Regulatory guidance for facilities managers

Although they provide shelter, comfort and a means of defense, buildings can be dangerous if they are not properly constructed and maintained — two common objectives of health care codes, standards and regulations.

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Health care facilities must comply with a variety of local, state and federal codes and standards, adopted and managed by authorities having jurisdiction (AHJs). Failing to do so can result in penalties for noncompliance that can disrupt an organization’s financial situation, its reputation or its ability to operate.

And yet, some codes and standards work in opposition to one another or do little to address the problems they were created to solve. American Society for Health Care Engineering (ASHE) studies have shown that hospitals lose time, effort and money when codes and standards have conflicting requirements. Health care organizations also face challenges related to misinterpretations by those who enforce requirements and from issues like routine testing, inspections and capital costs that do not enhance safety or efficiency.

Additionally, organizations often must walk a tightrope between the expectations of the Centers for Medicare & Medicaid Services (CMS) and their Conditions of Participation (CoPs) on the one side and AHJs at all levels on the other. Unless a facility is directly managed by the federal government or is a cash-only clinic, it likely receives income from CMS reimbursement and must meet its conditions.

What’s more, while the CMS standards for reimbursement that relate to the physical environment are usually generated by other code development bodies, the adoption of those standards by CMS may be based on out-of-date versions of the codes. Additionally, local, state and federal AHJs do not always communicate or collaborate.

However, regulators exist for a reason. They provide valuable reviews of health care design and construction and help ensure compliance with the rules and regulations that exist to save lives, improve patient outcomes and ensure a consistently safe environment.

Facilities managers can influence the codes that govern their work through advocacy — by serving on the committees writing the codes, submitting public comments on code drafts and advocating for change with lawmakers. Also, they can collect the data and provide the field research that can shape future codes based on science and best practices.

Key handbook sections

To help facilities managers comply with and contribute to codes and standards, ASHE has published Understanding Health Care Compliance: The Facilities Manager’s Handbook as part of its Health Care Facilities Management Essentials Series.

The complete handbook, from which this article is excerpted, can be accessed online. Key sections of the handbook include the following:

Compliance landscape. Health care organizations are held accountable for physical environment compliance by a host of different entities, from the local building department to the federal government.

This means that every facility will have a unique mix of AHJs based on the services it provides and the location, with large systems finding themselves juggling distinct but overlapping oversight across the facilities they operate.

For most organizations, this begins with CMS and the need to qualify for Medicare and Medicaid reimbursement. To receive reimbursement, facilities must comply with physical environment codes adopted by CMS. The facility also may be subject to oversight by state agencies.

These agencies and versions of their respective codes vary from state to state, but all have requirements that must be met for licensure that sometimes don’t align with those adopted by CMS. State and local building and fire departments also have regulatory authority and adopt their own codes for compliance. Additionally, many facilities seek accreditation from third-party organizations, each of which has its own publications detailing codes and standards they have adopted.

AHJs should be viewed as partners who play an important role in keeping people in the buildings safe and supporting the mission of achieving good patient outcomes. It is a best practice to know the representatives of each AHJ that has oversight of a facility and to foster positive relationships with them.

As the professionals responsible for the physical environment, facilities managers will need in-depth knowledge of the various codes and standards adopted by different AHJs and accrediting organizations. They will also need to understand how to advocate with these entities on common interpretations, especially where codes and standards conflict.

In addition to CMS, they include local and state building codes, local AHJs, the Environmental Protection Agency (EPA), the Americans with Disabilities Act and accrediting agencies.

Documentation. When an organization interacts with an AHJ — whether for a building permit, a state license, federal requirements, accreditation or Medicare/Medicaid reimbursement — it must accept that the AHJ can knock on the doors of its facilities at any time, with or without an appointment.

It is a best practice for facilities managers to make sure that all records connected to inspection, testing and maintenance are part of the compliance routine so the facility is always ready for the visit. Complete documentation helps surveyors see that the required work has been accomplished and confirms the facilities manager has completed due diligence.

In addition, proper documentation serves as a tool in managing the physical environment, planning emergency response and conducting post-event analyses. In short, without compliance documentation and the proper analysis of that documentation, facilities managers cannot manage the physical environment or work to improve upon it.

Codes, standards and regulatory agencies. The codes and standards used by AHJs and accrediting bodies take significant time, effort and expertise to produce.

It would be difficult for any AHJ — even one with the scope of CMS — to find the staff and information to establish definitive standards on everything from fire safety to a fuel spill on a hospital parking lot. Therefore, code and standard development organizations exist to fill the gap.

Certain state and federal regulatory agencies outside of the field of human health — such as the Occupational Safety and Health Administration and the EPA — also address topics indirectly connected to health care delivery and produce codes and standards that must be considered in the accreditation process.

Other organizations include the National Fire Protection Association (NFPA), ASHRAE, the Centers for Disease Control and Prevention, the Department of Transportation and state licensing bodies.

Local code enforcement inspections. A health care organization interacts with many AHJs and stakeholders, but a facilities manager’s most frequent engagement is likely to be with local AHJs. These officials, which may include the fire marshal as well as representatives of municipal or state building departments, perform routine walkthroughs of the buildings on health care campuses. They do construction inspections, issue permits and look for compliance with international building and fire codes.

They partner with facilities managers to make sure health care campuses have well-built structures that are safe for human occupancy and serve to fulfill their organizational missions. They help facilities managers to stay accountable, provide quality environments of care and be responsible corporate citizens.

They connect managers to their communities, help facilities solve the thousands of small problems that pop up and respond to the big problems that occasionally challenge facilities teams.

Facilities personnel who begin with that mindset should have little difficulty finding the motivation to stay on top of the local code landscape and to build strong partnerships with the individuals who serve as AHJ representatives in the communities they share.

Emergency preparedness. Health care organizations exist, in part, to provide services to the public in the event of a civic disaster. Emergency preparedness, therefore, is a central part of a facilities manager’s mission and requires committed attention.

CMS and other regulatory bodies at the state and municipal levels take several of their regulations from codes developed by the NFPA. In the case of emergency preparedness, NFPA 99, Health Care Facilities Code; NFPA 1660, Standard for Emergency, Continuity, and Crisis Management: Preparedness, Response, and Recovery Code; and NFPA 3000, Standard for an Active Shooter/Hostile Event Response Program, have key relevance for facilities managers. (NFPA 101^®, Life Safety Code^® will be discussed in the next section.)

CMS pays particular attention to an organization’s ability to respond to a natural or man-made disaster. In 2016, it published a new CoP, § 482.15 Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, which outlines the requirements for all organizations that participate in its programs. To be eligible for Medicare/Medicaid reimbursement, every organization must be compliant with the regulations in this document.

When CMS adopted NFPA 99 in its CoPs, it did not include the emergency preparedness chapter (Chapter 12) of NFPA 99’s 2012 edition. However, it remains an important resource for health care facilities. In addition to being a thorough, well-considered guide to emergency management, other regulatory and accrediting bodies continue to adopt it as part of their own standards.

Most health care organizations have an entity or division that manages emergency management. This may be a full department or a single individual. The person tasked with spearheading this responsibility may be the facilities manager, but this is not consistent across the entire field. That said, facilities managers will likely play a pivotal role because the physical environment will greatly impact any emergency actions.

Compliance documentation for emergency preparedness should include a number of components, including leadership structure and program accountability; hazard vulnerability analysis; mitigation and preparedness activities; education and training; emergency operations plans, policies and procedures; exercises and testing; continuity of operations planning; disaster recovery; and program evaluation.

Emergencies can impact essential systems that allow a hospital to run and continue necessary care. CoPs Part 482.15 (e) makes specific reference to “emergency and standby power systems, including generator location, inspection, testing and fuel.”

The guidance outlines the need for written documentation for all utility systems that the facility considers essential or critical to provide care, treatment and services, which may include electrical distribution; emergency power; heating, ventilating and air-conditioning; medical gas and vacuum; network/communication systems; plumbing and steam boilers; and vertical and horizontal transport.

Moreover, approaches on how organizations meet this requirement are changing to allow for advancements in technology. According to the CMS QSO 23-11-LSC waiver, for instance, microgrids are an allowable means of storing emergency energy power. Because many of these utilize renewable energy sources, such as wind or solar, they may be attractive to organizations with sustainability goals.

Documentation must include a plan for how the facility will address food, water, medical and pharmaceutical supplies; temperatures to protect patient health and safety and for the safe and sanitary storage of provisions; emergency lighting; fire detection, extinguishing and alarm systems; and sewage and waste disposal. However, the specific requirements will depend on the plan.

Life safety. Although they provide shelter, comfort and a means of defense, buildings can be dangerous if they are not properly constructed and maintained. Even when buildings are constructed correctly, people can face additional threats to life and limb when navigating an emergency. History is full of hard lessons on what happens when facilities are constructed and occupied without going through a careful series of “what if” exercises.

Code development organizations exist because, in the aftermath of building-specific disasters, it was discovered that human errors led to terrible injuries and unnecessary losses of life. The codes and standards they recommend are intended to prevent similar tragedies from happening in the future.

The 2012 edition of NFPA 101 addresses the “danger to life” caused by fire and the “smoke, heat and toxic gases” that a fire can produce. Health care facilities often are full of equipment, materials and chemicals that could become critical threats in a building-specific emergency — especially one such as a fire. Every health care organization will face some incidents during the life of a facility; codes like NFPA 101 are intended to minimize the frequency of incidents and, more importantly, the chance of injuries and loss of human life.

Security. Hospitals and other health care facilities, schools and houses of worship have long been considered safe havens. But according to Bryan Warren, MBA, CHPA, CPO-I, president and chief consultant for WarSec Security in Gastonia, N.C., and former president of the International Association for Healthcare Security and Safety, there’s no safe haven any longer. “Schools, churches and health care facilities may have been largely immune to violence and criminal activities [in the past], but now anything can happen anywhere. It’s a societal change,” he says.

The Social Security Act dictates that patients have the right to receive care in a “safe environment.” Today, that encompasses not only well-built and maintained spaces but also secure spaces that protect people and organizational assets from criminal threats.

Organizations often find themselves retrofitting buildings and spaces that were constructed before design teams considered current threats. Facilities personnel find themselves in an especially challenging position, as changes that are made to the physical environment to make it more secure often make spaces more hazardous in other ways and take them out of compliance with other codes.

Warren suggests that successful compliance and a truly secure campus depend on a mix of objective and subjective things. “I believe security is a craft,” he explains. “It isn’t purely a science or an art but the ability to blend the numbers — the key performance indicators and metrics — with experience and understanding how things work together.”

Rounding, buildings and grounds. Health care organizations face considerable oversight regarding many aspects of the physical environment, with very clear and specific codes and standards for everything from fire doors to toilet stalls. However, other aspects of health care campuses, especially the grounds surrounding the buildings, have received surprisingly little attention.

Nevertheless, it is vital that the physical environment of the whole campus is as safe as an organization can make it. Achieving that goal comes not only from knowing the applicable codes and standards for a facility but also from keeping a close eye on the physical environment on a routine basis through rounding.

Keeping on track

The compliance landscape is complex, and facilities managers have many factors to consider and priorities to balance.

It is easy to understand how feeling overwhelmed and frustrated could lead even the most conscientious team toward a “check-the-box” mentality.

But facilities managers can avoid those pitfalls and keep their organizations on track through a focus on documentation, proactive orientation and advocacy.

About the handbook authors

The American Society for Health Care Engineering (ASHE) extends its most heartfelt gratitude to the individuals who offered their time, knowledge and effort to the creation of ASHE’s Understanding Health Care Compliance: The Facilities Manager’s Handbook. They are:

Lead author. Dave Dagenais, CHSP, FASHE, is the director of plant operations and safety officer at Wentworth-Douglass Hospital in Dover, N.H. He has been involved in the health care field and code development process for more than 30 years.

Contributors

• Chad E. Beebe, AIA, CHFM, CFPS, CBO, FASHE
• Joshua Brackett, PE, CHFM, FASHE
• Kara Brooks, MS, LEED AP BD & C
• Jonathan Flannery, MHSA, CHFM, FASHE, FACHE
• Anne M. Guglielmo, CHFM, CFPS, CHSP, FASHE, LEED AP
• Leah Hummel, AIA, CHFM, CHC, CHOP, SASHE
• Jeff O’Neill, AIA, CHFM, ACHA, SASHE
• Bryan G. Warren, MBA, CHPA, CPO-I
• John L. Williams

ASHE also would like to thank Carolyn Roark for her writing collaboration and editorial assistance, as well as its partners at Jenkins Group Inc. 

This article was excerpted and edited by Health Facilities Management staff from the American Society for Health Care Engineering’s Understanding Health Care Compliance: The Facilities Manager’s Handbook.