Codes+standards

ASHE reports increased attention to door issues

Plus: CMS to issue new ligature risk policy and ASHRAE updates legionellosis standard
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ASHE reports increased attention to door issues

The American Society for Health Care Engineering’s (ASHE’s) advocacy team reports seeing more citations of doors that stem from issues that began at installation, including an increased number of citations of rated doors being installed in the wrong barrier, noncompliant hardware being installed and some installations being plagued with ongoing problems due to poor work.

“This has brought up the question, ‘Who is responsible for verifying that doors comply with the approved design?’” states Chad Beebe, AIA, CHFM, CFPS, CBO, FASHE, ASHE’s deputy executive director. “The responsibility should be clearly laid out in the contract documents (CDs) but the owner has ultimate responsibility for accepting the final construction from the contractor. Identification of omissions, inconsistencies with the CDs or installation errors should be identified before final sign-off of the project.

Beebe advises that owners, construction managers or architects knowledgeable in door inspection and maintenance should closely inspect new doors for compliance while contractors are still on-site to make any necessary modifications, so hospitals can avoid paying for repairs later. “ASHE’s new door inspection and maintenance program will help individuals who want to know more about avoiding door installation problems,” Beebe adds.


CMS announces upcoming ligature-risk guidance

The Centers for Medicare & Medicaid Services in July announced via a memo that it will incorporate ligature-risk recommendations from The Joint Commission into comprehensive interpretive guidance it is creating to help reduce suicide and self-harm in health care facilities. The memo did not specify a timeline for when the guidance will be released. The American Society for Health Care Engineering has created several tools and resources, including a members-only advocacy alert, to help guide health care facilities in matters related to patient safety and ligature risks.


USP publishes proposed revisions to Chapter 797

United States Pharmacopeia (USP) recently published revisions to its General Chapter 797 Pharmaceutical Compounding — Sterile Preparations for a second round of public comments. Since the first public comment period, which began in September 2015, there has been significant input from stakeholders including roundtable meetings, discussion forums and review of more than 8,000 written public comments. The proposed revisions were pre-posted on the USP website for review prior to its publication in the Pharmacopeial Forum on Sept. 4. The public comment period for USP 797 will end Nov. 30.


ASHRAE publishes updated legionellosis standard

ASHRAE last month published a revised edition of its standard that provides a more comprehensive approach to preventing the growth and spread of Legionella. American National Standards Institute/ASHRAE Standard 188-2018, Legionellosis: Risk Management for Building Water Systems, establishes minimum legionellosis risk-management requirements for building water systems. The 2018 edition provides clarification of compliance requirements, as well as an update to enforceable, code-intended language to facilitate adoption of the standard for code and regulatory purposes.

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