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HFAP review offers key compliance tips on toughest EOC, Life Safety problems


August 1, 2019

By A.J. Plunkett (aplunkett@decisionhealth.com)

With the physical environment and infection control topping the list of standards most often cited, look for HFAP surveyors to seek better documentation of inspections and testing, along with improvements in fire safety and suicide prevention.

HFAP surveyors also will be looking for increased follow-through on a hospital’s evaluation and implementation of organizational policies.

The Healthcare Facilities Accreditation Program, or HFAP, recently posted its 2019 HFAP Quality Review on its website. It is recommending healthcare organizations use the report to evaluate their compliance performance against the trends identified in the review.

According to the HFAP announcement, the review shows that “incomplete processes and insufficient documentation remain the main concerns cited during accreditation surveys. To prevent these citations, HFAP recommends healthcare teams review standards by assessing existing policy, implementation, evaluation and reporting practices to ensure all requirements are fulfilled.”

The quality review not only outlines the most deficient standards for hospitals, but also comments on the problems most often behind the citations, with examples and tips for compliance.

Physical environment, IC top citations

Among acute care hospitals surveyed by HFAP in 2018, 68% faced a Condition of Participation (CoP)–level deficiency regarding two standards: Standard 11.00.01, on providing building safety in Physical Environment, and 07.01.02, requiring leadership and planning in Infection Prevention. A CoP-level deficiency leads to a follow-up survey to check that compliance has been corrected.

Tips for compliance are plain and to the point.

Hospitals failing under the Physical Environment standard—which could include ligature risk problems as well as some Life Safety violations—are advised to “read and understand each standard under Chapter 11 to be sure you have a process and the documentation required by the standard,” according to the review.

HFAP also advises hospitals to follow their own rules and procedures. “Be sure that patient safety risk assessments are written and used per policy.”

Hospitals failing under the Infection Prevention standard are advised to “teach staff to recognize infection control concerns and report to the infection control practitioner. Effective cleaning cannot occur where rust, torn furniture, walls and floor divots, and separating in flooring are noted.”

And in a note hospital compliance officers everywhere might recognize, regardless of accrediting organization, HFAP reviewers warn: “Cardboard boxes cannot be stored in the hospital due to the risk of vermin.”

Overall, the review is broken into four parts: Standards within the Physical Environment, Administrative Oversight, Patient Care and Safety, and Life Safety, which comprises the bulk of the problems as has been the case with all accrediting organizations for several years.

Within the first three categories, only 11 standards were considered problematic in at least 10% of HFAP hospitals surveyed in 2018, and of those only four stood out as problems for 40% or more of hospitals. Besides the two already mentioned, the other standouts were Physical Environment standard 11.03.03, on ventilation, light, and temperature controls, and Administrative Oversight standard 01.01.23, on quality monitoring of contractors.

For 47% of surveyed hospitals, the majority of problems identified under Physical Environment 11.03.03 were related to incorrect air pressure relationships that could lead to infection control issues, pushing those citations to condition-level problems, say reviewers. Examples of problems included:

  • Negative air pressures in spaces adjoining operating rooms (OR)
  • Clean supply rooms with negative pressures relative to adjoining areas
  • Dust and rust on air vents in the emergency department and kitchen
  • Missing daily temperature and humidity logs in required areas
  • ORs with equipment specific to 30% relative humidity (RH) but with an RH of 20% and no documentation of a risk assessment to support the RH reduction, as required by CMS

Compliance tips include having policy and documentation to verify air pressure relationships are checked as needed in critical areas and having a means to verify HVAC air vents are maintained in a clean condition.
“Remember that high-airflow—especially in ORs—can collect a lot of lint from scrubs and linen,” say HFAP reviewers. “Ever notice that lint build-up is the color of your scrubs?”

C-suite under scrutiny too

Under Administrative Oversight, standard 01.01.23 on contractor monitoring makes the hospital’s governing body “ultimately responsible for all services provided whether by employees, formal contract, joint ventures, informal agreements, shared services, or lease arrangements,” says the review.

Half of the hospitals surveyed by HFAP in 2018 failed that requirement.

At one hospital, during a review of the quality assurance and performance improvement (QAPI) program, “it was noted that five contracted services failed to report data to the QAPI program and therefore did not report data to the Governing Body.” The services included laundry, biohazard waste, the medical director, a confidential shredding service, and dialysis.

At another hospital, “there are 155 agreements for services for which no documentation exists demonstrating that an evaluation has been completed.” Another facility had a process for evaluation, “but the mechanism did not include the use of relevant and meaningful indicators to assess the quality of services rendered.”

To comply with this standard, hospitals are advised to develop a written policy describing the evaluation process for contracted services and ensuring that evaluations “travel through the quality review process up to the governing body.”

Life Safety leads numbers

The largest number of problems were identified under 33 Life Safety chapter standards, although only 11 of those were consistently identified at 40% or more of hospitals surveyed. Those 11 standards, with compliance tips from HFAP experts, include:

13.01.05, Means of Egress (50% of hospitals surveyed): Examples included multiple doors leading to a public area in the middle of the facility that were not safe exits in the event of a fire and didn’t have signs saying “NO EXIT,” as well as exit signs that were not illuminated at the entrance. A document review showed the monthly inspection was only of battery-powered exit signs and not all exit signs.

Compliance tips—Use facility rounding to manage recurring compliance issues and “do not believe or portray these issues as insignificant: coworkers will believe the same.” Also follow-up and train, and ensure staff are “well-versed in identifying egress compliance issues.”

13.02.02, Fire Detection Systems, fire alarm testing (56%): Reviewers note fire alarm system testing was not compliant “far more frequently than system installation and maintenance.” Examples included a report that six devices or dampers in air handling units were listed as failing to alarm during tests, but the hospital couldn’t clarify what the issues were or if they had been corrected. Water flow and tamper switches were tested annually instead of semi-annually as required, and the heat and duct detectors installed didn’t match testing documentation.

Compliance tips—Review testing requirements as set out by the NFPA and HFAP; verify that documentation reflects testing and provides evidence of correction and retesting. “Since these activities cannot be witnessed by surveyors, the testing documentation is legal proof and evidence of how you performed an activity and the results of that activity.”

13.03.01, Fire Suppression Systems, water-based system installation and maintenance (47%): Installation problems most often involved items stored so that they blocked the spray from fire sprinkler heads. Examples included a sprinkler head covered with what appeared to be paint and sprinkler heads in patient room closets installed within six inches of the shelves.

13.03.02, Fire Suppression Systems, testing and inspection (53%): Examples included a hospital unable to show documentation of monthly control valve and pressure gauge inspection tests, and another facility that could not show evidence of monthly inspection of fire sprinkler control valves.

Compliance tips—Review the testing requirements and verify that testing documentation accurately reflects testing activities; follow through on deficiencies, providing evidence of correction and retesting to compliance conditions.

13.04.01, Fire Safety Systems, fire-rated barriers (44%): Here, reviewers state simply: “Whether a fire safety deficiency is observed as a single example or in multiple locations, each observation will be cited.” Examples included unsealed conduits above ceiling grids or the use of expanding foam that did not appear to be tested as a fire-stopping product.

13.04.01, Fire Safety Systems, smoke barriers (41%): Examples included a smoke barrier wall that had been cut open to expose a valve and was left unsealed in a soiled utility room, and unsealed areas round conduits in smoke barrier walls.

13.04.07, Fire Safety Systems, fire-rated door assemblies (50%): Examples included holes left behind when magnetic locks removed from double doors, and a lack of a fire-rating label as required.

13.04.09, Fire Safety Systems, ceilings (59%): Examples were gaps at ceiling tiles and pipes penetrating the ceiling with large gaps in an area formerly used for central sterile processing.

Compliance tips—Review the physical state of rated assemblies and smoke partitions, especially when there is work on above-ceiling systems. Rated doors are high-use items and compliance can change between annual inspections, so be sure “everyone knows to report maintenance issues promptly,” and identify a list of fire-stopping materials and wall repair methods to use “consistently throughout the facility.”

13.05.09, Building Services, utility systems (56%): Reviewers caution that “a process for review and acceptance of compliance testing documentation is required for every piece of evidence that is used to prove compliance.” They advise that rounding processes should include “a review of standards compliance issues that are a result of staff action and attention.” Examples of utility system problems were electrical panels that were missing labels, or missing the “required metal panel cover” altogether.

13.05.10, Building Services, medical gas systems and equipment, maintenance (47%): Medical gas problems included oxygen E-cylinders that were not segregated into full and empty storage, and storage was within five feet of combustibles. In one document review session, medical gas systems had not been tested within the previous year, a violation of the frequency set out in the hospital’s own medical gas testing policy.

Compliance tips—Again, hospitals are advised to review the testing requirements as set out by the NFPA, and to provide adequate documentation that the work is being done. Follow-through and retest, and provide evidence of correction.

13.06.04, Operating Features, Life Safety drawings (44%): Deficiencies found here are always the result of the drawings not matching actual conditions. Examples were areas of buildings with sprinkler coverage that was not identified, as well as floor plans that did not identify furthest travel distance to the exits.

At one hospital, some rooms were identified as being hazardous areas when they actually weren’t. And while these rooms didn’t meet compliance in terms of the hazardous areas they were marked as on the Life Safety drawings, they were compliant for their actual uses. Reviewers note: “You will be surveyed to the greater of what YOU require or what HFAP requires.”

Compliance tips—The drawings serve as a map for surveyors to review and determine compliance at your facility, say HFAP reviewers. Review them regularly and update them when there is a change in room use, or “when non-compliance is discovered and requires correction.” And help yourself by helping whoever is creating or updating your drawings. “Forward a copy of the HFAP standards for life safety drawings to the entity or staff preparing your drawings; many deficiencies could be avoided by providing all elements noted in the HFAP Standard that do not appear on the drawings.”

Find the full 2019 HFAP Quality Review at https://hfap.org/media/Annual_Quality_Report/2019_Quality-Report.pdf.


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