VHA DIrective1850_D_2023-01-30.pdf

T-1

Department of Veterans Affairs VHA DIRECTIVE 1850 Veterans Health Administration Transmittal Sheet Washington, DC 20420 January 30, 2023

ENVIRONMENTAL PROGRAMS SERVICE

1. SUMMARY OF MAJOR CHANGES:

a. Adds and modifies responsibilities in paragraph 2 for the Under Secretary for Health; Assistant Under Secretary for Health for Support; Assistant Under Secretary for Health for Operations; Executive Director, Health Care Environment and Facilities Programs; Director, Environmental Programs Service; Veterans Integrated Service Network Director and Department of Veterans Affairs (VA) medical facility Director.

b. Updates descriptions in paragraph 5 for the Veterans Health Administration (VHA) Health Care Environmental Sanitation Program, Interior Design Operations and Management Program, Waste Management and Recycling Program, Textile Care Management Program, Integrated Pest Management Program and the Comprehensive Environment of Care Program.

2. RELATED ISSUES: VHA Directive 1002, Bed Management Solution for Tracking Beds and Patient Movement Within and Across VHA Facilities, dated November 28, 2017; VHA Directive 1108.12, Management and Monitoring of Pharmaceutical Compounded Sterile Preparations, dated November 5, 2018; VHA Directive 1116(2), Sterile Processing Services, dated March 23, 2016; VHA Directive 1131(5), Management of Infectious Diseases and Infection Prevention and Control Programs, dated November 7, 2017; VHA Directive 1330.01(6), Health Care Services for Women Veterans, dated February 15, 2017; VHA Directive 1608, Comprehensive Environment of Care Program, dated June 21, 2021; VHA Directive 1850.02, Pest Management Operations Program, dated December 22, 2022; VHA Directive 1850.03(1), Textile Management Services, dated April 4, 2017; VHA Directive 1850.04(1), 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; and VA Directive 7531, Acquisition of Artwork, Decorative Furnishings and Decorative Items, dated March 1, 2017.

3. POLICY OWNER: The Office of Environmental Programs Service (19HEFC) is responsible for the content of this directive. Questions may be addressed to VHA19HEFCAction@va.gov.

4. RESCISSIONS: VHA Directive 1850, Environmental Programs Service, dated March 31, 2017, is rescinded.

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

mailto:VHA19HEFCAction@va.gov

January 30, 2023 VHA DIRECTIVE 1850

T-2

6. IMPLEMENTATION SCHEDULE: This directive is effective 3 months after 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 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

ENVIRONMENTAL PROGRAMS SERVICE

1. POLICY

2. RESPONSIBILITIES

3. TRAINING

4. RECORDS MANAGEMENT

5. BACKGROUND

6. REFERENCES

ENVIRONMENTAL PROGRAMS SERVICE

1. POLICY

It is Veterans Health Administration (VHA) policy that the Environmental Programs Service (EPS) provides oversight and operational guidance to all Department of Veterans Affairs (VA) medical facilities to ensure a clean, safe and aesthetically healing environment for Veterans, their family members, caregivers, volunteers, visitors and employees. AUTHORITY: 42 U.S.C. § 4332, 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 Service Networks (VISNs).

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

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

d. Executive Director, Health Care Environment and Facilities Programs. The Executive Director, Health Care Environment and Facilities Programs is responsible for:

(1) Overseeing VHA EPS.

(2) Periodically assessing VHA EPS for continued need, currency and effectiveness.

(3) Coordinating with the Assistant Under Secretary for Health for Support, VISN Directors and VA medical facility Directors to ensure all necessary action is taken and funding is obtained to address EPS program performance 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) Developing and implementing the EPS program in VHA.

(2) Developing and deploying EPS national policy.

(3) Assessing implementation of EPS programs at VA medical facilities for continued need and effectiveness to ensure the level of quality throughout VHA is consistently and effectively applied and to ensure continued trialing of advances in technology related to health care sanitation, interior design and other EPS program elements.

(4) Issuing EPS standard operating procedures. The most up-to-date standard operating procedures may be accessed at http://vaww.hefp.va.gov/resources/eps-sanitation-procedure-guide. NOTE: This is an internal VA website that is not available to the public.

(5) Providing guidance and support to all VA medical facilities in the operation of EPS scopes of service.

(6) Advising VA medical facility leadership of policy and procedural changes that affect their Environmental Management Service (EMS) programs.

(7) Overseeing data collection for compliance, planning and procedural effectiveness as outlined on the EPS intranet website located at http://vaww.hefp.va.gov/environmental-programs-service. NOTE: This is an internal VA website that is not available to the public.

(8) Generating data requests, reports and program site review actions for review and action by the VA medical facility Director.

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

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

(2) Appointing a VISN-level representative through organizational alignment or collateral duty with EMS expertise to carry out obligations associated with Health Care Environmental Sanitation, Interior Design, Waste Management and Recycling, Integrated Pest Management, Textile Management and oversight for addressing EMS network-wide deficiencies within the EMS checklist of the CEOC Assessment and Compliance Rounding Tool.

(3) Coordinating with the Assistant Under Secretary for Health for Support, Executive Director, Health Care Environment and Facilities Programs and VA medical facility Directors to ensure all necessary action is taken and funding is obtained to address EPS program performance in a manner that meets the requirements of http://vaww.hefp.va.gov/resources/eps-sanitation-procedure-guide http://vaww.hefp.va.gov/resources/eps-sanitation-procedure-guide http://vaww.hefp.va.gov/environmental-programs-service

Federal, State and local statutes and regulations; applicable Executive Orders; and VA and VHA directives.

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

(1) Ensuring adherence to EPS policies, memoranda, guides and manuals as outlined on the EPS intranet website located at http://vaww.hefp.va.gov/environmental-programs-service. NOTE: This is an internal VA website that is not available to the public.

(2) Coordinating with the Assistant Under Secretary for Health for Support, Executive Director, Health Care Environment and Facilities Programs and VISN Directors to ensure all necessary action is taken and funding is obtained to address EPS program performance in a manner that meets the requirements of Federal, State and local statutes and regulations; applicable Executive Orders; and VA and VHA directives.

(3) Ensuring data requests, reports and program site review actions generated by the Director, EPS are completed as requested.

(4) Ensuring program functions associated with EPS are fully implemented to ensure a safe, sanitary and aesthetically healing environment.

(5) Ensuring VA medical facility EMS staff are competent to carry out the duties and responsibilities of the EPS program.

(6) Ensuring EMS functions are resourced with the necessary training, staffing, space and equipment to maintain an effective program.

3. TRAINING

There are no formal training requirements associated with this directive.

4. RECORDS MANAGEMENT

All records regardless of format (e.g., paper, electronic, electronic systems) created by this directive shall 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 must be addressed to the appropriate Records Officer.

5. BACKGROUND

a. EPS provides direction and operational guidance for the scopes of service aligned to health care environmental programs at VA medical facilities. EPS develops and implements standards, services and initiatives to spread best practices to improve the performance of EPS programs and maximize the effectiveness of VA medical facility operations. The various scopes of service aligned are individually critical but intentionally integrated to ensure VA medical facilities comprehensively maintain a safe, clean, functional healing environment in an operationally effective condition. EPS is where VHA’s technical subject matter experts for environmental services are housed.

b. EPS provides guidance, templates, resources and tools to VA medical facilities that serve as the foundation for operational effectiveness and ensure program-specific excellence located on the EPS intranet website at http://vaww.hefp.va.gov/environmental-programs-service. NOTE: This is an internal VA website that is not available to the public. The effectiveness of these programs directly impacts the image of VA medical facilities, as the quality of patient care is often based upon the appearance and cleanliness of the environment. Clarifying expectations, optimizing productivity and implementing data-driven decisions are crucial to ensure EPS programs are carried out in a manner that enhances the overall Veteran experience. EPS fulfills its oversight and policy responsibilities through the following scopes of service:

(1) Health Care Environmental Sanitation Program. The Health Care Environmental Sanitation Program outlines the procedures, reporting requirements and operational guidelines pertaining to health care sanitation within VA medical facilities.

These requirements include, but are not limited to, cleaning and disinfecting processes and procedures, waste handling, floor care, grounds maintenance, utilization of various management software platforms, infection prevention and control, chemical efficacy, equipment selection, standardization, task frequency driven staffing, quality assurance monitoring, employee competency development and contractual services. NOTE: For additional information about the Health Care Environmental Sanitation Program, see VHA Directive 1850.01, Health Care Environmental Sanitation Program, dated March 29, 2023.

(2) Interior Design Operations and Management Program. The Interior Design (ID) Operations and Management Program provides the requirements for establishing and maintaining an ID Program within VA medical facilities. These requirements include, but are not limited to, planning and standardization, programming, project development, budget, customer service, training and affiliations. The ID Program ensures materials, finishes, furniture and accessories are suitable for the health care environment and comply with VA standards. NOTE: For additional information about the ID Program, see VHA Directive 1850.05, Interior Design Program, dated January 11, 2023.

(3) Waste Management and Recycling Program. The Waste Management and Recycling Program provides the requirements for managing municipal solid waste, regulated medical waste and recycling; reporting requirements for all waste categories into VHA supported database; tracking waste trends and diversion rates and collaborating with other VA and VHA organizations on waste initiatives. NOTE: For additional information about the Waste Management and Recycling Program, see VHA Directive 1850.06, Waste Management Program, dated July 22, 2022.

(4) Textile Care Management Program. The Textile Care Management Program outlines the procedures, operating guidelines and reporting requirements for textile processing, distribution and textile care facility operations throughout VHA. These requirements include, but are not limited to, employee uniform issuance, linen committee oversight, textile inventory and control, standardization and textile production guidelines and procedures. NOTE: For additional information about the Textile Care Management Program, see VHA Directive 1850.03(1), Textile Management Services, dated April 4, 2017; VHA Directive 1850.04(1), Employee Uniforms, dated April 6, 2017;

and VHA Directive 1850.07(1), Textile Care Processing Facility Operation, dated April 5, 2017.

(5) Integrated Pest Management Program. The Integrated Pest Management (PM) Program provides the requirements for establishing and maintaining a comprehensive PM plan with emphasis on surveillance, exclusion and monitoring, as well as minimizing pesticide use within VA medical facilities. These requirements include, but are not limited to, maintaining an effective pest management plan, ensuring proper licensure, overseeing pesticide application and fulfilling PM reporting requirements. NOTE: For additional information about the Integrated Pest Management Program, see VHA Directive 1850.02, Pest Management Operations Program, dated December 22, 2022.

(6) Comprehensive Environment of Care Program. The Comprehensive Environment of Care (CEOC) Program provides the requirements to define, standardize, monitor, review, maintain and improve the environment in which health care services are provided throughout VHA. The scope of CEOC services includes all disciplines as outlined within The Joint Commission Environment of Care standards.

EPS responsibilities are to monitor CEOC program elements as they relate to EPS programs and environmental management at the VISN and VA medical facility levels.

NOTE: For additional information about the Comprehensive Environment of Care Program, see VHA Directive 1608, Comprehensive Environment of Care Program, dated June 21, 2021.

6. REFERENCES

a. 38 U.S.C. § 7301(b).

b. 42 U.S.C. § 4332.

c. VHA Directive 1608, Comprehensive Environment of Care Program, dated June 21, 2021.

d. VHA Directive 1850.01, Health Care Environmental Sanitation Program, dated March 29, 2023.

e. VHA Directive 1850.02, Pest Management Operations Program, dated December 22, 2022.

f. VHA Directive 1850.03(1), Textile Management Services, dated April 4, 2017.

g. VHA Directive 1850.04(1), Employee Uniforms, dated April 6, 2017.

h. VHA Directive 1850.05, Interior Design Program, dated January 11, 2023.

i. VHA Directive 1850.06, Waste Management Program, dated July 22, 2022.

j. VHA Directive 1850.07(1), Textile Care Processing Facility Operation, dated April 5, 2017.

k. Environmental Programs Service Standard Operating Procedures.

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

l. Environmental Programs Service Intranet. http://vaww.hefp.va.gov/environmental-programs-service. NOTE: This is an internal VA website that is not available to the public.

http://vaww.hefp.va.gov/resources/eps-sanitation-procedure-guide