Industry Update - January 2020

by Joe Brothman, Director, EHS & EM, UCI Health


Click here to access the full PDF version of this month's update.

ASHE Comments on Tamper-Resistant Receptacles in Patient Settings


ASHE is aware the combination of a tamper-resistant receptacle (TRR), ground fault circuit interrupter receptacle (GFCI), and arc fault interrupter breaker (AFCI) has become a major patient safety topic in the behavior health setting. ASHE is informing the industry that it does not advocate for the use of a combination of TRR, GFCI and AFCI as this combination significantly increases a risk of disruption to patient care through nuisance tripping, which distracts staff.

The FGI 2010 Guidelines requires “electrical receptacles in psychiatric patient rooms shall be tamper-resistant or equipped with ground-fault circuit interrupters.” Both the 2014 and 2018 Guidelines state for electrical receptacles provided in a patient bedroom, the receptacles shall only be: 

  • Tamper-resistant.
  • All controlled by a single switch outside the room and under the control of staff.
  • Either ground-fault circuit interrupter devices or on a circuit protected by a ground-fault circuit breaker.

Several states have additional requirements to use a combination of TR, GFCI and AFCI devices for patient safety. Hospitals should consult with their authorities having jurisdiction for any additional requirements.

The risk associated with these devices is because the technology is not currently at an acceptable level to perform at a rate that would allow all three devices to work in a beneficial manner. ASHE will continue to monitor and evaluate technology for applicability as advances in these applications continues.

ASHE recommends a performing a risk assessment associated with electrical usage in behavioral health settings. Reduction or elimination of receptacles, providing lockable covers, switched receptacles in patient bedrooms, and one-on-one observation are all potential options.

ASHE Academy and ASHE Education Showcase


The American Society for Health Care Engineering (ASHE) has launched two exciting, new programs for 2020: ASHE Academy and ASHE Education Showcases. ASHE Academy provides an intensive learning environment led by experienced leaders in health care facility management. It will be held twice a year in different locations offering a variety of educational opportunities. In 2020, ASHE Academy will be held in Nashville, TN from May 4-8 and Las Vegas, NV from November 9-13. Detailed information about the programming and schedule can be found at

ASHE will also be hosting five Education Showcases in centrally located Chicago. Attendees will join ASHE’s trusted faculty at the American Hospital Association’s headquarters to expand skill sets and network with health care peers. Registration for all programs are now open, and the first showcase featuring education on NFPA 99 and accreditation survey readiness will kick off Feb. 10-11 in Chicago. For program descriptions and registration information, visit

AAAHC Report Identifies Areas For Improvement


The Accreditation Association for Ambulatory Health Care (AAAHC) has issued the 2019 AAAHC Quality Roadmap, its report on accreditation survey results. The AAAHC Quality Roadmap provides an analysis of more than 1,250 surveys conducted using the current AAAHC standards. The report is designed to help ambulatory care facilities address common areas of deficiencies as they pursue ongoing quality improvement throughout the accreditation cycle. The report covers findings on high-compliance and high-deficiency standards, and presents actionable data that can be used to help ambulatory care facilities develop stronger policies, procedures and practices.

ASHE’s How to Submit Public Comments


Every facilities manager, design engineer, code enforcement official, etc. knows by heart a particular line of code they want changed. However, for many reasons including, lack of time, lack of understanding the process, or thinking someone else will change it, so few are proactive in the code/standard development process. Being proactive in the code development process doesn’t mean that an individual must sit on a technical committee, hold advanced knowledge about a particular subject, or even be a member of the standard development organization (SDO). Proactivity simply means following a particular standard during its development cycle (typically 3-years) and having a voice. To help its members, ASHE has developed these videos to help walk members through the processes of submitting comments with different code and standard organizations.

USP Delays Enforcing Chapter Standards


The United States Pharmacopeia (USP) notified stakeholders that it is postponing the official effective dates of several new and revised standards pertaining to pharmaceutical handling until further notice while it reviews appeals to the standards. Those standards include general chapters 795, 797, and 825. In addition, due to the pending appeals, USP new general chapter 800 Hazardous Drugs Handling in Healthcare Settings will remain official but only informational until the appeals process is complete.

ASHE USP 800 Resources


The aim of USP 800 is to protect health care workers and patients from harm associated with exposure to hazardous drugs (HDs). According to the Centers for Disease Control and Prevention (CDC), eight million health care workers are potentially exposed to HDs every year. This exposure can occur with workers who are unaware of their exposure and in departments outside of the pharmacy. USP 800 was developed to define the quality standards for the handling of HDs and the proper environmental controls for compounding to protect health care workers and patients. Aspects of handling HDs covered in USP 800 where exposure can occur include receiving, transporting, storing, compounding, dispensing, administering, spills, cleaning and waste disposal. Entities that handle HDs must incorporate the standards in chapter 800 into their occupational safety plan. The plan’s health and safety management must, at a minimum, include:

  • List of HDs
  • Facility and engineering controls
  • Competent personnel
  • Safe work practices
  • Proper use of appropriate Personal Protective Equipment (PPE)
  • Policies for HD waste segregation and disposal

This ASHE monograph discusses the physical environment provisions of USP 800 and is primarily intended for the use of health care facility managers. The USP 800 Risk Readiness Checklist, created by the American Society for Health Care Risk Management (ASHRM), will assist users in identifying areas where opportunities exist to comply with USP 800 required standards.

Modernization Strategies for Essential Electrical Systems in Health Care Facilities


Essential electrical systems in many health care buildings across America are rapidly reaching, or have already exceeded, their useful life expectancy. Moreover, because many hospitals are faced with the challenge of balancing profitability and operational disruptions with long deferred infrastructure improvements, many simply are not performing the maintenance required to uphold compliance with all necessary standards. This monograph will discuss why prioritizing the strategic modernization of the essential electrical systems in health care facilities is an effective solution for regulatory compliance and continuation of life safety and presents strategies for updating critical aging infrastructure that control costs and consider budget limitations while maximizing operator care and safety.

HHS, CDC Guide on Managing Category A-Waste


The Department of Health and Human Services’ Office of the Secretary for Preparedness and Response and the Centers for Disease Control and Prevention have released updated guidance to help health care providers and other stakeholders to safely manage solid waste contaminated with infectious substances classified by the Department of Transportation as Category A waste, including waste contaminated with Ebola virus. The guidance was produced by a federal interagency group with input from stakeholders, including the Association for the Health Care Environment.

CMS Updates Emergency Management Requirements


We are removing the requirements from our emergency preparedness rules for Medicare and Medicaid providers and suppliers that facilities document efforts to contact local, tribal, regional, State, and Federal emergency preparedness officials, and that facilities document their participation in collaborative and cooperative planning efforts.

We are revising this requirement so that applicable providers and suppliers review their Emergency program biennially, except for Long Term Care facilities, which will still be required to review their emergency program annually.

We are revising the requirement that facilities develop and maintain a training program based on the facility's emergency plan annually by requiring facilities to provide training biennially (every 2 years) after facilities conduct initial training for their emergency program, except for long term care facilities which will still be required to provide training annually. In addition, we are requiring additional training when the emergency plan is significantly updated.

For inpatient providers, we are expanding the types of acceptable testing exercises that may be conducted. For outpatient providers, we are revising the requirement such that only one testing exercise is required annually, which may be either one community-based full-scale exercise, if available, or an individual facility-based functional exercise, every other year and in the opposite years, these providers may choose the testing exercise of their choice.

Advocacy Alert: Pressure relationship between operating rooms and other areas


ASHE has heard reports of surveyors issuing findings regarding the pressure relationship of operating rooms (ORs) and sterile storage rooms and the restricted areas of operating suites. ASHRAE 170 Table 7.1 Design Parameters indicates that operating rooms (OR) and sterile storage are to have a positive pressure relationship to adjacent areas. The FGI Guidelines Section 2.2- requires that the surgical suite be divided into two designated areas. The restricted area of the OR suite is intended to support a high level of asepsis control. ASHRAE 170 Table 7.1 does not specifically address the pressure relationship of the restricted area but does generally in Section 7.1.a.1, which requires that ventilation systems shall provide air movement that is generally from the clean to less clean areas. ORs, due to patient vulnerability, should be considered the cleanest areas within an OR suite while sterile storage, due to containing items that need to be protected from contamination, should be considered a cleaner area than the OR suite restricted area. ASHRAE issued a formal interpretation on this issue in May of 2013.

2019 Health Facilities Management/ASHE/AHE Salary Survey Results


The facilities, construction and environmental services (EVS) professionals who responded to this year’s Health Facilities Management (HFM) biennial Salary Survey reported a strong interest in improving their professional prospects by utilizing the wide variety of career development tools being offered by professional societies and others serving the health facility operations and construction fields.

When asked how often they think about taking actions to develop a successful career, for instance, 69% of respondents stated “often” or “always.”

Moreover, when asked what actions they had taken in the previous two years to develop their careers, 70% had attended a conference, 64% had taken on additional responsibility, 57% had joined or renewed membership in a professional organization, and 57% had taken an online or in-person training course.

This year’s Salary Survey demonstrates that education and training are top priorities for many health facilities professionals. Moreover, those making the effort to advance their learning, training and experience often are finding a commensurate improvement in their compensation packages as well.