VHA Directive 1850.pdf

T-1

Department of Veterans Affairs VHA DIRECTIVE 1850.01(1) Veterans Health Administration Transmittal Sheet Washington, DC 20420 March 29, 2023

HEALTH CARE ENVIRONMENTAL SANITATION PROGRAM

1. SUMMARY OF CONTENT:

a. Amendment dated September 5, 2024: adds additional details to an existing training requirement for VA medical facility Environmental Management Service (EMS) staff (see paragraph 3.a.(1)) and a newly required training course for VA medical facility EMS staff who perform any function on inpatient mental health units to align with training requirements stated in VHA Directive 1167, Mental Health Environment of Care Checklist for Mental Health Units Treating Suicidal Patients, dated May 12, 2017 (see paragraph 3.a.(2)).

b. As published March 29, 2023, this Veterans Health Administration (VHA) directive outlines the responsibilities of VHA Environmental Programs Service (EPS) management and leadership teams regarding the Health Care Environmental Sanitation Program (HESP).

2. RELATED ISSUES: VHA Directive 1850, Environmental Programs Service, dated January 30, 2023; VHA Directive 1850.02, Pest Management Operations Program, dated December 22, 2022; VHA Directive 1850.03, Textile Care Management Program, dated April 4, 2017; VHA Directive 1850.04, Employee Uniforms, dated April 6, 2017;

VHA Directive 1850.05, Interior Design Program, dated January 11, 2023; VHA Directive 1850.06, Waste Management Program, dated July 22, 2022; VHA Directive 1850.07(1), Textile Care Processing Facility Operation, dated April 5, 2017; VHA Directive 1608, Comprehensive Environment of Care (CEOC), dated June 21, 2021;

VHA Directive 1002, Bed Management Solutions For Tracking Beds and Patient Movement Within and Across VHA Facilities, dated November 28, 2017; VHA Directive 1108.12, Management and Monitoring of Pharmaceuticals Compounded Sterile Preparations, dated November 5, 2018; VHA Directive 1116(2), Sterile Processing Service (SPS), dated March 23, 2016; VHA Directive 1131(5), Management of Infectious Diseases and Infection Prevention and Control Programs, dated November 7, 2017.

3. POLICY OWNER: The Office of the Assistant Under Secretary for Health for Support

(19) is responsible for the content of this directive. Questions may be addressed to the Director, EPS (19HEFC) at VHA19HEFCAction@va.gov.

4. RESCISSIONS: None.

5. RECERTIFICATION: This VHA directive is scheduled for recertification on or before the last working day of March 2028. This VHA directive will continue to serve as national VHA policy until it is recertified or rescinded.

6. IMPLEMENTATION SCHEDULE: This directive is effective 6 months from the date of mailto:VHA19HEFCAction@va.gov

March 29, 2023 VHA DIRECTIVE 1850.01(1)

T-2 publication.

BY DIRECTION OF THE OFFICE OF THE

UNDER SECRETARY FOR HEALTH:

/s/ Alfred A. Montoya Jr., MHA, FACHE Acting Assistant Under Secretary for Health for Support

NOTE: All references herein to Department of Veterans Affairs (VA) and VHA documents incorporate by reference subsequent VA and VHA documents on the same or similar subject matter.

DISTRIBUTION: Emailed to the VHA Publications Distribution List on April 10, 2023.

i

CONTENTS

HEALTH CARE ENVIRONMENTAL SANITATION PROGRAM

1. POLICY

2. RESPONSIBILITIES

3. TRAINING

4. RECORDS MANAGEMENT

5. BACKGROUND

6. REFERENCES

HEALTH CARE ENVIRONMENTAL SANITATION PROGRAM

1. POLICY

It is Veterans Health Administration (VHA) policy to maintain all Department of Veterans Affairs (VA) medical facilities in a state of physical and biological cleanliness in accordance with applicable health care industry sanitation standards; Federal, State and local regulatory requirements; and department policies. AUTHORITY: 38 U.S.C. § 7301(b).

2. RESPONSIBILITIES

a. Under Secretary for Health. The Under Secretary for Health is responsible for ensuring overall VHA compliance with this directive.

b. Assistant Under Secretary for Health for Support. The Assistant Under Secretary for Health for Support is responsible for establishing policy and providing guidance and oversight as necessary to ensure the timely and successful implementation of this directive.

c. Assistant Under Secretary for Health for Operations. The Assistant Under Secretary for Health for Operations is responsible for:

(1) Communicating the contents of this directive to each of the Veterans Integrated Services Networks (VISNs).

(2) Assisting VISN Directors to resolve implementation and compliance challenges in all VA medical facilities within that VISN.

(3) Providing oversight of VISNs to ensure compliance with this directive and its effectiveness.

(4) Coordinating with the Executive Director, Healthcare Environment and Facilities Program (HEFP), VISN Directors and VA medical facility Directors to ensure all necessary action is taken and funding is obtained to address health care sanitation-related deficiencies in a manner that meets the requirements of Federal, State and local statutes and regulations; applicable Executive Orders; and VA and VHA directives.

d. Executive Director, VHA Healthcare Environment and Facilities Program. The Executive Director, HEFP is responsible for:

(1) Overseeing VHA Environmental Programs Service (EPS).

(2) Periodically assessing EPS’s Health Care Environmental Sanitation Program (HESP) related initiatives for continued need, currency and effectiveness.

(3) Coordinating with the Assistant Under Secretary for Health for Operations, VISN Directors and VA medical facility Directors to ensure all necessary action is taken and funding is obtained to address health care sanitation-related deficiencies in a manner that meets the requirements of Federal, State and local statutes and regulations;

applicable Executive Orders; and VA and VHA directives.

e. Director, Environmental Programs Service. The Director, EPS is responsible for:

(1) Providing oversight for the implementation of this directive and serving as the national health care sanitation subject matter expert (SME), advisor and point of contact for VISNs and VA medical facilities.

(2) Establishing guidelines and recommending standardized health care sanitation processes and practices as outlined on the EPS intranet website (see http://vaww.hefp.va.gov/topics/healthcare-environmental-sanitation. NOTE: This is an internal VA website that is not available to the public.).

(3) Overseeing the collection and analysis of health care sanitation data from VISNs and VA medical facilities in response to specific inquiries to ensure compliance, planning and procedural effectiveness.

f. Veterans Integrated Service Network Director. The VISN Director is responsible for:

(1) Ensuring that VA medical facilities within the VISN comply with this directive and informing leadership when barriers to compliance are identified.

(2) Ensuring adequate resources are available at all VA medical facilities within the VISN to maintain effective Environmental Management Service (EMS) programs.

(3) Coordinating with the Assistant Under Secretary for Health for Operations, Executive Director, HEFP, and VA medical facility Directors to ensure all necessary action is taken and funding is obtained to address health care sanitation-related deficiencies in a manner that meets the requirements of Federal, State and local statutes and regulations; applicable Executive Orders; and VA and VHA directives.

(4) Providing health care sanitation data analysis, upon request, to the Director, EPS. NOTE: This data may include, but is not limited to, site review findings and hiring information as it pertains to Environmental Services (EVS) Technicians.

g. VA Medical Facility Director. The VA medical facility Director is responsible for:

(1) Ensuring VA medical facility compliance with this directive and appropriate corrective action is taken if non-compliance is identified.

(2) Ensuring that the VA medical facility has appropriate systems in place to assure a safe, clean and high-quality environment for Veterans, their families, visitors and employees.

http://vaww.hefp.va.gov/topics/healthcare-environmental-sanitation

(3) Ensuring identified health care sanitation deficiencies are addressed within established timelines.

(4) Ensuring adequate resources are available to support EMS program functions, including staffing, education, training, equipment and supplies.

(5) Ensuring that VA medical facility EMS staff have the skills and knowledge necessary to safely perform required health care sanitation duties.

(6) Coordinating with the Assistant Under Secretary for Health for Operations;

Executive Director, HEFP and VISN Directors to ensure all necessary action is taken and funding is obtained to address health care sanitation-related in a manner that meets the requirements of Federal, State and local statutes and regulations; applicable Executive Orders; and VA and VHA directives.

(7) Providing health care sanitation data analysis, upon request, to the Director, EPS. NOTE: This data may include, but is not limited to, site review findings and hiring information as it pertains to EVS Technicians.

h. VA Medical Facility Chief, Environmental Management Service. The VA medical facility Chief, EMS is responsible for:

(1) Serving as the SME and advisor to the VA medical facility regarding HESP.

(2) Coordinating a complete HESP in accordance with guidance by the Director, EPS. More information can be found on the EPS intranet website (see http://vaww.hefp.va.gov/topics/healthcare-environmental-sanitation. NOTE: This is an internal VA website that is not available to the public.).

(3) Determining appropriate actions to resolve identified health care sanitation deficiencies.

(4) Ensuring the EVS Technician workforce is knowledgeable, competent and trained in health care sanitation practices to effectively perform the tasks as outlined in paragraph 3.

(5) Ensuring adequate staffing levels in accordance with VHA’s health care sanitation staffing model, based upon a VA medical facility-specific Task Frequency Analysis (TFA). NOTE: TFA is a business solution utilized within the cleaning industry to identify tasks required of the EVS Technicians and the frequency in which those cleaning tasks are required resulting in a site-specific defined EVS staffing model.

(6) Ensuring the procurement of sufficient equipment, tools and supplies, including personal protective equipment (PPE), for the performance of job duties.

(7) Ensuring chemicals and supplies available within the Medical/Surgical Prime Vendor (MSPV) catalog are procured for proper chemical efficacy (effectiveness of disinfectants against pathogens). NOTE: For more information, see http://vaww.hefp.va.gov/topics/healthcare-environmental-sanitation https://www.va.gov/opal/sac/mspv.asp.

(8) Ensuring the Quality Assurance Monitoring Program operates in accordance with the established EPS Quality Assurance Guide. The guide can be found at:

http://vaww.hefp.va.gov/resources/eps-quality-assurance-guide. NOTE: This is an internal VA website that is not available to the public.

(9) Ensuring standard operating procedures (SOP) are created in accordance with the established EMS SOP. The EMS SOP can be found at:

https://vaww.hefp.va.gov/resources/ems-standard-operating-procedure. NOTE: This is an internal VA website that is not available to the public.

(10) Ensuring patient-centered care initiatives operate in accordance with the established Patient-Centered Care Improvement Guide. The guide can be found at:

http://vaww.hefp.va.gov/resources/eps-patient-centered-care-improvement-guide. NOTE:

This is an internal VA website that is not available to the public.

(11) Ensuring contractual service requirements related to health care sanitation are identified and addressed.

3. TRAINING

a. The following trainings are required for certain VA medical facility EMS staff as specified below:

(1) DOT Regulated Medical Waste (RMW) Training (Talent Management System (TMS) curriculum EES-152, which includes course VA 131000509). In accordance with 49 C.F.R. § 172.704, this training must be completed by VA medical facility EMS staff who perform any function subject to the hazardous materials regulations, such as loading and unloading, preparing the packaging and markings, working with hazardous materials paperwork (i.e., manifests), or driving the vehicle transporting the hazardous materials. NOTE: See 49 C.F.R. § 173.134(a)(5) for the definition of “regulated medical waste.” Initial training must be completed prior to performing the function subject to the hazardous materials regulations. Refresher training must be completed every 3 years.

This requirement also includes any non-EMS staff (e.g., located at a Community-Based Outpatient Clinic).

(2) Mental Health Environment of Care Checklist (MHEOCC) Training for Non- Clinical Staff (TMS Course: VA 1290950). In accordance with VHA Directive 1167, Mental Health Environment of Care Checklist for Mental Health Units Treating Suicidal Patients, dated May 12, 2017, this training must be completed by VA medical facility EMS staff who perform any function on inpatient mental health units. Initial training must be completed through staff orientation and annually thereafter.

b. The following annual trainings are highly recommended for all VA medical facility EMS staff:

(1) Level 1 Magnetic Resonance Imaging (MRI) Safety Training (TMS course https://www.va.gov/opal/sac/mspv.asp http://vaww.hefp.va.gov/resources/eps-quality-assurance-guide https://vaww.hefp.va.gov/resources/ems-standard-operating-procedure http://vaww.hefp.va.gov/resources/eps-patient-centered-care-improvement-guide number VA 9696). This training should be completed by any EMS staff that enter the MRI area to perform duties as well as all EMS work leaders and supervisors.

(2) Infection Control: Personal Protective Equipment (TMS course number VA 8588). This training should be completed by all EMS staff, including EMS work leaders and supervisors.

(3) Bed Management Solution (BMS) – Environmental Management Service (enduring material) (TMS course number VA 40790). This training should be completed by any EMS staff that perform bed turnover cleaning to facilitate patient throughput and movement and whose duties include utilization of BMS. All EMS work leaders and supervisors should also complete this training.

(4) 2 Step Clean (TMS course number VA 37050). To augment annual competency training, it is highly recommended that this additional training be completed by any EMS staff that perform health care sanitation functions, including all EMS work leaders and supervisors.

(5) Training Series: “Meaning of Clean”. Training series “Meaning of Clean,” is located at https://dvagov.sharepoint.com/sites/VHA10NA5C/sanitation/SitePages/Meaning-of- Clean.aspx. NOTE: This is an internal VA website that is not available to the public. To augment annual competency training, it is highly recommended that this additional training be completed by any EMS staff that perform health care sanitation functions, including all EMS work leaders and supervisors.

c. Recommended training for designated EMS staff is identified on the EPS Training and Professional Development website at:

https://dvagov.sharepoint.com/sites/VHA10NA5C/training/SitePages/Healthcare- Sanitation-Certifications.aspx. NOTE: This is an internal VA website that is not available to the public.

4. RECORDS MANAGEMENT

All records regardless of format (e.g., paper, electronic, electronic systems) created by this directive must be managed as required by the National Archives and Records Administration (NARA) approved records schedules found in VHA Records Control Schedule 10-1. Questions regarding any aspect of records management should be addressed to the appropriate Records Officer.

5. BACKGROUND

a. HESP outlines the procedures, reporting requirements and operational guidelines pertaining to health care sanitation within VHA. EPS provides oversight of HESP across VHA consistent with the guidance outlined by the Centers for Disease Control and Prevention (CDC), which has authority to implement regulations aimed at protecting health and safety. EPS compiles, assesses, develops and influences standards related to the practice of infection prevention, incorporating CDC guidance along with other https://dvagov.sharepoint.com/sites/VHA10NA5C/sanitation/SitePages/Meaning-of-Clean.aspx https://dvagov.sharepoint.com/sites/VHA10NA5C/sanitation/SitePages/Meaning-of-Clean.aspx https://dvagov.sharepoint.com/sites/VHA10NA5C/training/SitePages/Healthcare-Sanitation-Certifications.aspx https://dvagov.sharepoint.com/sites/VHA10NA5C/training/SitePages/Healthcare-Sanitation-Certifications.aspx health care sanitation industry practices and protocols.

b. The effectiveness of HESP directly impacts the care Veterans receive within VA medical facilities, their perception of that care and the overall Veteran experience, and further supports the positive image of VA medical facilities. EMS is responsible for ensuring a state of physical and biological cleanliness and orderly appearance at the VA medical facilities in compliance with HESP.

c. The EMS SOP, found at: https://vaww.hefp.va.gov/resources/ems-standard-operating-procedure, provides EMS departments with templates to be modified and made VA medical facility-specific through stakeholder collaboration, review and concurrence. NOTE: This is an internal VA website that is not available to the public.

6. REFERENCES

a. 38 U.S.C. § 7301(b).

b. 49 C.F.R. §§ 172.704, 173.134(a)(5).

c. VHA Directive 1167, Mental Health Environment of Care Checklist for Mental Health Units Treating Suicidal Patients, dated May 12, 2017.

d. EMS SOP, https://vaww.hefp.va.gov/resources/ems-standard-operating-procedure. NOTE: This is an internal VA website that is not available to the public.

e. EPS Patient-Centered Care Improvement Guide, http://vaww.hefp.va.gov/resources/eps-patient-centered-care-improvement-guide. NOTE:

This is an internal VA website that is not available to the public.

f. EPS Quality Assurance Guide, http://vaww.hefp.va.gov/resources/eps-quality-assurance-guide. NOTE: This is an internal VA website that is not available to the public.

g. EPS Welcome Guidebook, http://vaww.hefp.va.gov/resources/eps-welcome-guidebook. NOTE: This is an internal VA website that is not available to the public.

h. Healthcare Environmental Sanitation, http://vaww.hefp.va.gov/topics/healthcare-environmental-sanitation. NOTE: This is an internal VA website that is not available to the public.

i. Healthcare Sanitation Certifications, https://dvagov.sharepoint.com/sites/VHA10NA5C/training/SitePages/Healthcare- Sanitation-Certifications.aspx. NOTE: This is an internal VA website that is not available to the public.

j. Office of Procurement, Acquisition and Logistics (OPAL) Medical/Surgical Prime Vendor (MSPV) Program, https://www.va.gov/opal/sac/mspv.asp.

https://vaww.hefp.va.gov/resources/ems-standard-operating-procedure https://vaww.hefp.va.gov/resources/ems-standard-operating-procedure https://vaww.hefp.va.gov/resources/ems-standard-operating-procedure https://vaww.hefp.va.gov/resources/ems-standard-operating-procedure http://vaww.hefp.va.gov/resources/eps-patient-centered-care-improvement-guide http://vaww.hefp.va.gov/resources/eps-quality-assurance-guide http://vaww.hefp.va.gov/resources/eps-quality-assurance-guide http://vaww.hefp.va.gov/resources/eps-welcome-guidebook http://vaww.hefp.va.gov/resources/eps-welcome-guidebook http://vaww.hefp.va.gov/topics/healthcare-environmental-sanitation http://vaww.hefp.va.gov/topics/healthcare-environmental-sanitation https://dvagov.sharepoint.com/sites/VHA10NA5C/training/SitePages/Healthcare-Sanitation-Certifications.aspx https://dvagov.sharepoint.com/sites/VHA10NA5C/training/SitePages/Healthcare-Sanitation-Certifications.aspx https://www.va.gov/opal/sac/mspv.asp

k. Meaning of Clean, https://dvagov.sharepoint.com/sites/VHA10NA5C/sanitation/SitePages/Meaning-of- Clean.aspx. NOTE: This is an internal VA website that is not available to the public.

https://dvagov.sharepoint.com/sites/VHA10NA5C/sanitation/SitePages/Meaning-of-Clean.aspx https://dvagov.sharepoint.com/sites/VHA10NA5C/sanitation/SitePages/Meaning-of-Clean.aspx