shall post such recommendations on the Department of Public Health's website on the internet” (PA 03-272, § 1; CGS § 19a-522a).

We asked DPH about this 2003 law and were told by several officials that it has not made a recommendation for a maximum temperature but has, since 2003, annually provided a notice of “Recommendations for Management of Nursing Home Residents During Hot Weather” to nursing homes. The document (enclosed) provides guidelines for various measures that nursing homes should take in hot weather, but it contains no requirement for a maximum temperature. Many nursing homes in Connecticut do have air conditioning, but some have it only in the common areas or hallways, not in individual patient rooms. Some of the older ones may not have it and the high cost to retrofit an older building would likely be an issue for requiring it. DPH has no statistics on how many nursing homes have or do not have air conditioning.

Federal regulations also do not require air conditioning, but they require nursing homes to “provide a safe, functional, sanitary, and comfortable environment for the residents, staff and the public” (42 CFR § 380.70 (h)). Further, another section of the regulations also refers generally to comfortable and safe temperature levels, but it states that newer facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81 degrees Fahrenheit (42 CFR 483.15(h)(6); see exception for northern states below).

The general requirement that homes must have “comfortable and safe temperature levels” applies to all nursing homes in Connecticut. The specific temperature range applies only to newer homes built since 1990 in Connecticut as in all other states, and air conditioning is one way of complying with it. But since the state has had a moratorium on new nursing home beds since 1991 which continues to 2007 (with some exceptions), very few homes would likely be covered by the specific federal temperature range requirement.

In addition, the federal guidance provided to state personnel doing the periodic nursing home inspections allows temperatures in homes in the most northern states to exceed 81 degrees during rare, brief episodes of unseasonably hot weather. The guidance states “this interpretation would apply in cases where it does not adversely affect resident health and safety, and would enable facilities in areas of the country with relatively cold climates to avoid the expense of installing air conditioning equipment that would only be needed very infrequently” (Guidance to Surveyors – Long Term Care Facilities F257, enclosed).

Arkansas regulation state that, “The institution shall be equipped with heating and cooling equipment that will maintain a minimum temperature of seventy-five (75) degrees F during winter and eighty (80) degrees F during summer in all patient areas when the temperature outside does not exceed ninety-five (95) degrees F. If temperature outside exceeds one-hundred (100) degrees F, there shall be a fifteen (15) degree F difference in exterior to interior temperature. If air conditioner should break down or malfunction, the OLTC should be notified immediately. Patients' toilets and bathroom temperature shall be maintained at eighty (80) degrees F.” (016.06 Code of Arkansas Rules and Regulations 004, Rules and Regulations for Nursing Homes: Office of Long-term Care).

Florida regulations state, ““(a) Air conditioning, heating and ventilating systems.

1. All patient occupied areas shall be heated or cooled by individual or central units. Heating units shall be designed to provide a minimum of 72 degrees Fahrenheit (22.22 Celsius) ambient indoor temperature and air conditioning units shall be designed to provide a minimum of 78 degrees Fahrenheit (25.55 Celsius) ambient indoor temperature” (Florida Administrative Code § 58A-2.025).

Illinois currently has no requirement that all nursing homes have air conditioning, but the city of Chicago has an ordinance requiring it and an Illinois lawmaker, state Representative Jack Franks, is preparing a proposal to require it statewide. An initial text has been completed but has not yet been filed. Since the legislature has adjourned from its 2006 session and has only a veto session scheduled for November, it seems unlikely that the bill will be introduced before the 2007 session starting in January. The representative's office provided us with a copy of the draft of the bill, which we have enclosed. Relevant articles on the issue in Illinois can be found at:

Kansas regulations state that, “(1) Heating, air-conditioning, and ventilation system design specifications for facilities constructed after February 15, 1977 shall be as follows: (A) The system shall be designed to maintain a year-round indoor temperature range in resident care areas of 70 [degrees] F to 85 [degrees] F. The winter outside design temperature of the facility shall be -10 [degree] F dry bulb, and the summer outside design temperature of the facility shall be 100 [degrees] F dry bulb.” (Kansas Administrative Regulations § 28-39-162c)

Maryland regulations state, “R. Air Conditioning. All new facilities shall be equipped with a properly maintained air conditioning system capable of maintaining 75 degrees throughout the patients' section of the building. The system shall be in compliance with ASHRAE and NFPA Code and all State and local codes” (Code of Maryland Regulations § 10.07.02.26).

Massachusetts regulations state, “(13) Heating and Air Conditioning Equipment. (b) Every facility shall be equipped with a heating system that is sufficient to maintain a minimum temperature of 75 [degrees] F throughout the facility at all times at winter temperatures. . . (e) Every facility shall by June 21, 2000 provide air conditioning in dining rooms, activity rooms, day rooms, solariums, sitting rooms or equivalent other common resident areas that is capable of maintaining a maximum temperature of 75 [degrees] F in those areas at all times at summer design temperatures. Temperatures must be maintained at a level which ensures the comfort and health of residents of the facility.”

New Jersey regulations state, “Mandatory space and environment; all facilities (a) The facility shall provide for and operate adequate ventilation in all areas used by residents. All areas of the facility used by residents shall be equipped with air conditioning and the air conditioning shall be operated so that the temperature in these areas does not exceed 82 degrees Fahrenheit” (New Jersey Administrative Code § 8:39-31.8). “(p) The facility shall establish a written heat emergency action plan which specifies procedures to be followed in the event that the indoor air temperature is 82 degrees Fahrenheit or higher for a continuous period of four hours or longer.

1. These procedures shall include the immediate notification of the Department of Health and Senior Services.

2. In implementing a heat emergency action plan, a facility shall not prevent a resident from having a room temperature in his or her resident room in excess of 82 degrees Fahrenheit if the resident and the resident's roommate, if applicable, so desire, and if the resident's physician approves.

3. A heat emergency plan need not be implemented if the resident care areas are not affected by an indoor temperature in excess of 82 degrees Fahrenheit.

4. The heat emergency action plan shall include a comprehensive series of measures to be taken to protect residents from the effects of excessively high temperatures” (N.J.A.C. § 8:39-31.6).

(a) The heating and air conditioning systems shall be capable of maintaining adequate temperatures and providing freedom from drafts. (b) A minimum temperature of at least 70 degrees Fahrenheit (21 degrees (c) in all bedrooms and in all other areas used by residents, unless resident preference is documented for deviations” (New Mexico Administrative Code § 7.9.2.71).

New York regulations state, “(h) Environment. The facility shall provide: (1) a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. . . (4) comfortable and safe temperature levels. . .” (10 New York Compilation of Codes, Rules, & Regulations § 415.5).

Rhode Island statute states, “Heat relief. – Any nursing home facility which does not provide air conditioning in every patient room shall provide an air conditioned room or rooms in a residential section or sections of the facility to provide relief to patients when the outdoor temperature exceeds eighty (80) degrees fahrenheit” (Rhode Island General Laws § 23-17.5-27)

Rhode Island regulations echo this requirement, “Heat relief: Pursuant to section 23-17.5-27 of the Rhode Island General Laws, as amended, any nursing home facility which does not provide air conditioning in every patient room shall provide an air conditioned room or rooms in a residential section(s) of the facility to provide relief to patients when the outdoor temperature exceeds eighty (80) degrees Fahrenheit.” (Code of Rhode Island Rules § 14-090-023).

Vermont regulations state, “A nursing facility must provide: (a) a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. . . (f) comfortable and safe temperature levels (not lower than 71 [degrees] F)” (Code of Vermont Rules § 13-110-005).

The state of Washington's regulations require new nursing home construction, effective March 26, 2000, to have “(1) a mechanical cooling system capable of maintaining a temperature of 75 degrees Fahrenheit for areas occupied by residents and (2) a cooling system that has mechanical refrigeration equipment to provide summer air conditioning to resident areas, food preparation areas, laundry, medication rooms, and therapy areas by either a central system with distribution ducts or piping, or packaged room or zonal air conditioners” (Washington Administrative Code § 388-97-47010), available at: http://apps.leg.wa.gov/WAC/default.aspx?cite=388-97-47010.


August 24, 2006		2006-R-0534
NURSING HOMES AND AIR CONDITIONING

By: Helga Niesz, Principal Analyst