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HFAP revises emergency management standards

HFAP has revised its Emergency Management standards in our Acute Care, Critical Access, and Ambulatory Surgical Center manuals to be in compliance with “Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, Final Rule.” The chapter is the only change to the manuals.

The updated requirements include the need for:

  1. A written Emergency Operations Plan (EOP)
  2. Conducting a Hazards Vulnerability Analysis (HVA)
  3. Policies and procedures that address evacuation, staff responsibilities, transportation, communication, use of volunteers, and more
  4. Emergency testing (disaster drills) and evaluation twice per year

Acute Care Hospitals, Critical Access Hospitals, and Ambulatory Surgical Centers must implement and be in full compliance by November 15, 2017. This is the same date that The Joint Commission and CMS’ emergency requirements will go into effect. 

CMS withdraws proposal to have AOs post survey reports online

A proposal by CMS to have accrediting organizations (AOs) post the details of survey reports online was withdrawn by the agency, not because of negative comments — although there were plenty — but because, well, it might be prohibited under federal law.

CMS first made the proposal in April, tucking it into the latter pages of the always-long proposed on changes to the Inpatient Prospective Payment System (IPPS) for the upcoming fiscal year.

The proposal was to have AOs post final survey reports online within 90 days that the same information is available to the hospital or other health care organization, including details of all initial and recertification surveys at that provider in the prior three years, as well as the accepted plans of correction (PoCs).

AOs now post only whether an organization is accredited or not, and do not make details of findings public.

CMS argued its proposal was to promote transparency in health care, and noted that it posts its own  survey reports online. But critics responded that the CMS reports are made available in a hard-to-read spreadsheet and that the federal agency was responsible for far fewer surveys at health care organizations that were often surveyed only after a complaint (IJC 5/1/17).

In public comments to CMS concerning the proposal, The Joint Commission said that requiring survey details be made public would have “chilling effect” on efforts to raise standards of quality. Dr. Mark R. Chassin, president and CEO of The Joint Commission, wrote: “There will be a race to the bottom on quality as health care organizations seek out oversight bodies that will report on the least number of standards comparable to the Medicare requirements. This may also lead to a growth in non-accredited facilities that will then be surveyed at taxpayer expense and with fewer oversight visits.”

Other groups similarly weighed in against the proposal, and offered alternatives. In the end though, it was shot down because it might potentially be prohibited.

In the IPPS final rule published Aug. 2, CMS noted that its proposal included revising the federal regulations overseeing Medicare to incorporate the requirement for AOs to post report details publically.

“Section 1865(b) of the Act prohibits CMS from disclosing survey reports or compelling the AOs to disclose their reports themselves. The suggestion by CMS to have the AOs post their survey reports may appear as if CMS was attempting to circumvent the provision of section 1865(b) of the Act. Therefore, this provision is effectively being withdrawn.” — A.J. Plunkett (aplunkett@h3.group)

Resource:

Today the Joint Commission and HFAP start surveying to the 2012 Life Safety Code®

As of today, CMS, The Joint Commission, and HFAP will be surveying hospitals to the 2012 Life Safety Code® (LSC). The LSC was adopted by CMS in June, with some of the big changes required under the final rule including:

  • Facilities located in buildings taller than 75 feet are required to install automatic sprinkler systems within 12 years after the rule’s effective date.
  • Facilities are required to have a fire watch or building evacuation if their sprinkler systems is out of service for more than 10 hours.
  • Greater flexibility for long-term care (LTC) facilities in what they can place in corridors. LTC facilities will be able to include more home-like items such as fixed seating in the corridor for resting and certain decorations in patient rooms.
  • Fireplaces will be permitted in smoke compartments without a one-hour fire wall rating, which makes a facility more home-like for residents.
  • For ambulatory surgical centers, alcohol-based hand rub dispensers now may be placed in corridors to allow for easier access.
  • Fire watches must be continuous, “constantly circulating” through impaired
  • All side-hinged swinging fire doors must be tested annually.
  • Once every five years, an internal inspection of sprinkler pipe is required.
  • Fire hose valves must be inspected quarterly and tested annually/every three years, depending on size.
  • 1-hour fire-rated barriers are required between non-sprinklered construction areas and occupied egress areas.

Visit the Federal Register to see the full list of changes

Click here to learn more about the updated standards and policies The Joint Commission and HFAP have made.

 

HFAP releases 2017 CAH, ASC prepublication manuals

HFAP this week released its prepublication manual for critical access hospital (CAH), and ambulatory surgical center (ASC) surveys. The manuals have been updated to include requirements of the 2012 Life Safety Code® (LSC), which was recently adopted by CMS.  The CMS adoption of the 2012 LSC went into effect in July, and the new requirements will go into effect for HFAP facilities on November 1, 2016.

The changes to the accreditation requirements for CAHs are in Chapters 3, Chapter 14, and Chapter 17. They also include a CAH Facility Demographic Report and a HFAP-CMS Crosswalk.

The changes for ASCs are in Chapter 5, and include a ASC Facility Demographic Report.

HFAP releases prepublication standards manual

HFAP this week released its prepublication manual for acute care hospitals. The manual has been changed to include requirements of the 2012 Life Safety Code® (LSC), which was recently adopted by CMS.  The CMS adoption of the 2012 LSC went into effect in July, and the new requirements will go into effect for HFAP facilities on November 1, 2016.

The changes to the accreditation requirements are in Chapters 9, 11, and 13 of the manual and can be read here.

HFAP will hold off on assessing certain Life Safety Code standards

Earlier this year, CMS announced that it was finally adopting the 2012 Life Safety Code [LSC], which went into effect on July 5. However, until CMS had approved modification to HFAP’s manuals the accreditor isn’t allowed to enforce the new LSC requirements. CMS has announced that the new requirements will go into effect on November 1, 2016.

This means for the next four months, HFAP facilities will not be assessed on the following requirements:

  • Fire watches must be continuous, ‘constantly circulating’ through the impaired area.
  • Maximum 4 inch projection into corridors.
  • All side-hinged swinging fire doors must be tested annually.
  • Once every 5 years, an internal inspection of sprinkler pipe is required.
  • Fire hose valves must be inspected quarterly and tested annually/3 years, depending on size.
  • 1-hour fire rated barriers are required between non-sprinklered construction areas and occupied egress areas.

HFAP releases updated 2015 Acute Care Manual

On June 10, the Healthcare Facilities Accreditation Program (HFAP) released the second version of its 2015 Acute Hospital Care Final Standards. The updated manual supersedes the prepublication standards that the accreditor had published on January 25. All of the prepublication standards released this January were approved as written except for Standard 25.00.05 Management, which clarifies the expectations and job description of the pharmacy director. The changed text now reads: “The Pharmacy Director must meet the qualifications established by the Medical Staff.  It is NOT required that the Pharmacy Director undergo the Medical Staff Credentialing and Privileging process.”

The updated manual will go into effect on September 1, 2016 and includes 11 revised pharmacy related standards:

  1. Standard 25.00.00 Condition of Participation: Pharmaceutical Services
  2. Standard 25.00.01 Pharmacy Services
  3. Standard 25.00.04 Pharmacy Management & Administration
  4. Standard 25.00.05 Management
  5. Standard 25.01.01 Medication Control & Distribution
  6. Standard 25.01.02 Supervision of Pharmacy Activities
  7. Standard 25.01.03 Security of Medications
  8. Standard 25.01.07 Inventory Management System:
  9. Standard 25.01.09 Automatic Stop Medication Orders
  10. Standard 25.01.12 Informational Resources
  11. Standard 16.01.01 Preparation and Administration Drugs

HFAP has also published a new crosswalk, Acute Care Manual 2015 v2 New Standards to Old Standards. Those with questions about the 2015 version 2 Acute Care Hospital manual should email info@hfap.org.

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HFAP publishes top-cited deficiencies of 2012-2015

The Healthcare Facilities Accreditation Program (HFAP) recently released information on top-cited deficiencies for acute care hospitals  , clinical laboratories, critical access hospitals, and ambulatory surgical centers.

Covering data from 2012-2015, the documents identify each deficiency by its HFAP standards number and its corresponding Code of Federal Regulations number. The documents also include graphs showing the percentage of Conditions of Participation cited by year. For acute care hospitals, the most-cited deficiencies were standards 15.01.09 (exercise of patient rights) with 54%, 10.01.01 (content of the record) with 40%, and 30.00.09 (standards of practice) with 37%.