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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.

New job openings

Hello AHAP members,

We’ve received a couple job openings and have been asked if we could share them with the membership in case anyone was interested in pursuing either of them. Please feel free to share amongst your colleagues. Contact information is at the end of the details below.

Job posting #1

Accreditation Manager – Presence Saint Joseph Medical Center, Joliet, Illinois

Lead and manage all aspects of accreditation readiness and regulatory compliance according to the Centers for Medicare and Medicaid Services (CMS), the Illinois Department of Public Health (IDPH), and The Joint Commission.  Provide strategic and tactical guidance to leaders and staff on accreditation readiness and educate personnel about accreditation requirements, implications and changes. Promote coordination and continuous integration of all performance and process improvement initiatives in collaboration with leaders. Coordinate, monitor and provide status report of all Meaningful Use objective measures related to the demonstration of compliance to CMS and other payers. Collaborate with leadership to identify and implement solutions for compliance challenges. Serve as Chair, Hospital Policy and Procedure Committee.

Education and/or Experience

  • Bachelor Degree in business or health care administration
  • 2 years of hospital clinical experience in quality improvement or experience with regulatory agency standards compliance including 2 years project management experience


  • Master’s degree nursing or health care administration or related field
  • Experience with managing and supporting organizational accreditation preparation
  • Business or office automation experience utilizing the principles and practices of health care quality management

For information please contact


Job posting #2

Manager of Accreditation- Western, NC

Responsible for the administration and oversight of all activities concerning the achievement of continuous regulatory and quality excellence and survey readiness for large acute care hospital.  The position is responsible for strategic and operational implementation of regulatory requirements, guidelines, and standards, and provides leadership and mentorship for collaborative team relationships in achieving continuous excellence.  Working closely with the quality and safety department and all levels of management, this position supports the facilitation, development, and implementation of outcomes through process improvement activities. The position monitors to ensure the medical staff, management, and staff are in a state of continuous compliance with the rules and regulations of regulatory agencies and that hospital policies and procedures are consistently followed.

Education and/or Experience

  • Bachelor’s Degree required
  • Five years management experience

For more information please contact

Coming soon: Forms and tools library to the AHAP website

AHAP is gathering tried-and-tested tracers, policies, and education/training materials for the upcoming launch of our new membership benefit: a library full of sample forms and tools to help you with your survey readiness needs.

If you have a helpful survey readiness tool, sample policy, or form that you would like to submit to the Association of Healthcare Accreditation Professionals (AHAP), please email associate director Jaclyn Zagami at

Soon, AHAP members will be able to download and use these tested tools and forms developed by your accreditation colleagues. Accreditation expert volunteers will ensure the compliance and effectiveness of materials, and new policies, tracers, and education materials will be added regularly, saving you time and effort.

Also, note that these forms will be posted to the AHAP website to be shared among the AHAP membership, but credit to the original developer will be required for use.

We want your survey bloopers

Has a Joint Commission surveyor ever called you by the wrong name? Did you accidentally fumble your words while presenting the findings of your mock tracer to leadership? Or maybe you answered a series of survey questions perfectly only to find out you had a huge piece of spinach in your teeth the whole time.

We want to hear about it! If you have a funny or awkward story to tell involving a surveyor or survey prep activity that you’d like to share with your peers, please e-mail associate director Jackie Beck at with your story. We’ll feature the collection of stories in our next issue of the AHAP Insider, a quarterly membership journal published exclusively for AHAP members.

It is our promise that your stories will be 100% anonymous.