HFAP: Problems Continue With Physical Environment, IC, Quality

By A.J. Plunkett

CMS has signaled that accrediting organizations (AO) like HFAP can resume even more surveys in areas where the COVID-19 patient surge is slowing. But what will HFAP surveyors be looking for?

In late August, the oldest of the accrediting organizations released its 2020 HFAP Quality Review, highlighting the problems and trends identified by surveyors during on-site visits in 2019 at acute care hospitals, critical access hospitals, laboratories, and ambulatory surgery centers.

“The Quality Review plays a vital role in our commitment to help continuously improve the quality of care that HFAP-accredited organizations provide,” said Meg Gravesmill, CEO of AAHHS/HFAP, in a statement announcing the release of the review. “This can be used as a self-assessment guide and should be reviewed by organizations as they evaluate their yearly performance. In light of the global pandemic, it is especially important for organizations to heighten awareness of infection prevention and emergency management standards.”

The statement noted “common citations such as insufficient documentation and inconsistent compliance with processes and procedures.”

The review also showed that “healthcare organizations continue to struggle with integrating quality as a driver of documentation and process excellence during accreditation surveys, mirroring past years’ top deficiencies.”

Note that the review particularly highlights concerns with infection control and emergency management, the two specific areas CMS is encouraging AOs to look at as surveys resume.

Here’s a rundown of problems, according to the statement.

Physical environment

Common deficiencies were related to the management of the built environment “and its impact on patient, staff and visitor safety, particularly with regard to infection control.  Common examples included issues with eye wash stations, non-compliant air-pressure relationships, and defects in ceiling, wall, floor and other surfaces.”

Citations were also issued related to the NFPA’s Life Safety Code®standards. “Examples of this year’s deficiencies include compliance with standards for smoke alarms and other utility systems, such as emergency generators, as well as compliance with requirements for doors located in exit halls.”

Patient safety

Infection prevention and control citations were down in some areas, but they “did remain the most frequently cited deficiency in 2019. Surveyors identified specific failures of cleanliness and failure to follow policies as written. A few examples include no HEPA filter, construction spaces not being maintained in a negative pressure state, containment barriers being compromised by staff for ease of circulation, and inappropriate traffic flow in the sterile and clean supply rooms.”

Emergency management

Hospitals still struggled with comprehensive emergency preparedness plans, with specific citations including “not having an Emergency Operations Plan (EOP) that considers at-risk individuals, identifies services that hospitals will provide under activation of the plan, and addresses the need for nutritional services.”

HFAP is advising facilities to use “the 2020 public health emergency as an opportunity to review lessons learned. In addition, everyone should review the standards and determine the specific HFAP requirements to be delineated within an organization’s policies and procedures. Most importantly, promote a culture of inclusiveness by increasing the communication between the emergency preparedness office and other relevant departments through frequent committee meetings and drill evaluations.”

A.J. Plunkett is editor of Inside Accreditation & Quality, a Simplify Compliance publication.