Our Services

Healthcare Environment Institute Services

Inspiring High Reliability in Healthcare

Survey Preparation and Readiness


General Acute Care Hospital and Long-Term Care State Licensing

HEI professionals have extensive working knowledge of the provisions and requirements within the California statues (Health & Safety Code), and regulations (Title 22 Division 5), surveys and documents that apply to obtaining and renewing GACHs and SNF licenses. They will provide expert guidance on survey preparedness, building features, assembling evidence of compliance, 2567 POC preparation, and state (CAB) applications.

Physical Environment

Accreditation for Hospitals and Ambulatory Surgical Units

Collectively, the 3 HEI Partners have provided leadership and guidance to assist facilities in over 75 successful accreditation surveys, and have developed nationally published TJC survey prep guidelines. We will assist with interpretation and application of accreditation Standards, preparation for surveys, site surveys, building inspections and mock tracers, risk assessments and written Evidence of Standards Compliance.

CMS Conditions of Participation

CMS Conditions of Participation/Coverage

HEI processionals understand the interplay and arrangement of CMS Certification for Medicare/Medicaid program eligibility, associated federal regulatory conditions, deemed status and the standards of approved Accrediting Organizations. HEI will help navigate through the various provisions and structure compliance programs, on a bedrock of safety, quality and the intent of the legal language.

Management Plan

Management Plans, Program Evaluations, and Policies/Procedures

HEI consultants are equipped to review, revise and/or develop compliant, useful written management plans, policies, procedures and assessments. HEI consultants have served on editorial advisory boards for ASHE, Bureau of National Affairs and Opus Communications.

Occupational Health and Safety


OSHA Regulations Compliance

We will develop written programs, policies and provide specialized training designed to better ensure compliance with federal and state Occupational Health & Safety Regulations, to include: Mechanical ventilation; Aerosolized Transmissible Diseases; Bloodborne Pathogen Program; Indoor Air Quality/Industrial Hygiene; Hazardous Materials Management; Control of Hazardous Energy (Lock Out/Tag Out).

Workplace Violence Prevention

Workplace Violence Prevention, Training and Plan Development

HEI consultants will work with the organization’s security departments to conduct a comprehensive assessment to gauge your facility’s risk of violence. HEI will assist in the development and implementation of environmental and administrative controls to include effective procedures of identifying, evaluating, and correcting workplace violence hazards, designing and implementing training, and reporting and investigating workplace violence incidents.

Active Shooter Training

Active Shooter Training, Written Plan Development and Drills

HEI professionals will assist develop and provide customized written plans and procedures, as well as training to help demonstrate the three recommended tactics to use to keep yourself and others safe during an active shooter incident—run, hide, and fight.

Emergency Management

Emergency Management

Featured speakers at California OES conferences, we will assist with the design of the facility’s Hazard Vulnerability Analysis and the development written comprehensive emergency management program that utilizes an all-hazards approach and is aligned with NFPA® 1600: Standard on Continuity, Emergency, and Crisis Management and NFPA® 99: Health Care Facilities Code.

HEI will organize and facilitate exercises to train staff and to test emergency operations plan and response procedures.

Patient Safety

Survey Preparation and Readiness

Fall Prevention Systems

Fall prevention involves managing a patient’s underlying fall risk factors and optimizing the facility’s physical design and environment.

The HEI Team’s Chief Medical Officer provides clinical expertise and a unique approach to blending direct patient care and environmental factors to develop, implement, and sustain a pragmatic, effective fall prevention program.

National Patient Safety Goals

National Patient Safety Goals

We will assist and provide consultation in the development of effective, sustainable plans, programs and training to address The Joint Commission® published National Patient Safety Goals (NPSG) that pertain to the physical environment.

These include NPSG 06.01.01 – Make improvements to ensure that alarms on medical equipment are heard and responded to on time. NPSG.15.01.01 – Identify patient safety risks; reduce risk of suicide.

Root Cause Analysis

Root Cause Analysis / Comprehensive Systematic Analysis

The HEI Team will provide assistance and expertise with conducting comprehensive systematic analysis to identify the causal and contributory factors to any significant event. A root cause analysis, for example, is one common type of comprehensive systematic analysis. Our Chief Medical Officer brings a high level of clinical and direct patient care knowledge to this critical evaluation process.

NFPA Code Compliance

The NFPA series is a compendium of  written Codes  originally developed by the National Fire Protection Association to provide  documents addressing all aspects of fire protection and prevention, that aligns with other nationally recognized industry codes and standards.

HEI consultant services include  reviewing life safety blueprints and  drawings, reviewing, revising and/or developing policies and plans, and conducting facility site assessments to better ensure compliance with the myriad of NFPA Codes applicable to healthcare facilities, including but not limited to:

    • NFPA 25 – Standard for the Inspection, Maintenance and Testing of Water-based Fire Protection Systems
    • NFPA 30 – Flammable and Combustible Liquids Code
    • NFPA 70E – Standard for Electrical Safety n the Workplace
    • NFPA 72 – National Fire Alarm and Signaling Code®
    • NFPA 99 – Health Care Facilities Code (HCFC)- Piped Medical Gas/Mechanical Ventilation/Compressed Gases/Electrical Systems/Emergency Management
    • NFPA 101 Life Safety Code®
    • NFPA 110 – Standard for Emergency and Standby Power Systems
NFPA Code Compliance

Physical Environment

Physical Environment

Facility Inspections

We have the expertise to provide thorough, documented facility inspections/tours, mock Tracer assessments, and Environmental Compliance Audits.

AHA/ASHE published our Internal Environmental Audit Plan.



Our HEI experts have extensive experience in planning, opening, licensing and accrediting new hospitals, renovations, and rehabilitations

We can help navigate through applicable building code requirements, and advise on substantial project completion, inspections, and occupancy approvals with governmental building safety and licensing representatives.

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Other Areas of Expertise include:

  • Water Quality – Waterborne Pathogens
  • Air Quality
  • Industrial Wastewater
  • Regulated Waste Management
  • Sterile Rx Compounding Environments (USP 797)

Interim Leadership

Interim Leadership

Our HEI experts will fill your management/leadership vacancies on a temporary basis to allow your operations to continue while you select or mentor the most suitable candidate for your organization’s culture and goals.

HEI can also assist in the recruitment and selection process and offer interview questions covering  Leadership,  Technical and Legal knowledge, Performance Improvement and Operations.

HEI can cover the following interim positions:

      • Director Level/Manager Level
      • Facilities Services Director
      • EH&S Director
      • Security Director
      • Vice President of Support Services

Healthcare Environment Institute

Inspiring High Reliability in Healthcare