I can help your facility meet health and safety standards through individualized consulting services. This typically includes the following steps individualized for each client:

  1. Listen to your concerns, gather information, define specific goals and objectives, and prioritize where help is needed most.
  2. Review and compare your facility’s life safety testing, emergency operations plan and environment of care documents against the CMS Conditions of Participation (CoP), the Joint Commission Standards and the Accreditation Association for Ambulatory Health Care (AAAHC) standards.
  3. Review your OSHA plans.
  4. Conduct a building tour with staff interviews.
  5. Identify mitigation strategies.
  6. Create a prioritized list of opportunities for improvement for implementation.
  7. Validate the corrective actions periodically to assist in sustaining the improvements.
  8. Provide training and education

Following these steps helps your facility understand and meet the compliance requirements moving forward to protect patients and workers.

OSHA: Beyond COVID-19

Although the Public Health Emergency Declaration ended in May 2023, COVID-19 remains a public health threat. OSHA requires all facility to follow all the General Duty Clause provisions: to maintain a workplace free from recognized hazards that could cause physical injury or death. This includes maintaining mitigation strategies against all infectious diseases: hand hygiene, surface disinfection, employee screening for communicable diseases. Masking and vaccinations are key mitigation strategies.

OSHA also requires all healthcare facilities to have a written Blood Borne Pathogen (BBP) Exposure Control Plan (1910.1030), a written Hazard Communication Plan (1910.1200), general safety and emergency plans, Infection Prevention/TB written Plans as well as annual training. A written Respiratory Protection Plan (1910.134) with fit-testing and annual training is required if any employees wear N95 respirators or powered air purifying respirators (PAPRs). I can assist with annual plan review, revisions/updates, and training.

The OSHA penalties have been increased in 2023 to $15,625 per serious violations and $156, 259 per willful or repeat violations. OSHA will also enforce an instance-by-instance (IBI) citation structure for high hazard willful violations such as falls, trenching, machine guarding, respiratory protection, permit-required confined spaces and lockout tagout. Many OSHA citations were written in 2021 and 2022 to health care facilities that did not comply with the training and fit testing requirements of the OSHA Respiratory Protection Standard.

Environment of Care EPA/RCRA

The Environment of Care is the physical environment in which safe patient care, treatment and services occurs every day. I provide education to clinical staff as well as to those conducting environmental surveys to transition from “finding and fixing” to “tracking and trending.”

Services include Environment of Care plan reviews for safety and security, hazardous materials and waste, fire response, medical equipment and utilities; selection and tracking of performance indicators, review of the annual evaluation of effectiveness and assistance with documenting risk assessments.

OSHA regulates worker safety, CMS (Centers for Medicare and Medicaid) controls reimbursement for safe patient care, treatment and services and the EPA (Environmental Protection Agency) regulates hazardous waste. Healthcare is faced with complying with the complex and sometimes conflicting regulations from these federal agencies.

Services include navigation of the regulations and a gap analysis to ensure that all elements of compliance are addressed.

Emergency Management

All facilities are expected to be in full compliance with all published updates to the CMS Emergency Preparedness Conditions of Participation (CoP). Healthcare is structured to provide very good care every day. There are times when there is a rapid increase in the demand for services. Emergencies may be handled by the resources on hand or with the need for additional resources. Everything gets accomplished but at a quicker pace. Disasters may require significant amounts of external resources and coordination and every need may not be met.

Emergency management is the process of planning for and mitigating (reducing the impact of) internal and external events that may require additional resources. Emergency response is the activation of pre-planned processes to respond to and recover from internal or external events and to restore the day-to-day operations of the hospital.

Exercises, drills and actual events are ways to test the current emergency capabilities related to communications, the allocation of resources, staff roles, safety and security, utilities and patient care and staff support. After action reports identify strengths to be maintained and opportunities for improvement.

Services include tailored checklists for exercise design, Emergency Management Committee education, exercise evaluation and after action reports with opportunities for improvement and periodic assessments for completion and sustainability of the improvements

Life Safety Mock Surveys & Plan Review

A mock survey follows the agenda of regulatory surveys. Joint Commission mock surveys use the life safety document review and facility tour to assess compliance with the standards and elements of performance. The mock survey includes an Environment of Care and Emergency Management session for coaching and plan review. The EOC plan reviews include each of the management plans for safety and security, hazardous materials and waste, fire response, medical equipment and utilities well as the annual evaluation of effectiveness.

CMS mock surveys include life safety document review and facility tour to assess compliance with the Conditions of Participation. The mock survey includes a session for coaching staff in the Conditions of Participation, the expectations for federal surveys and mitigation strategies for the opportunities for improvement identified.

Hospitals are built to “defend in place.” Managing facilities is a challenging and ongoing proposition. I provide an extra set of eyes to help identify opportunities for improvement and strategies for managing those opportunities.

AAAHC mock surveys include a review of the physical environment chapter and supporting documentation

Services include facility tours, life safety plan and document review, interim life safety staff education, and associated plans for improvement as well as assistance in developing a prioritized list for implementation.

Infection Prevention for Construction

Infection prevention for construction has evolved from “just for” large construction and renovation projects to include a required risk assessment for maintenance and small projects. These small projects may fly under the radar of the facility planning and construction committee but may impact vulnerable populations, even if only for a short period of time.

Services include staff and contractor education as well as strategies for and preparation of risk assessments, monitoring of projects related to the project and document review.

See the facilities modification risk assessment (FMRA)

This document can be used as an infection prevention risk assessment for maintenance and repairs.


Legionella and other waterborne pathogens continue to cause illness and fatalities in the U.S. The Centers for Medicare and Medicaid (CMS) as well as other Authorities Having Jurisdiction (The Joint Commission, DNV, HFAP) have required Water Management Plans for several years. The focus for healthcare surveys now includes a review of implementation, monitoring, control, and validation. I can assist with a risk assessment for your facility, plan review and training. A key element to success regarding a flushing program can include the use of a Water Infection Control Risk Assessment (WICRA) as outlined in the recently published ASSE 12080 Standards. I have successfully completed the ASSE 12080 requirements for the Legionella Water Safety & Management certification. Let’s review the status of your WMP and make updates as needed.