| 8:00 am - 9:00 am |
HUG 2025 Alarm Fatigue Process
Alarm fatigue in critical care hospital environments—especially within Building Management
Systems (BMS)—is a growing threat to patient safety, operational reliability, and regulatory
compliance. Excessive, non-actionable alarms can desensitize staff, often leading to delayed
responses, missed alerts, and increased risk of adverse events. This session examines the
underlying causes and far-reaching impacts of alarm overload in high-acuity zones, outlines
best practices and technological innovations for alarm rationalization, and explores the
regulatory and clinical landscape affecting alarm management in healthcare settings.
Participants will gain insight into practical strategies for reducing alarm fatigue, leveraging
advanced digital tools, and fostering cross-functional collaboration to achieve sustainable
improvements in clinical safety and environmental quality.
Session objectives:
- Define alarm fatigue in Building Management Systems (BMS).
- Identify the impact of alarm overload in critical care zones.
- Explore regulatory and clinical implications of alarm management.
- Apply strategies to reduce alarm fatigue.
- Leverage technology to improve alarm management.
- Promote cross-functional collaboration for sustainable solutions.
Speaker: Damon Greeley co-founded OnSite-LLC, with Dr. Jennifer Wagner, to further their
passions for advancing infection prevention in healthcare environments through innovation
and creativity. As an active member of OnSite’s research team, he investigates emerging
methodologies and technologies that improve infection control and life cycle cost efficiency.
Damon is LUMA Institute trained, facilitating human-centered solutions and interactive
sessions based on the MAYA approach (most advanced yet acceptable). He serves on
The Center for Health Design’s EDAC Advisory Council and educates healthcare engineers
on evidence-based design implementation. Damon’s professional certifications include
CEM (2004), HFDP (2005), CBCP (2006), EDAC (2011), CHFM (2016), and a-IPC (2020).
On-site tri-annual surveys conducted by CMS and Accreditation Organizations are critical assessments that evaluate healthcare facilities' adherence to regulatory standards and quality measures. This presentation will equip participants with essential best practices for effectively preparing for and navigating these surveys, ensuring smooth, successful outcomes, and ongoing compliance with CMS Conditions of Participation and Accreditation Organization standards.
The session will focus on understanding the survey process, from pre-survey preparations to post-survey follow-up. Attendees will gain insights into common surveyor expectations, the critical areas of focus during the survey, and the importance of readily organizing documentation. Additionally, the presentation will address the significance of staff training, proactive risk management, and ensuring that all policies, procedures, and practices align with regulatory requirements.
A key focus will also be handling the new CMS concurrent validation process. This emerging practice allows real-time compliance validation during the survey process and requires healthcare facilities to be well-prepared for simultaneous documentation review and feedback. Participants will learn strategies for handling this concurrent validation, ensuring that all necessary data and evidence are readily available and that any issues identified during the survey can be promptly addressed to avoid findings or delays in certification.
Proper etiquette for surveyor scribes and escorts will also be highlighted. Attendees will learn the roles and responsibilities of scribes, who document the surveyor's findings, and escorts, who accompany surveyors throughout the facility. Key topics will include maintaining professionalism, respecting confidentiality, facilitating smooth communication, and fostering a collaborative and transparent environment with the surveyors.
Practical strategies for fostering a survey-ready culture within the facility will be covered, emphasizing continuous improvement, mock surveys, and real-time issue resolution. Participants will also learn how to respond to survey findings, develop corrective action plans, and maintain ongoing compliance to avoid penalties or negative survey outcomes.
By the end of the session, attendees will have a comprehensive understanding of the survey process, the best practices required to manage the CMS or Accreditation Organization tri-annual survey confidently and effectively, the proper etiquette for interacting with surveyors, and how to handle the CMS concurrent validation process, ultimately contributing to improved healthcare quality, safety, and compliance.
Speaker: Michael Jones, CHSP, CHCM, HACP-PE, HACP-IC, HACP-CMS - Principal Consultant, Covenant Rock Consulting
Mike has over 19 years of experience and expertise in Environment of Care, Life Safety, and Emergency Management and is well-versed in CMS, Joint Commission, DNV, CIHQ, AAAHC, NFPA, OSHA, EPA, and DOT codes and standards.
He has served in multiple leadership roles throughout his career. Working in a variety of Hospitals and associated offsite Emergency Departments, Ambulatory Surgical Centers, and Clinics, he conducted internal accreditation audits for Life Safety, Environment of Care, and Emergency Management, provided direction & assistance to all levels of leadership in the development & application of life safety, employee safety, environmental protection, and emergency management programs, and developed and implemented standardized Life Safety policies, procedures and permit forms for multiple Acute Care Hospitals.
His current certifications include Certified Healthcare Safety Professional (CHSP), Certified Hazard Control Manager (CHCM), Certified Six Sigma Green Belt (CSSGB), Healthcare Accreditation Certification Program (HACP) – CMS, Infection Control, and Physical Environment, HVAC Fire and Life Safety Inspections Certification, Certified OSHA 30, Incident Safety Officer Certification, Incident Command System for High Rise Operations (NFA) Certification, FEMA MGT-457, NIMS 100, 200, 700, 800, SFFMA Firefighter 1, Emergency Medical Technician (2002-2014), Department of Transportation Training for Regulated Medical Waste and Hazardous Waste, Hazardous Materials (CFR 40).
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| 9:30 am - 10:30 am |
JCAHO R3 Report New Standards
Presentation highlights:
The discussion will include a review of the JCAHO R3 Report new standards for hospitals,
extended care facilities, critical access facilities, potable water requirements for Joint
Commission Survey. We will spend some time discussing what surveyors are asking for
specifically and what we are seeing facilities get tags for. JCAHO Standards under
EC 02.05.02 and the rationale of the 7 control measures (with ranges) in helping determine
your water quality and any potential issues. Share CDC data on the prevalence of
water-borne infections in healthcare settings (22%) and the significant risks it poses to patients. Reviewing pros and cons of 3 different potable water treatment options most currently utilized in
healthcare s settings. Discussing mineralized oxychloride solution as an emerging
technology that is both EPA and NSF 60 approved, as well as a green chemistry for treatment i
n potable water and how it compares to the above-mentioned options. Also sharing some
insight on Oklahoma facilities that have made the news for Legionella outbreaks, and the
Oklahoma Health Department’s testing process and procedures that we are seeing in
healthcare facilities all over the state.
Speaker: Dave Merhi, Legionella Specialties
The speaker has spent the majority of his career in the medical device field, serving in a
variety of roles. Over the years, I’ve participated in more than 100 clinical studies across
diverse healthcare settings, with a focus on tracking and reducing hospital- acquired
infection rates. I am also one of three owners of Legionella Specialties, a company
dedicated to Water Management Plans, water quality testing, Joint Commission compliance,
remediation services, and automated treatment systems for both potable and emergency
water systems. We are a nationwide company serving 150 healthcare facilities.
Outside of work, I am an outdoor enthusiast who enjoys hiking, trail running, skiing, and fishing. I also love classic cars. I believe in the value of being of service to others.
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