Emergency management, physical environment and life safety codes were the most frequently cited areas for deficiencies at healthcare facilities surveyed by the Healthcare Facilities Accreditation Program (HFAP) in 2016, according to the organization’s latest quality report.
Collected from onsite HFAP surveys of acute care hospitals and critical access hospitals (CAHs), as well as laboratories and ambulatory surgery centers (ASCs), the report can help facilities by pointing out where others struggle with regulatory compliance. It could also help facilities prepare for their next—or their first—accreditation survey, or to revise their current standards long before inspectors return.
One particular deficiency stuck out: problems with fire alarm installation. Seventy-eight percent of surveys conducted for acute care hospitals cited deficiencies in this area, such as mounting smoke detectors too close to air diffusers or mounting them more than 12 inches below a deck.
“Life safety code standards are based heavily on regulations from other organizations such as the National Fire Protection Association (NFPA). Making these resources readily available to building and engineering teams can play a crucial role in achieving compliance through proper inspections and maintenance,” the report said.
Forty-nine percent of surveys at acute care hospitals cited deficiencies with ceilings, such as missing ceiling tiles or holes and gap which are larger than one-eighth of an inch.
In physical environment standards, 33 percent of acute care facilities were found to be deficient on eyewash station standards, including not testing the stations on a weekly basis or having them installed within 55 feet of hazardous materials. There were also other fire suppression issues found, such as penetrations in fire-rated barriers, or missing documentation of fire ratings where required.
Six percent were cited for “periodic monitoring for safety issues,” such as leaving offsite locations that handle patient care unmonitored. Failure to conduct quarterly fire drills which include all staff members and all shifts was also a common problem.
“Engineering and safety teams can avoid physical environment citations of noncompliance by creating routines for regular monitoring and maintenance of facilities and equipment as well as scheduling frequent drills to ensure all clinical and administrative teams participate,” the report said.
In emergency management standards, the most common problem was lacking a written business continuity plan for how a facility will recover from an emergency event, cited in 32 percent of HFAP surveys of hospitals.