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HFAP reports most-cited standards, suggestions for improvements

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March 1, 2018

The Healthcare Facilities Accreditation Program (HFAP) has released an annual quality report that lists the most commonly cited standards found during its 2016 surveys.

The first annual HFAP Quality Report is being touted by the group as the first of a planned annual compilation and review of data from surveys conducted the prior year — much like the reports that hospitals have come to expect from other accreditors such as The Joint Commission.

Surveys from each HFAP accreditation program are reviewed for noncompliant ratings by surveyors for each standard at acute care hospitals and critical access hospitals (CAH), laboratories, and ambulatory surgical centers (ASC).

According to a written statement from the HFAP board chairs, the report is being provided for three distinct uses: to help prepare for an initial accreditation survey, to prepare for reaccreditation, and to help conduct a mid-cycle self-assessment.

“The myth that accreditation is a cycle of ‘heavy lifting’ that occurs in the months just prior to a survey can be dispelled by shifting your point of view,” wrote HFAP board chairs Jack Egnatinsky, MD, and Lawrence U. Haspell, DO. “Look to accreditation as an ongoing cycle of continuous improvement. With that mindset, this report can be a tool for frequent self-assessment. Rather than waiting to prepare for reaccreditation when the next survey is in sight, use this report with the current standards manual as a framework for regular review of how your facility delivers important aspects of care and maintains the physical environment.”

The report highlights the frequency of deficiencies associated with the healthcare physical environment, including life safety and emergency management. For in-stance, the top five physical environment deficiencies touched on eye-wash stations; building safety issues; fire drills; medical equipment management; and ventilation, light, and temperature controls.

The report also provides common examples from surveyors’ experiences and gives tips for how to improve and achieve compliance.

The information in the report comes from HFAP surveyors’ ratings of compliance with the 2016 standards and their comments describing the nature of any deficiencies found.

Data that is collected during on-site surveys are segmented by type in the report, such as acute care hospitals, CAHs, laboratories, and ASCs.

“Because the physical environment is constantly changing and the relevant standards include ongoing monitoring and maintenance that often is performed or overseen by an engineering department, the high-deficiency standards for emergency management, life safety and physical environment are identified in their own section of this report,” according to the report’s authors.

The report only includes data collected from initial and reaccreditation surveys, and does not include focused surveys or those that were the result of a formal complaint.

Life safety deficiencies
The HFAP quality report is very easy to read, and along with the deficiencies listed, it also lists several suggestions for how hospitals can do a better job of complying. The standards referenced in the report come from Accreditation Standards for Acute Care Hospitals as well as from Accreditation Standards for Critical Access Hospitals and Accreditation Standards for Ambulatory Surgical Centers. In addition, many of the standards are those that may be regulations in-cluded in NFPA 99 or 101, which serve as additional references for life safety requirements in ASCs.

The most-cited standards include:
13.02.01/14.02.01/05.03.07 Fire Alarm Sys-tems–Installation. The deficiencies cited mainly include smoke detectors that were mounted too close to air diffusers, or mounted more than 12 inches below a deck.
Tips for improvement include reading and understanding NFPA 72-2010 fire alarm installation requirements, discussing fire alarm system installation issues with fire alarm contractors, and conducting frequent facility inspections.

13.01.05/14.01.05/05.03.03, 04 Means of Egress–Signage. These citations usually involved “Exit” signs that were not installed where the path of egress was not readily apparent. Also, they involved “No Exit” signs that were not installed where a door may have been confused as an exit. Tips for improvement include conducting a self-inspection of each path of egress, and making sure egress paths are properly marked with “Exit” signs.

13.02.02/14.02.02/05.03.07 Fire Alarm Systems–Testing. In these citations, HFAP found that not all of the devices connected to the fire alarm system were actually tested. In some cases, there was no device inventory identifying a “Pass” or “Fail” decision, or a report was not signed by the technician performing the service, or the report did not reference the correct NFPA standard or edition. Tips for improvement from HFAP include copying Table 14.4.5 from NFPA 72-2010 and making sure your testing contractor tests every component listed that you have in your system. Also, use HFAP standard 13.00.07 as a template to ensure your report has all of the required information.

13.05.09/14.05.09 Utility Systems. These types of citations involved junction boxes above the ceiling that did not have covers. Access to electrical panels and controls may have been obstructed. Tips for improvement include doing your own frequent inspections above the ceiling, and in electrical rooms, looking for items of noncompliance.

13.00.05/14.00.05 Facility Demographic Report (FDR). HFAP found that these citations usually were written when the FDR was not completed properly, such as if there were questions left unanswered. Also, construction types might not have been listed in NFPA vernacular, or occupancy classification was not listed in NFPA vernacular. Tips for improvement include ensuring the person who completes the FDR is qualified to provide the answers, and has a working knowledge of the hospital facility and of the NFPA codes and standards.

13.01.02/14.01.02/05.03.06 Door Locks. Here, doors in the path of egress were locked and did not comply with the Life Safety Code® (LSC). Access-control locks did not have a motion sensor installed on the egress side, and delayed egress locks were installed in buildings that were not fully protected with sprinklers. There may have been inappropriate use of “clinical needs” locks, or a mistaken belief that security overrides the need for safety. Tips for improvement from HFAP include reading and understanding section 19.2.2.2.4 of the 2012 LSC regarding the exceptions that permit certain doors to be locked in the path of egress in a hospital. Also, remember that life safety compliance always overrides security. Do not allow security people to install locks on doors that do not comply with the LSC.

13.04.01/14.04.01 Fire-rated Barriers. Unsealed penetrations in fire-rated barriers usually led to these kinds of citations, HFAP found, as did tops of fire walls that did not always extend to the deck above. Some facilities had patches installed on fire-rated barriers that did not comply with the UL listing. Tips for improvement include establishing an above-ceiling permit program, making sure that every contractor who works above the ceiling receives a permit from the engineering department. Engineering then tracks all work and holds that contractor responsible for filling all unsealed penetrations in rated barriers. In addition, conduct frequent inspections above the ceiling on rated walls, looking for unsealed penetrations and improperly applied patches over holes.

13.06.04/14.06.04 Life Safety Drawings. In this case, drawings did not include all of the required information, or did not accurately reflect as-built conditions. Tips for improvement include contracting with an architect that has experience with healthcare and the LSC to create working drawings of your rated wall system. 

13.04.07/14.04.07 Fire-rated Door Assemblies. In these cases, labels identifying the fire rating were missing or painted over, or the door and frame were not fire-rated. Tips for improvement include conducting annual (or more frequent if necessary) inspections of all fire-rated door assemblies.

13.04.09/14.04.09 Ceilings. Holes and gaps in ceiling were larger than one-eighth inch, and there were some missing ceiling tiles. HFAP says tips for improvement include replacing all missing or damaged ceiling tiles as soon as they are discovered, and do not let a day pass without all the ceiling tiles in place. Also, conduct frequent inspections, and add ceilings to the list of things to inspect.

Physical environment
In addition, the HFAP report found a number of physical environment deficiencies that hospitals should look out for during surveys.

11.01.10/03.01.02 Eye-wash Stations. In these citations, eyewash stations were not tested on a weekly basis, or did not meet ANSI Z358.1-2014 requirements. In other cases, eyewash stations were not located within 55 feet of hazardous materials. Tips for improvement include purchasing a copy of the ANSI Z358.1-2014 standard on eyewash stations and complying with the installation and testing requirements.

11.01.02/03.01.02 Building Safety. HFAP surveyors found ligature risks in behavioral health units without a risk assessment, which is also increasingly a Joint Commission survey hot spot. Rooftop exhaust fans for isolation areas were not marked with biohazard symbols, and dirty ceiling tiles, dirty vents, and cracked walls were found in exam rooms. Trash compactors were found with keys left in the controller. Tips for improvement include conducting frequent inspections of behavioral health units looking for potential ligature risks.

11.04.02/03.04.02 Fire Drills–Quarterly. In these cases, off-site locations did not conduct drills, or fire drills were not conducted on all shifts every quarter.

To improve, HFAP recommends scheduling fire drills once per shift per quarter. Also, stagger the start times for fire drills on the same shift each quarter by two hours.

For more information, and to check out the entire HFAP report, go to https://hfap.org/media/Annual_Quality_Report/2017_Quality_Report.pdf




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