To view the manual, login to hfap.org and direct your mouse to the ‘Manual Viewer’ link on the left-hand sidebar of the web page. The facility that is associated with your profile will appear on the next page, hit the ‘Select’ button next to your facility. This will take you to a page that gives you two options. By clicking on ‘Select’ you will be taken to our online manual viewer; if you click on ‘Download Printable Version’ you will be directed to a page that allows you to download the 2012-2013 ASC Manual in its entirety or by individual chapter. The online manual viewer contains only the main standards that are involved in HFAP ASC Accreditation while the ‘Download Printable Version’ contains all the documents that are included in the traditional print version (Table of Contents, Glossary, Index, etc.).

Should you encounter any issues, please direct your email to info@hfap.org or call us at (312) 202-8258.

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Questions? Contact George Reuther, MBA at 312-202-8084 or greuther@osteotech.org.

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This article was originally published in the March/April 2013 issue of BI&T (Biomedical Instrumentation & Technology), a bimonthly, peer-reviewed journal from the Association for the Advancement of Medical Instrumentation, www.aami.org. Posted with permission. Any other distribution of AAMI-copyrighted material requires written permission from AAMI.

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Key deficiencies discussed will be:

• CMS and its Selection of Life Safety Code Editions
• The Top Five LSC Findings including:
• Corridor Clutter, and when is it officially not Corridor Clutter
• Rated Wall Penetrations
• Fire Alarm Records
• Doors
• Alternative Life Safety Measures (ALSM) Implementation

Click here for more info and to register.

Questions? Contact George Reuther, MBA at 312-202-8084 or greuther@osteotech.org.

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Here are the specific significant changes to the HFAP BAA document:

• Section 3 E. now covers contractors that create, receive, maintain, or transmit PHI on behalf of HFAP.  The old BAA covered contractors “to whom HFAP provided PHI.”
• Section 3 J. (i) now states HFAP shall abide by all applicable provisions of the Security Rule, instead of the several regulations that had been cited specifically in the old BAA.
• Section 3 J. (ii) was deleted because it is no longer necessary.
• Section 3 N. is newly added and states that, To the extent HFAP has been delegated responsibility under this agreement to carry out any of a Surveyed Organization’s obligations under the Privacy Rule, HFAP shall comply with the requirements of the Privacy Rule that apply to Surveyed Organizations in the performance of such delegated obligation.

To access the latest version of the HIPAA agreement, log on to www.hfap.org and you will find the HIPAA Agreement link under the “Resources” tab in the drop-down menu.

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We encourage each facility to download the most up-to-date version of the 2012-2013 Acute Care Manual. This can be done in the ‘Manual Viewer’ section of our website. These documents can be downloaded by signing into our website, www.hfap.org, and clicking the ‘Manual Viewer’ link on the left-hand sidebar of the website. Next, select your facility and then select the ‘Download Printable Version’ for the ‘Accreditation Requirements for Acute Care Hospitals 2012-2013.’ The most up-to-date version of the Acute Care Manual (including the November 2012 CMS updates) is available by selecting and downloading the file ‘000 Accreditation Requirements for Acute Care Hospitals 2012-2013.’ If you would rather download Chapter 24 by itself, you can select the individual chapter on the list below the full version of the manual (033 24 – Nutritional Services).

We apologize for this inconvenience. Should you have any questions or concerns please, do not hesitate to contact the Central Office at 312-202-8258 or submit a question via info@hfap.org.

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The recent hurricane Sandy created conditions that would be described as challenging at best and disastrous at worst for many hospitals across the eastern seaboard of the country. Normal power supplies were cut-off for extended periods of time and hospitals were dependent on their emergency power generators to sustain routine and life-saving activities. At the point when the severe weather strikes is not the time to learn if your emergency power generator will be up to the task of providing power to continue your mission.

Therefore, HFAP has decided to require all accredited organizations to conduct the 3-year, 4-hour load test, as referenced in the NFPA 110 Standard for Emergency and Standby Power Systems(2005 edition), section 8.4.9.  This 3-year, 4-hour load test must have been accomplished within the past 36 months by July 1, 2013 for every accredited organization which has emergency power generators.  This 3-year, 4-hour load test is in addition to the monthly and annual (if required) load tests already required by current HFAP standards. Each load test is designed to ensure emergency power capability will be provided in the event of an actual normal-power outage.

Here is a summary of each test:

• A monthly load test no sooner than 20 days and no later than 40 days from the previous monthly test, operates the generator at 30% (or more) load capacity for 30 minutes. If the generator cannot meet the 30% load requirement for one (or more) of the monthly tests, then the monthly tests are still conducted and documented, but an annual load test will now be required.

• An annual load test 12 months from the previous annual load test (if conducted), plus or minus 30 days, may be required if one (or more) of the monthly load tests fails to meet the 30% capacity rule. If all 12 monthly load tests meet or exceed the 30% load capacity, then the annual test is not required. The procedure for the annual test is to operate the generators at:
  • 25% (or more) capacity for 30 minutes
  • 50% (or more) capacity for 30 minutes
  • 75% (or more) capacity for 60 minutes, for a 2-hour continuous test

• The 3-year, 4-hour load test is not dependent on the monthly or annual load tests. The generator needs to operate at a minimum of 30% capacity for 4 continuous hours. The test needs to be conducted 36 months from the previous 3-year, 4-hour test, plus or minus 45 days. An actual power outage event that operates the generator for 4 continuous hours at a load capacity of at least 30% would qualify the generator as meeting this load test, but it would have to be documented.

Some organizations have asked if they can combine the annual test with the 3-year, 4-hour load test, and the answer is yes, provided all the provisions of both tests are met. This means if the test starts at 25% load for 30 minutes, then 50% load for the next 30 minutes, then 75% load for the next 180 minutes, and then stops, it would not meet the requirements of the 3-year, 4-hour load test because it started at 25% load instead of 30% load. The test did not operate for 4 continuous hours at a minimum of 30% load.

Making sure the generators can operate for at least 4 hours during a power outage is an important building safety issue, and one that HFAP will require the organization to be in compliance.

Please contact info@hfap.org with any questions or comments about generator testing.

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Date: Wednesday, March 27, 2013
Time: 2:00 – 3:30 p.m. EST (11:00 a.m. – Noon PST)
Cost: FREE

Electronic Health Records (EHR) offer tremendous clinical value as well as support patient safety standards that are paramount on all our minds. However, with all the national attention and state mandates to automate or become Meaningful Use compliant; we rarely have the opportunity to focus on the core values providers and their patients will derive from with the use of EHRs.

The successful implementation of an EHR enables new-found efficiencies including a reduction in documentation time, immediate access to patient data, improved cash flow, streamlined clinical work flow, increased reimbursement, and detailed real-time aggregate reporting. Patient data is accessible to multiple personnel at the same time — allowing up to date medication information, history and clinical data at every step of care delivery.

AATOD has partnered with Netsmart to present this valuable, no-cost web seminar, Preparing Opioid Treatment Providers for EHR’s, HIE’s and Health Care Reform to educate and prepare you on the benefits of implementing an EHR. Lew Cordina, VP, Methadone Systems will review and discuss:

The state of Healthcare IT today

• Background
• Moving to Electronic Health Records (EHR)
• What are the benefits of an EHR?
• Things to consider when evaluating EHRs
• Interoperability, HIE’s and 42 CFR Part 2

PRESENTED BY:
Lew Cordina, VP, Methadone Systems

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Visit the new CMS eHealth website to view the resources, including:

• eHealth Fact Sheet – Explains the goal of eHealth, and how the initiative will affect the future of health care.

• eHealth Roadmap – Provides a visual overview of how eHealth will improve quality of care, create better health outcomes, and reduce costs.

CMS also encourages you to read the blog posts about eHealth on the CMS blog, where you can find updates on eHealth and important program milestones.

Media Resources
Also available to health care publications is an eHealth drop-in article, which allows editors to print and post the content of the document in their publications and websites.

Join the Twitter Conversation!
CMS is tweeting about the EHR Incentive Programs and other eHealth initiatives. Join the conversation by using #CMSeHealth and following the @CMSGov Twitter handle.

Note: Make sure to add cmslists@subscriptions.cms.hhs.gov to your approved senders list so that eHealth listserv messages do not get caught in your spam folder.

Want to find out more about eHealth?
Visit the CMS eHealth website for the latest news and updates on CMS’ eHealth initiatives.

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