2025 OAHE Tulsa Conference Agenda

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.

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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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Critical Elements of Successful Commissioning in Healthcare

Abstract

In today’s healthcare construction landscape, the success of complex facilities relies on more than technical excellence. It demands genuine collaboration built on trust and proactive problem-solving across disciplines through effective communication. This presentation explores how an integrated commissioning approach grounded in collaboration, trust-based relationships, advocacy, and consistent processes drives project success from early design through occupancy and beyond.

Through a conversational Q&A-style discussion between two seasoned commissioning professionals, this session will illustrate how early engagement, transparent communication, and a culture of accountability enable teams to anticipate challenges and deliver high-performing buildings that meet owners’ operational and sustainability goals. Attendees will be invited to join the conversation through live prompts and audience questions, creating an engaging dialogue around lessons learned and best practices in healthcare commissioning.

Real-world examples will demonstrate how proactive commissioning teams balance technical rigor with human connection: leveraging cloud-based issue tracking and real-time data, collaborative charrettes to streamline decision-making, and the impact of leading with positivity. The session offers replicable strategies for healthcare organizations and project teams seeking to strengthen trust, performance, and outcomes in complex delivery environments.

Learning Objectives

By the end of this session, participants will be able to:

1. Describe how proactive leadership and early engagement improve commissioning outcomes in healthcare projects.
2. Identify methods for building trust-based relationships that promote transparency, accountability, and shared project goals.
3. Understand why advocacy is critical to aligning commissioning activities with owner values, sustainability targets, and facility performance expectations.
4. Evaluate real-time documentation and collaboration tools that enhance clarity and consistency in project delivery.
5. Implement strategies to define “done” collaboratively, reducing conflicts and ensuring successful project turnover.

Bethany Beers, CCP, LEED AP BD+C

Bethany is a 20+ year commissioning and sustainability professional. She has spent the last seven years focusing on complex facilities, including healthcare and life sciences, and in addition to commissioning several large hospitals, has worked on resilience and decarbonization planning projects for large healthcare portfolio clients. Bethany also has the unique experience of having been on the owner’s side of the table, having been the Building & Energy Engineer at New Belgium Brewing, where she managed over $120M in capital projects, ranging from a full BAS controls upgrade to office and beer garden expansion, and even a new brewing production facility in Asheville, NC.

Bethany is a Certified Commissioning Professional (BCxA) and LEED AP in Building Design & Construction (USGBC). She has worked on over 175 LEED projects across the country, and currently serves as a Board Director for the Sustainable Living Association, advancing Youth Sustainability Education across Colorado.

Jeff Nichols, PE, BCxP, CEM, LEED AP

Jeff is a facility systems and commissioning expert with over 40 years of experience delivering high-performance building solutions in healthcare, other mission critical sectors. He is a recognized leader in commissioning complex projects, combining deep technical rigor with a collaborative, owner-focused approach that emphasizes long-term operational excellence.

Jeff’s healthcare and large-scale facility commissioning experience includes major hospital campuses, laboratories, and highly regulated environments where reliability and sustainability are critical. His leadership philosophy centers on empowering teams through trust, advocacy, and proactive engagement — ensuring design intent translates into measurable performance outcomes.

Jeff is a Licensed Professional Engineer in 10 states and holds credentials as a Building Commissioning Professional (ASHRAE), Certified Energy Manager (AEE), and LEED Accredited Professional (USGBC). He is an active member of Building Commissioning Association’s Advocacy Board, contributing to the advancement of engineering standards and professional ethics in the built environment.

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