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

2. 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.

3. 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.

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

5. 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

6. 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

7. 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

8. 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

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

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

11. 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

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

13. 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
day window for a triennial survey

14. 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

15. 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

16. Conditions of Participation -
Acute Care Hospitals

17. 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

18. 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)

19. 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

20. 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

21. HFAP Survey Findings

22. 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

23. 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

24. 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.

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. QUESTIONS? Please submit questions to: Sheryl Miller
Operations Manager or
Donna Tiberi
Standards Interpretation & Accreditation Specialist or Or