Quality & Patient Safety

HFAP's top-cited deficiencies for critical access hospitals

Briefings on Accreditation and Quality, August 1, 2016

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Editor's note: Recently, the Healthcare Facilities Accreditation Program (HFAP) released lists of its most-cited deficiencies of 2012-2015 for acute care and critical access hospitals. The following is an edited Q&A with Karen Beem, RN, MS, standards interpretation specialist for HFAP, and Brad Keyes, CHSP, engineering advisor for HFAP. Beem and Keyes spoke to us about the common issues that caused these citations, and suggested ways to prevent them in the future. All HFAP standards are based on CMS' Conditions of Participation.

BOAQ: What are the big takeaways from the top-cited deficiencies lists for critical access hospitals (CAH) and acute care hospitals (ACH)?

Keyes: From a physical environment standpoint, there are several key takeaways in the top-cited deficiencies lists for critical access and acute care hospitals. First, we see organizations being rated noncompliant for very avoidable pitfalls. This highlights how important it is to use the preparation time before an accreditation survey as an opportunity to improve not just your procedures, but also the physical environment of your organization. An organization administrator could walk through his or her hallways today and address some of these "problem area" common deficiencies, including:

  • Making sure doors in the path of egress are not locked (in compliance with the Life Safety Code®) and that the path of egress is properly marked with "exit" signs
  • Making sure access to electrical panels, medical gas shutoff valves, and fire alarm pull stations is not obstructed
  • Making sure fire-rated doors and frames are properly labeled
  • Making sure rooftop exhaust fans are labeled with biohazard symbols

Secondly, there are common physical environment pitfalls that highlight the need for integrating important Life Safety Code procedures into a facility. The following are common deficiencies that, while not difficult to meet, require the attention and commitment of a responsible staff member to institute:

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