Why Staying Current with Code Updates is Critical for Health Care Facilities

Evelyn Dougherty • March 23, 2026

Why staying current with code updates is critical for health care facilities

Here are seven reasons facilities professionals should get involved in the code development process

By Chad E. Beebe reprinted from HFM Magazine Oct 13, 2025

 

In the complex world of health care facilities management, staying up to date with the latest codes and standards isn’t just a best practice, it’s essential. While the Centers for Medicare & Medicaid Services (CMS) often lags in updating its Conditions of Participation (CoPs) sometimes by a decade or more, there are compelling reasons why health care professionals should actively engage with and apply the most current codes available.



1. ASHE Advocacy: A voice for practical, patient-centered code development

The American Society for Health Care Engineering (ASHE) plays a vital role in shaping the codes that govern health care facilities. ASHE’s Advocacy Team and members work tirelessly to address issues as they arise, whether it’s correcting misinterpretations, removing outdated requirements, or introducing new provisions that reflect real-world challenges. Our success stems from a deep understanding of the health care environment and a commitment to improving patient care through practical, feasible code changes.

Over the past decade, ASHE has tracked more than 600 code changes that positively impact health care environments. These include clarifications, conflict resolutions and proactive updates that reflect the evolving needs of facility managers. Without ASHE’s involvement, code updates would be riddled with impractical requirements and costly surprises.


2. Embracing new technology with updated codes

Technology in health care evolves rapidly, and outdated codes often fail to address new innovations. This leads to confusion among authorities having jurisdiction (AHJs), who may interpret the absence of guidance in varying ways. For hospital systems operating across multiple jurisdictions, this inconsistency can create significant operational burdens.

Take, for example, flexible medical gas tubing, a technology not addressed in the 2012 editions of the National Fire Protection Association’s NFPA 101, Life Safety Code, and NFPA 99, Health Care Facilities Code. However, these are the codes referenced in CMS’s CoPs. Without updated codes, facilities would not be able to use this product. Fortunately, CMS granted a categorical waiver, allowing consistent use nationwide. This underscores the importance of updated codes in enabling safe, efficient adoption of new technologies.


3. New practices require clear guidance

Some may assume that if a practice isn’t addressed in a code, it’s fair game. Unfortunately, that’s rarely the case. In reality, AHJs determine compliance, and without clear code language, interpretations vary widely. This sometimes leads to unsafe or overly burdensome requirements.

A prime example is the introduction of hybrid operating rooms. In the absence of specific guidance, many AHJs combined requirements for operating and imaging rooms, resulting in unnecessary mandates like access to toilet facilities and increased risks from mixing staff roles. Updated codes help avoid these pitfalls by providing clear, tailored guidance.


4. Newer codes offer solutions when older ones fall short

Even when CMS mandates older code editions, newer codes can offer valuable guidance in areas not previously addressed. For instance, microgrids, which are critical for energy resilience, aren’t covered in the 2012 codes. However, newer editions provide frameworks for their safe and effective implementation. Only those familiar with current codes can identify and leverage these opportunities.


5. ASHE serves a diverse membership beyond CMS requirements

Not all ASHE members are bound by CMS’s outdated codes. Many operate under state or private regulatory bodies that adopt current editions. ASHE supports these members by offering educational resources and frequent updates, ensuring they remain informed and compliant with the latest standards.


6. Code update presentations: Informing and engaging the community

ASHE’s conferences and code update presentations serve dual purposes: educating attendees and gathering feedback for future advocacy. As the gap between adopted and current codes widens, member engagement becomes even more critical. Without firsthand experience of new code impacts, feedback dwindles making it harder for ASHE to advocate effectively.


7. Preventing unwanted surprises through continuous involvement

Code development involves many stakeholders, each with their own interests. ASHE ensures that proposed changes are practical, feasible and ultimately beneficial to patient care. Our advocacy emphasizes simplicity, clarity and consistency, which makes codes easier to interpret and apply.


ASHE also considers financial implications. For example, we successfully opposed a proposal to the International Building Code requiring equivalent underground space in hurricane-prone areas. While well-intentioned, the proposal ignored the logistical and safety challenges of relocating patients underground, as well as the prohibitive costs.

ASHRAE 170 2025 Edition Ventilation rqmnt changes

October 15, 2026
The memo specifies the roles of state and federal agencies versus accrediting organizations when facilities temporarily lose their Medicare-deemed status May 4, 2026 | Leah Hummel On March 25, the Centers for Medicare & Medicaid Services (CMS) issued revised memo QSO-18-12-Deemed Providers/Suppliers to clarify the roles of accrediting organizations (AOs) and state survey agencies (SAs) when a provider’s or supplier’s Medicare-deemed status is temporarily removed due to condition-level noncompliance. CMS may temporarily remove deemed status when an SA or federal survey team identifies condition-level deficiencies. When this occurs, the CMS location formally notifies the organization and places it under the jurisdiction of the state survey agency, rather than the AO. The revised memo reinforces that accrediting organizations must suspend or postpone Medicare deeming recertification surveys while deemed status is removed. Importantly, CMS clarifies that if a provider’s regular 36-month accreditation cycle lapses during this period, the AO will not be cited as late or noncompliant for missing the survey. CMS also notes that while non-deeming accreditation surveys are not prohibited during state oversight, CMS recommends postponing these activities to avoid confusion or duplication while the organization works toward regaining compliance. The revised guidance also provides additional clarification on complaint investigations, emphasizing the need for coordination between SAs and AOs. During temporary removal of deemed status, the SA maintains primary responsibility for investigating complaints, while keeping the AO appropriately informed. Why this matters for facilities For hospitals and health systems, including facilities and physical environment leaders, the memo underscores the importance of understanding who has regulatory authority during periods of noncompliance. While temporary loss of deemed status due to a state survey agency or federal team survey does shift oversight of follow-up activities it does not penalize organizations or their AOs for unavoidable survey delays while corrective actions are underway. Leah Hummel, AIA, CHFM, SASHE, CHC, CHOP, is senior associate director of ASHE Regulatory Affairs 

CMS Clarifies Oversight

October 15, 2026
In the June 3, 2026 article by Matthew Daniel in Health Facilities Management, entitled Are Joint Commission environment of care management plans still required?, Matt explains many good reasons why facilities should consider keeping their management plans even though since January 2026, they are no longer required (except for ambulatory care). He explains that “while the formatting of its standards would change, JC made it clear that the requirements themselves would not and that hospitals and CAHs should not make changes to their existing programs since they are still held to CMS’s requirements.” “In its January 2026 issue of Environment of Care News, JC stated that hospitals and CAHs are no longer required to have environment of care management plans for each of the … physical environment areas. The newsletter stated that “except for ambulatory care organizations, Joint Commission no longer requires a written management plan or separate plans addressing each of the physical environment functional areas: safety, security, hazardous materials and waste, utilities, and medical equipment.” JC further clarified that the only management plans that will be evaluated during a survey will be the organization’s fire response plan, water management plan and emergency operations plan.” Mr. Daniel gives many good reasons for keeping elements of the management plans including the fact that “ the management plans are used by organizations to not only provide a roadmap to all of the required aspects of the standards for each respective plan but also to ensure that any supporting policies or procedures also are incorporated into the program — whether it’s an internal policy or procedure or a requirement of the accreditation process.” He concludes his article by stating, “While the requirement for environment of care management plans is not contained in JC’s new Physical Environment Chapter for hospitals and CAHs, the foundation of organizational compliance within the physical environment is still required, and continuing the process of evaluating and updating these management plans provides a path to help ensure continuous compliance.”  For a copy of the full article see Matthew Daniel . Matthew Daniel, CHSP, is a senior consultant at Daniel Consulting LTD. He can be reached at matthew.daniel@danielconsulting.net.

Keeping EoC Mgt Plans

October 15, 2026
In the June 3, 2026 article by Matthew Daniel in Health Facilities Management, entitled Are Joint Commission environment of care management plans still required?, Matt explains many good reasons why facilities should consider keeping their management plans even though since January 2026, they are no longer required (except for ambulatory care). He explains that “while the formatting of its standards would change, JC made it clear that the requirements themselves would not and that hospitals and CAHs should not make changes to their existing programs since they are still held to CMS’s requirements.” “In its January 2026 issue of Environment of Care News, JC stated that hospitals and CAHs are no longer required to have environment of care management plans for each of the … physical environment areas. The newsletter stated that “except for ambulatory care organizations, Joint Commission no longer requires a written management plan or separate plans addressing each of the physical environment functional areas: safety, security, hazardous materials and waste, utilities, and medical equipment.” JC further clarified that the only management plans that will be evaluated during a survey will be the organization’s fire response plan, water management plan and emergency operations plan.” Mr. Daniel gives many good reasons for keeping elements of the management plans including the fact that “ the management plans are used by organizations to not only provide a roadmap to all of the required aspects of the standards for each respective plan but also to ensure that any supporting policies or procedures also are incorporated into the program — whether it’s an internal policy or procedure or a requirement of the accreditation process.” He concludes his article by stating, “While the requirement for environment of care management plans is not contained in JC’s new Physical Environment Chapter for hospitals and CAHs, the foundation of organizational compliance within the physical environment is still required, and continuing the process of evaluating and updating these management plans provides a path to help ensure continuous compliance.”  For a copy of the full article see Matthew Daniel . Matthew Daniel, CHSP, is a senior consultant at Daniel Consulting LTD. He can be reached at matthew.daniel@danielconsulting.net.