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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%.