OSHE News & Issues|
OSFM Fire and Life Safety Services Branch: "CMS - New Team, New Look, Same Focus"|
[July 4, 2017]
[Above: L to R: Compliance Specialist Matthew Rodriguez, Deputy State Fire Marshal David Mills, Compliance Specialist Gordon Simeral, Assistant Chief Deputy Michael Trabue, and Compliance Specialist Mark Crawford.
by Deputy State Fire Marshal David Mills
This article provides an update of
staffing and process changes in the
OSFM Fire and Life Safety Services Branch.
Over the past twelve months, we have been revising the process in our Healthcare
Unit on how we perform fire and life safety surveys of the federal government’s
Centers for Medicare and Medicaid Services (CMS) licensed healthcare facilities.
These changes, made in collaboration with our agency partners at the
of Human Services (DHS) and the
Oregon Health Authority (OHA), are in response
to industry stakeholder demands for improved delivery of this service.
So what is the CMS Program?
The federal government’s CMS maintains oversight for compliance with the
Medicare health and safety standards for laboratories, acute and continuing care
hospitals, nursing homes, home health agencies (HHAs),
end-stage renal disease (ESRD) facilities, hospices, ambulatory surgery centers
(ASC)], and other facilities serving Medicare and Medicaid beneficiaries. This
is an optional program with which many of these facilities participate in order
to receive federal reimbursement for services provided to patients covered by
Medicare or Medicaid insurance programs.
What is a CMS facility Survey?
The survey (inspection) is to determine a facility's compliance to participate
in this federal reimbursement program and is performed on behalf of CMS by the
individual State Survey Agencies. The functions the states perform for CMS under
the agreements in Section 1864 of the Social Security Act are referred to
collectively as the certification process. In Oregon, the State Survey Agencies
are the Department of Human Services (DHS) and the Oregon Health Authority (OHA).
What is the role of the Office of the State Fire Marshal (OSFM)?
The OSFM conducts Life Safety Code (LSC -
NFPA 101 &
NFPA 99) surveys on behalf,
and under the direction of, DHS and OHA as part of their performance of the CMS
certification process of participating healthcare facilities in Oregon. The
portions of a facility receiving an LSC survey is generally limited to patient
care areas and those portions providing direct support of patient care. This
survey work has most recently been performed by OSFM Deputy State Fire Marshals
(DSFM) Sean Condon and Jonathon Jones.
What are the changes in the CMS Survey Program at OSFM?
The people, the scope, and the services we provide.
For the past eight months, the OSFM has been preparing to transition the CMS
healthcare survey work that DSFMs Condon and Jones have been performing to our
three new Health Care Unit CMS Compliance Specialists. Compliance Specialists
Matt Rodriguez, Gordon Simeral, and Mark Crawford have completed their
transition to full time LSC surveyors of CMS facilities. They have been well
trained and prepared for their new roles in the unit. DSFM David Mills will
assist as their lead for the next six to twelve months as they get comfortable
with their new responsibilities.
LSC surveys are now solely focused on Life Safety Code requirements (NFPA 101 &
NFPA 99), verifying compliance with federal fire and life safety standards of
existing facilities and for new facilities who wish to be certified to receive
federal CMS funding. This is a significant change in the scope of the CMS
program at OSFM as our Healthcare Unit surveyors no longer enforce Oregon Fire
Code requirements when they are conducting their healthcare facility surveys.
New construction and tenant improvement plan review - The OSFM will begin
participating in OHA’s expansion of their new construction and tenant
improvement plan review process by the end of September. This new service will
allow our LSC surveyors to determine compliance with federal requirements prior
to facility construction, with the goal to minimize any conflicts with state
construction codes and lack of CMS compliance at the time a Certificate of
Occupancy is issued.
Unified code and standard interpretation services - All requests for OSFM
CMS code and standards are now being referred to the
Technical Services Unit of the
Fire and Life Safety Services Branch, the same
unit that currently provides for interpretations of the Oregon Fire Code (OFC).
This change is in response to stakeholder demands for consistent code
interpretations of CMS-related compliance questions that will also identify and
address any potential conflicts with
State Building and Fire Codes. This new
service will provide for one voice and one contact for code-related questions
ensuring we deliver the best customer service available.
Regulated community/stakeholder outreach - We have met with, and will continue
to meet with, healthcare facility management and maintenance directors to
educate them on the changes we are making at OSFM, increasing collaboration on
our process improvements and to get feedback on how we can continue to improve
What does this mean to the fire service?
Determining compliance with the OFC in healthcare facilities is now the
responsibility of local fire jurisdictions within their respective communities.
Any assistance required from the OSFM will be mutually determined in concert
with the DSFM serving the local jurisdiction’s region. It will also mean more
collaboration in addressing fire code and CMS regulation conflicts that
occasionally arise when multiple regulatory Authorities Having Jurisdictions (AHJs)
all look at the same issue being regulated.
Benton, Linn, and Marion counties will now have a dedicated DSFM assigned to
provide them service. Fire inspection and investigation service support for
theses counties has been provided by Deputy State Fire Marshals Shannon Miller,
Kristina Deschaine, and Ted Megert for the past thirteen months as our office
has been making these changes.
Effective June 19th, DSFM Sean Condon has transitioned out of our Healthcare
Unit and is serving
District 3 (Marion County). DSFM Jonathon Jones will follow
on July 3rd and will serve District 4 (Linn/Benton counties). This will mean a
decrease in workload for DSFMs Miller, Megert, and Deschaine as they have been
filling the gaps in those Districts. Sean’s and Jonathan’s priority will be to
become familiar with the needs of the fire departments and districts in their
service areas and increase the level of service to them.
Please welcome Sean and Jonathan as they assume their new roles in the branch
and congratulate Matt, Gordon, and Mark with the completion of their very
intense training and testing, and their new role in our Healthcare Unit.
OSHE has once again earned the Platinum Level of Affiliation with ASHE for 2015|
[August 1, 2016]
The Platinum Level is the highest Level of Affiliation that can be attained by
an ASHE Chapter. This accomplishment reflects our membership's dedication to
Education, Leadership, Communication, and Advocacy for the Healthcare
Engineering profession. OSHE has consistently performed at a higher level,
maintaining a Gold Level Affiliation from the inception of the program in 1997
to 2008 and Platinum Level Affiliation in 2009 - 2014.
For OSHE to earn Platinum level there are a few requirements:
- Conduct 24 hours or more of educational programming in the year
- Attendance at the annual Chapter Leadership Forum.
- Submit an application/nomination for the Emerging Regional Leader Award
- Chapter President & President-elect must both hold active ASHE membership.
- Joint ASHE/Chapter Membership: Maintain a minimum of 25% active members who
hold joint ASHE membership in OSHE.
- Distribute a minimum 12 or more member communications.
OSHE met or exceeded minimum criteria for the Platinum level in several areas,
2. Number of OSHE members who are also ASHE members
3. Communications from OSHE officers to members
4. Four quarterly OSHE Newsletters
5. Four quarterly OSHE Codes & Standards issues
6. Blast e-mails to all members throughout the year.
ASHE chapters participating in the Levels of Affiliation Awards Program submit
documentation demonstrating that they have met several criteria based on
affiliation objectives ASHE would like to achieve to make its chapters stronger
and more viable, which in turn benefits the fields of healthcare engineering and
A BIG "Thank You" to those outstanding OSHE members that assisted in the
Platinum level for 2015 application.
Register for 52nd ASHE Annual Conference & Technical Exhibition July 12 - 15|
[June 28, 2015]
More than 3,000 professionals gather on-site each year to get vital information on health care compliance, codes and standards updates, emerging trends, and best practices for efficiency, sustainability, emergency preparedness, and other pressing topics in the field. Attend the ASHE Annual Conference and Technical Exhibition to connect with colleagues in the field and to "stay fit" in your role as a health care facility management professional.
Sheraton Boston Hotel
39 Dalton St., Boston, MA 02199
> Annual Conference
Website for Registration and Agenda
Your Opportunity to Comment on Proposed Code Involving Legionella Risk
[October 13, 2014]
ASHRAE Releases Legionellosis Standard for Fourth Public Review Draft
ATLANTA - A fourth version of ASHRAE's proposed legionellosis standard is open
for public comment until November 10, 2014.
Standard 188P, Legionellosis: Risk Management for Building Water Systems,
currently under development, will establish minimum legionellosis risk
management requirements for building water systems. The standard is intended for
use by building owners and managers and those involved in the design,
construction, installation, commissioning, operation, maintenance and service of
centralized building water systems and components.
The draft of the document and instructions on submitting comments can be found
The proposed standard will be available for access until Nov. 10, 2014.
Changes to the proposed standard since its last public review in January 2013
- Alignment of the document with the revised title, purpose and scope.
- Removal of hazard analysis and critical control points (HACCP)
terminology; some of the principles of the - HACCP process are consistent
with the process utilized in the document.
- Inclusion of a normative appendix for health care facilities meeting
specific requirements that provides an alternate compliance path that is more
stringent than for other facilities.
- More emphasis on requirements for design, construction, installation,
commissioning, operation, maintenance and service.
Tom Watson, chair of the Standard 188P committee, notes that the standard
contains both normative sections and appendices that specify what is required to
comply. It also contains informative appendices and references as guidance about
how to do things that may be necessary for a given building water system.
"Building water systems vary substantially in their design and their capability
for transmission of Legionella," Watson said. "Scientific evidence is either
lacking or inconclusive in certain aspects of Legionella control. The
informative guidance is included to provide suggestions, recommendations and
To learn more about actions regarding ASHRAE standards, visit
There, ASHRAE provides subscriptions to a variety of listserves, including one
for Standard 188P, that enable interested parties to stay up to date with the
latest news, publication offerings, and various other Society activities.
ASHRAE, founded in 1894, is a global society advancing human well-being through
sustainable technology for the built environment. The Society and its more than
50,000 members worldwide focus on building systems, energy efficiency, indoor
air quality, refrigeration and sustainability. Through research, standards
writing, publishing, certification and continuing education, ASHRAE shapes
tomorrow's built environment today.
> More Information on the
ASHRAE News page
alert: Changes to Power Strip Use, Plans for Improvement|
[June 5, 2014]
ASHE members should be aware of several important compliance changes affecting
hospitals and other health facilities. The Centers for Medicare & Medicaid
Services (CMS) is significantly restricting the use of power strips in patient
care areas effective immediately. Also, the Joint Commission is requiring
hospitals to address overdue plans for improvement (PFIs) by July 1, 2014.
Joint Commission Department of Engineering Director George Mills states that CMS
is not allowing relocatable power taps, referred to as RPTs or power strips, to
be used with medical equipment in patient care areas—effective immediately. That
includes operating rooms, patient rooms, and areas for recovery, exams, and
diagnostic procedures. Mills reports that many facility professionals are
frustrated by the change, arguing that restrictions on power strips would lead
to tripping hazards from long extension cords stretching across rooms.
> Continue Reading "Changes
to Power Strip Use, Plans for Improvement" Article on ASHE Website
Spring 2014 Conference Presentations|
[May 23, 2014]
View our 2014 Spring Conference Attendee List in our
Members Only section
"Lean, 3P Design in Healthcare and the Lean Leader" [26 pages]
Presented by Stephen Grose, Director of Facilities and
Production at Emerald Environmental Services and Cedar Grove
Composting; ASHE Region 10 Director, 2010-2011
The presentation explores awareness of the principles of
Kaizen/LEAN activities, values and challenges with
implementation efforts at VMMC.
"Fire Safety System Testing Requirements & Documentation per
NFPA: EC.02.03.05" [27 pages]
Presented by Bill Morgan, CHFM, FASHE, Senior Consultant,
The presentation reviews initial and on-going required testing
of Fire Safety Systems including performance test process,
frequency and parameters as well as documentation requirements
for FS testing and scheduled maintenance.
Clarifying 7 Concerns about Proposed Changes to Hospital Smoke Compartment Size|
[May 27, 2014]
ASHE supports a proposal to change NFPA 101: Life Safety Code® that would increase the maximum smoke compartment size in new facilities from 22,500 square feet to 40,000 square feet. The proposal will be voted on at the National Fire Protection Association’s Technical Meeting in Las Vegas June 11-12, which is part of the NFPA Conference & Expo that runs June 9-12. However, some who will be attending the meeting have raised concerns about the proposal. A new ASHE advocacy alert explains the concerns—and the facts behind them—and urges ASHE members to contact their local building officials, fire marshals, and other NFPA members about the issue.
> Continue Reading "7 Concerns" Article on ASHE Website
New OSHE Contact Info|
[January 16, 2014]
In January, OSHE partnered with new management and your ways to contact us have
changed. Please make note of the following in your contact methods:
OSHE: Oregon Society for Healthcare Engineering
5727 Baker Way NW, Suite 200
Gig Harbor, WA 98332
FAX: (253) 265-3043
Mobile ASHE app provides resources for health care facility professionals|
[October 28, 2013]
CHICAGO – A new app for mobile devices provides on-the-go access to resources for busy health care facility professionals, including regulatory updates, news, education opportunities, and acronyms.
Health care facility managers and engineers often work away from computers as they deal with issues around their facilities. The new Mobile ASHE app provides free mobile access to the following information:
News: The ASHE news feed provides the latest developments in the field, including regulatory updates on codes and standards, news stories, and press releases.
Acronyms: The health care field includes many acronyms. The Mobile ASHE app allows users to browse or search to find meanings for hundreds of health care, business, and military acronyms.
Monographs: ASHE members can access these publications, which cover single topics on issues such as facility engineering, design and construction, and safety and security management. One recent monograph tackled how to evaluate electrical distribution equipment to determine replacement needs, while another compared editions of the Life Safety Code®.
Calendar: The calendar provides an updated listing of ASHE events, including conferences, webinars, workshops, and educational opportunities.
Social Media: This section of the app connects users with ASHE’s social media channels, including LinkedIn, Twitter, YouTube, and the ASHE Blog.
Mobile ASHE is available now for Apple and Android devices. Visit the iTunes store or Google Play and search for Mobile ASHE to find and download the app.
> Read More