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HFAP releases 2017 CAH, ASC prepublication manuals

Accreditation Insider, September 13, 2016

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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.

Modifications to the CAH manual include:

Chapter 3:  Physical Environment

  •   Updated code references to the 2012 LSC, the 2012 National Fire Protection Association [NFPA] 99 Health Care Facilities Code, and the 2010 NFPA 110 Standard for Emergency and Standby Power Systems 
  • Standards 03.01.03- Safety Committee and Safety Officer Requirements
  • Standard 03.04.02 Fire Drills Requirements
  • Standard 03.04.04 Approval by State and Local Fire Agencies
  • Standard 03.07.01 Adequate Facilities and Supplies
  • Standard 03.07.07 Monitoring the Physical Environment

Chapter 14:  Life Safety

  • An ‘Introduction’ statement has been added defining the three different occupancy chapters in the LSC. Also describes the appropriateness for requesting ‘Waivers’ and ‘Equivalencies’
  • Multiple standards have been updated to reflect LSC requirements.
  • Standard 14.00.04 Notification of Emergency Response Forces
  • Standard 14.00.06 Testing and Inspection
  • Standard 14.00.09 Fire Watch

Chapter 17:  Emergency Management

  • Updated code references to Chapter 12 of the 2012 NFPA 99 Health Care Facilities
  • Standard 17.02.01 Emergency Exercises

Facility Demographic Report (FDR)

  • In response to the above changes, the Facility Demographic Report has also been updated to reflect the LSC and 2012 NFPA 99 Health Care Facilities Code.

The changes for ASCs include:

Chapter 5:  Emergency Management

  • Updated code references to the 2012 LSC, the 2012 National Fire Protection Association [NFPA] 99 Health Care Facilities Code, and the 2010 NFPA 110 Standard for Emergency and Standby Power Systems

Facility Demographic Report (FDR)

  • In response to the above changes, the Facility Demographic Report has also been updated to reflect the LSC and 2012 NFPA 99 Health Care Facilities Code.



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