HFAP Accreditation Process Sheryl R. Miller Accreditation Operations Manager & Donna Tiberi, RN,BS,MHA Standards Interpretation May 6, 2015

Sheryl Miller - Bio Sheryl Miller has been with HFAP for over 6 years. She began her career as an administrative assistant and currently is the Accreditation Operations Manage. Sheryl manages and coordinates all day-to-day operations of the accreditation program for healthcare facilities. She serves as primary support staff for the Director of Accreditation Services on Medicare-related health care accreditation issues; provides consultation to HFAP customers on HFAP accreditation standards; works collaboratively within the organization to promote the expansion of the Healthcare Facilities Accreditation Program (HFAP); oversees communications and application processing for organizations seeking accreditation or certification by HFAP; and ensures that accredited/certified facilities receive excellent customer service and that their accreditation/certification needs are met in a timely manner. Sheryl hails from Long Island, NY, but received her Bachelor of Science in Recreation from Calvin College located in Grand Rapids, MI. She has over 15 years of work experience ranging from event planning, to administrative assistant duties to being a manager, all in different work environments.

Donna Tiberi- Bio Donna Tiberi is the Standards Interpretation & Accreditation Specialist at the Healthcare Facilities Accreditation Program in Chicago. In this role, she provides guidance and direction to the HFAP accredited facilities in assisting them with the process to obtain a successful accreditation. Donna Tiberi is a diploma graduate of the South Chicago Community School of Nursing. She received Bachelor’s Degree in Health Arts and a Master’s of Health Administration from the University of St. Francis , Joliet, Illinois. Ms. Tiberi has over thirty years of progressive experience in the health care industry directing operations, managing patient outcomes and providing nursing expertise both in the hospital and ambulatory settings. Most recently the last eight years have been working with accreditation programs providing standards interpretation for health care organizations. Prior to joining HFAP, Ms. Tiberi was a member of the Standards Interpretation Division at the Joint Commission.

Objectives Discuss the HFAP accreditation/certification programs Describe the HFAP Survey Process List common compliance issues found during HFAP accreditation surveys

HFAP Accreditation/Certification Program HISTORY Began in 1945 – American Osteopathic Association Accrediting Hospitals and Other Health Care Facilities for Over 67 Years Accrediting Hospitals Under Medicare since its inception in 1965 Deeming Authority from the Centers for Medicare and Medicaid Services (CMS): Hospitals, CAHs, ASCs, and Clinical Labs – CLIA ‘88 HFAP is the oldest, continuous accreditation organization in the U.S. Recognized by all states and major payers

Healthcare Facilities Accreditation Program Eight (8) Programs: Acute Care Hospital Accreditation Stroke Certification Critical Access Hospital Accreditation Healthcare Facilities Accreditation Program Ambulatory Surgical Centers Accreditation Behavioral / Mental Health Accreditation Office-Based Surgery Accreditation Laboratory Accreditation Ambulatory Health Care Accreditation

Accreditation Process The standards scoring is straightforward Compliant Not Compliant The accreditation decisions are straightforward 3 years Accreditation 3 years Accreditation w/follow up survey within 1 year Denial of Accreditation

Accreditation Process Length of the survey is based on: Size of hospital Note: smaller hospital does not significantly reduce team size Complexity of services offered Presence of excluded units and/or swing beds Offsite locations

e-Access to Accreditation Manual Acute Care Manual Ambulatory Surgical Center Manual Critical Access Hospital Manual

e-Access to Application All programs except Stroke are on www.hfap.org Accreditation Coordinators & CEOs have full access to site All applications are required via website Upload supporting documentation directly to application online

HFAP Account Managers Survey Event Your assigned Account Manager will guide you through the process of becoming and remaining an HFAP accredited facility. Accreditation Account Manager Pre-Survey Account Manager Post-Survey Survey Event

Standards Interpretation Staff Dedicated Standards Interpretation Staff Provides support to surveyors onsite FAQs-Frequently Asked Questions Team

Survey Scheduling Initial Surveys Reaccreditation Surveys Facility provides a “ready date” Facilities without a CCN must see a minimum number of patients prior to HFAP scheduling a survey HFAP will schedule the unannounced accreditation survey within 90 days Payment due at time of application Reaccreditation Surveys Facilities are notified 12 months prior to accreditation expiration date to reapply Facility submits application & payment 9 months prior to accreditation expiration date Acute Care Hospital up-front fees are based on Triennial Calculation Form/Medicare Cost Report All other programs have set forth pricing 120 - 180 day window for a triennial survey

Survey Process A survey team will include, at a minimum: a physician an administrator a registered nurse a life safety surveyor (1 or 2 days) The typical length of a survey is three calendar days With the exception of the Stroke program, all surveys are unannounced With the exception of the Stroke program, all facilities will be invoiced after a survey has been conducted for direct cost of survey

Survey Process Observations of Care Medical Record Review Patient and Family/Caregiver Interviews Staff Interviews/patient interviews Building Tour Document Review Personnel Files Credential Files Maintenance Records Policy and Procedures Contracted Services

Conditions of Participation - Acute Care Hospitals

HFAP STANDARDS 80% direct crosswalk to CMS regulatory requirement 10% HFAP proprietary standards 10% standards adopted from the National Quality Forum (NQF) National Patient Safety Initiatives

Post-Survey Process Surveyors provide verbal report to facility members of their findings HFAP submits formal Deficiency Assessment Report electronically to facility within 10 business days of last day of survey Facilities have 10 calendar days to electronically submit a comprehensive Plan of Correction (PoC)

Post Survey Process All deficiency reports and PoCs go before the Bureau of Healthcare Facilities’ Executive Committee for final decision Executive Committee meets every 6 weeks After Executive Committee meets, Account Managers electronically submit notice of accreditation to facilities Information is sent to CMS Facilities who have at least 1 (one) Condition of Participation/Condition for Coverage cited during their survey are subject to a full or focused resurvey. Plan of Correction & Executive Committee process starts over

Post Survey Process Once awarded accreditation, there may be a required Interim Progress Report Listed on your Bureau Progress Report you will receive Due dates are listed, template & instructions included Unless otherwise noted*, HFAP will not return onsite until it is time for your triennial *Focused Resurveys may occur *HFAP may determine 3 year accreditation with a 1 year follow up survey to occur Notified in accreditation notification letter *Complaints may come in to HFAP Triaged and determined whether an onsite survey is necessary

HFAP Survey Findings

Common Survey Findings Examples of non-compliance in Patient Rights Patient Rights are not posted in appropriate areas, for example; hospital lobby, hospital departments, admission/registration area, waiting rooms No policies found to support the Patient Rights No education provided to the hospital staff including the physicians One or more of the required rights are absent Grievance process is incomplete with no designated timeframes for follow-up response

Common Survey Findings Examples of non-compliance in Patient Rights Policies lack approval by the Medical Director and Governing Body Required policies are not written-missing Policies are outdated Purchased policies are not customized Policies do not include references; i.e. National Practice Guideline

Common Survey Findings Physical Environment non-compliance Findings Maintenance Ensures Safety & Quality Facilities, supplies, and equipment shall be maintained to ensure an acceptable level of safety and quality.

Common Survey Findings Examples of non-compliance in Infection Control There is no hospital – wide infection control plan developed IC Program lacks all required components No designated infection control officer (ICO) ICO lacks the necessary training for this position in order to implement the infection control program There is no infection control annual report to the Board IC activities are not included in QAP Hand washing surveillance and environmental rounds are not completed consistently and are not documented

Common Survey Findings Examples of non-compliance Governing Body Minutes IC and QAPI activities are not discussed nor documented in committee minutes Failure to approval policies and contracts Physician credentialing and privileging elements are incomplete or missing Missing or incomplete documentation of the compliance program

Common Survey Findings Examples of non-compliance in QAPI Lacking or incomplete hospital-wide QAPI plan failure to include all departments Data collection performed , however analysis and problem resolution is lacking Outcome data is poorly documented or missing Staff not informed and are unable to describe the quality initiatives Staff education not been provided regarding QAPI activities and performance results

Common Survey Findings Examples of non-compliance in Chart Review Missing H&Ps or outdated H&Ps Missing or incomplete Informed Consents H&Ps Updates not performed or documented day of surgery H&Ps fail to include a comprehensive inquiry by systems and a physical exam (update includes review of H & Ps, patient examination, documentation of date/time/approval Procedure name not written in at a forth grade level on consent

Common Survey Findings Examples of non-compliance in Medical Records Review Inadequate security or lack of security for Medical Records Physician orders and other documents missing signatures, dates and times of documentations Lacking pain assessment/reassessments documentation with use of a pain scale tool No documentation that the patients received the Patient Rights, Advance Directives, disclosure of ownership and agency phone numbers on the day of surgery

Common Survey Findings Examples of non-compliance in Human Resources Failure to perform or obtain PSV for licenses and references are not obtained, verified nor documented Orientation, training and competencies lacking or incomplete documentation Annual employee performance evaluations are found not completed in a timely fashion or absent

Common Survey Findings Examples of non-compliance on Facility Tour Exit signs observed to be either obstructed by other signs, and cannot be seen from a distance; or were non-existent Sprinkler heads were obstructed by other items, damaged head, dusty/dirty Evidence that Exit signs were inspected monthly to ensure they are still illuminated Outdated medications and supplies Unsecured medication in unoccupied areas Unsecured Oxygen tanks Obstructed Egress paths such as, corridor clutter, stairwell storage and doors that do not open fully Biomedical stickers are absent or not current MSDS not available or accessible OSHA requirements are not met

Common Survey Findings Examples of non-compliance in Patient Care & Procedure Observations Policies not followed such as, labeling of medications on the sterile field “items on the table need a label” Time-out procedure not followed, all staff not included Medication Administration Patient interviews & Staff interviews Restraint use such as lack of staff education Hand Hygiene Compliance, failure to monitor and report Use of radiology equipment (fluoroscopy) Sterile Processing- CDC guidelines

HFAP Survey Process PLAN OF CORRECTION Begin immediately Ask for suggestions Include pictures if appropriate Include audits showing compliance over time Include information to demonstrate how sustainability will be achieved

HFAP Survey Continuum Post your certificate of accreditation Develop and implement a plan to ensure and maintain a state of readiness Keep policies and approvals up to date Continue to conduct mock surveys on a regular basis to correct compliance issues identified as soon as possible

QUESTIONS? Please submit questions to: Sheryl Miller Operations Manager 312-202-8065 or smiller@hfap.org Donna Tiberi Standards Interpretation & Accreditation Specialist 312-202-8073 or dtiberi@hfap.org Or info@hfap.org