ACHC is here for you.
Volume 2025 | No. 2
Quality Review Edition THE Accreditation Resource for Data Nerds SURVEYOR
Volume 2025 | No. 2
SURVEYOR
TABLE OF CONTENTS
03 Corner View
04 From the Program Director
06 Frequent Deficiencies in Acute Care Hospitals
30 Frequent Deficiencies
in Physical Environment and Life Safety Standards
50 Frequent Deficiencies
in Critical Access Hospitals
BOARD OF COMMISSIONERS
LEADERSHIP TEAM
Brock Slabach, MPH, FACHE Chair CHIEF OPERATIONS OFFICER, NATIONAL RURAL HEALTH ASSOCIATION Maria (Sallie) Poepsel, PhD, MSN, CRNA, APRN Vice Chair OWNER AND CEO, MSMP ANESTHESIA SERVICES, LLC
Leonard S. Holman, Jr., RPh Treasurer HEALTHCARE EXECUTIVE AND CONSULTANT
José Domingos PRESIDENT AND CHIEF EXECUTIVE OFFICER, ACCREDITATION COMMISSION FOR HEALTH CARE Richard A. Feifer, MD, MPH, FACP CHIEF MEDICAL OFFICER, INNOVAGE
José Domingos PRESIDENT AND CHIEF EXECUTIVE OFFICER Patrick Horine, MHHA VICE PRESIDENT, ACUTE CARE SERVICES
John Barrett, MBA Officer-at-Large SENIOR CONSULTANT, QUALITY SYSTEMS ENGINEERING Gregory Bentley, Esq. PRINCIPAL, THE BENTLEY WASHINGTON LAW FIRM
Matt Hughes VICE PRESIDENT, COMMUNITY CARE SERVICES Jonathan Kennedy, CPA, MBA VICE PRESIDENT, FINANCE AND CORPORATE SERVICES
Denise Leard, Esq. ATTORNEY, BROWN & FORTUNATO
Mark S. Defrancesco, MD, MBA, FACOG Secretary WOMEN’S HEALTH CONNECTI CUT/PHYSICIANS FOR WOMEN’S HEALTH (RETIRED)
Marshelle Thobaben, RN, MS, PHN, APNP, FNP PROFESSOR, HUMBOLDT STATE UNIVERSITY
Jennifer Burch, PharmD OWNER, CENTRAL PHARMACY, CENTRAL COMPOUNDING CENTERS
achc.org | (855) 937-2242 | 1
Volume 2025 | No. 2
SURVEYOR
CORNER VIEW WITH PRESIDENT & CEO, JOS É DOMINGOS
You made a great decision when choosing ACHC to accredit your hospital. Whether you are new or have years of experience with us, I am confident that you have already felt first- hand our intense focus on customer service. Real support that builds your team ACHC doesn’t engage in “accreditation theatre” through complex scoring rubrics or punitive surveys that give an illusion of rigor without adding any true value for your organization. Instead, we focus on real support designed to close any gaps between your current state and full standards compliance. We are known as Accreditation Nerds for our genuine belief in— and passion for—the efficacy of accreditation to enhance quality and safety in healthcare organizations. But we know it works best when those organizations understand and embrace continuous performance improvement. The Quality Review edition of Surveyor is an excellent place to start. This publication is a resource, demonstrating how ACHC program teams work to help you develop individual expertise within and throughout your hospital, while recognizing that your staff may have varying levels of experience and current knowledge of accreditation. The standards listed are the most frequently noted as noncompliant on recent surveys and the compliance tips provided are divided into categories to make them useful for individuals across a range of roles and expertise. “Accreditation Nerd Newbies” are just that: individuals new to the process of compliance with accreditation standards. ACHC uses a Plan- Do-Study-Act framework to organize standards.
Even a "simple" standard may include multiple elements for full compliance. Under Compliance tips for Nerd Newbies, we offer a clear summary of the expectations for each standard. “Accreditation Nerd Apprentices” understand the concepts of meeting and maintaining standards. Compliance tips for Nerd Apprentices focus on using data on hand to continuously assess how well your organization is performing. Finally, “Accreditation Nerd Trailblazers” are those individuals who are passionate about maximizing their organization's capacity for excellence. They are enthusiasts who eagerly share their knowledge with colleagues to create a path forward. Nerd Trailblazers thrive on the goal of continuous improvement. Compliance tips for Nerd Trailblazers cover best practices designed to level up your organization. These tongue-in-cheek categories are our way of saying that it’s possible to approach accreditation seriously without being humorless. When we say that we want to help you develop your staff into a team of Accreditation Nerds, you immediately understand the goal. Partnership you can rely on Once a hospital is ACHC-accredited, we become your partner, dedicated to meeting your needs. ACHC's staff of Accreditation Nerds—account advisors, surveyors, clinical educators, quality and regulatory, and other experts— thrive on being helpful. Review the information on the pages that follow confident that we’re ready to dig in to answer questions, provide feedback, offer suggestions, and direct you to any additional resources you need.
MISSION STATEMENT
Accreditation Commission for Health Care (ACHC) is dedicated to delivering the best possible experience and to partnering with organizations and healthcare professionals that seek accreditation and related services.
achc.org | (855) 937-2242 | 3
2
Volume 2025 | No. 2
SURVEYOR
FROM THE PROGRAM DIRECTOR
ACUTE CARE HOSPITAL
This Quality Review edition of Surveyor identifies and analyzes the most challenging standards for ACHC-accredited acute care and critical access hospitals. Data presented in this year’s report span initial and renewal surveys conducted between June 1, 2024, and May 31, 2025.
General Results This year, it's all in the details. Frequently cited standards are generally consistent from year to year. Deficiencies are most common when the standard has a large number of required elements. Risk mitigation measures for infection prevention ( 07.02.01 for acute care and 18.02.01 for CAHs) represents a standard that requires compliance across all areas of the hospital. While it remains a frequently-cited standard, we are seeing improvement worth noting. While the frequency of this finding remains high, the severity has decreased by 67 percent due to fewer condition-level deficiencies. Given the breadth of this infection prevention standard and its many required elements, ACHC surveyors most often identify environmental issues that create infection risks, but this trend represents improvements in infection- based systemic failures. We would attribute a portion of this improvement to the ongoing education provided to our organizations. Our team uses deficiency data to identify areas where additional support is needed and develops education accordingly, benefiting all organizations as they prepare for survey. Acute Care Hospital Findings When looking for trends, ACHC Surveyors most often identify missed details. To improve, hospitals must focus on education. Every action requires attention to detail, whether managing security of medications (see 25.01.03 ), meeting established timelines ( 15.02.14 Violent Restraints and/or seclusion: One-hour face-to- face assessment ), recording patient care activities (see 16.00.10 Plan of care ), completing the credentialing and privileging process (see 03.01.15 Application and reapplication requirements ), measuring department
performance (see 1 2.00.01 Data Collection and analysis: Program scope ), or writing policies and procedures for disinfecting instruments (see 07.04.03 Processing flexible and semi-rigid endoscopes ). The required documentation begins with planning and continues through training and evaluation/ assessment. Health care is a team-based activity. This is why we look so carefully at your documentation. For each process, the participants need to pick up their individual responsibility for care delivery in a way that reflects the organization's intention as defined by policy and procedure. This is both a risk management strategy and a quality of care principle that benefits your patients. Critical Access Hospital Clinical and Administrative Results For CAHs, we are taking a close look at nine clinical and administrative standards distributed across six chapters. Standard 06.03.08 Policy requirements: Food preparation and storage (24.01.03 for acute care hospitals) is another consistent challenge. Here, we often see a gap between policy and implementation. Document review demonstrates that CAHs have the right approach, but direct observation often reveals opportunities to do better in practice. This standard also provides an example of required monitoring (for temperature) with flexibility in responding to out- of-range results. Whenever ACHC Standards require monitoring, there is an accompanying expectation that action will be taken when results are outside of defined parameters. Don't neglect to include that action when creating policies and procedures.
Physical environment and life safety results You’ll find the most frequent deficiencies in these areas on pages 30-51 for both acute care and critical access hospitals. These requirements are a focus for facilities teams, so we consider them separately from the clinical and administrative standards. However, maintaining a sanitary and secure environment is not the exclusive responsibility of facilities staff. Renew your engagement with quality ACHC is keenly aware that hospitals of all sizes continue to experience burdens and pressure. ACHC Accreditation is not intended to be a source of stress. We recognize your ongoing investments in improving patient care and we are here to act as a partner, not an adversary. I encourage you, once again, to take advantage of the full range of ACHC resources. This year has seen a new crop of templates and tools
available through ACHCU, including a Universal Risk Assessment that was a frequently requested resource.
We've had a lot of positive feedback about the expanding community of ACHC Accreditation Nerds. I hope to see more of you than ever at our next opportunity to gather for ACHCU Academy. Amelia Island, Florida next March will offer warm weather, inspiring sessions, and access to expertise from our team and your fellow registrants. Bring your team and recharge while earning CEUs and renewing your commitment to the safe, high-quality patient care we all want to deliver!
Deanna Scatena, RN Program Director
achc.org | (855) 937-2242 | 5
4
Volume 2025 | No. 2
SURVEYOR
ACUTE CARE HOSPITAL
CHAPTER 03: MEDICAL STAFF 03.01.15 Application and reapplication requirements Frequency of the citation: 26%
Overview of the requirement: Professionals seeking medical staff appointment must complete an application that is reviewed, evaluated, and summarized by credentialing professionals in preparation for Medical Executive Committee discussion and a subsequent recommendation to the hospital’s governing body regarding an appointment decision. Comment on deficiencies: Compliance is assessed through review of credentialing files, governing body meeting minutes, and appointment letters. Surveyors noted that individual files reviewed lacked one or more of the required elements. Examples of ACHC Surveyor findings: ■ The hospital has a core privileges form that is used universally. This results in inappropriate approval of telemedicine physicians for paracentesis, thoracentesis, lumbar puncture, insertion of central venous catheters and arterial lines, intubation, etc. ■ Files for initial applicants lacked work affiliation history. ■ Files lacked evidence of clinical activity associated with privilege requests for a physician assistant, anesthesiologist, emergency physician, internal medicine physician, and CRNA. ■ Files did not include the number of peer references required by the medical staff bylaws. ■ Files lacked evidence of a criminal background check.
ACUTE CARE HOSPITAL ACCREDITATION
FREQUENT DEFICIENCIES IN CLINICAL AND ADMINISTRATIVE STANDARDS IN ACUTE CARE HOSPITALS 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 03.01.15 03.15.01 07.02.01 07.04.03 08.00.03 10.01.16 12.00.01 15.01.02 15.02.07 15.02.14 15.02.15 15.02.17 15.03.01 15.03.02 16.00.10 16.01.02 16.02.02 24.01.03 24.01.08 25.01.03 30.00.11
Patient Rights and Safety
Nursing Services
Surgical Services
Nutritional Services
Medical Staff
Infection Prevention & Control
Medical Records
Quality Assessment & Performance Improvement
Pharmacy Services/ Medication Use
Materials Management
achc.org | (855) 937-2242 | 7
6
Volume 2025 | No. 2
SURVEYOR
ACUTE CARE HOSPITAL
Compliance tips for:
03.15.01 Ongoing professional practice evaluation Frequency of the citation: 26%
Specific areas must be reviewed prior to action on an application/reapplication for medical staff appointment and privileges. These include: ■ Confirmation of licensure, medical education and postgraduate training, and specialty board status based on primary source verification (PSV). A credentials verification organization (CVO) can be used. ■ Criminal history background check. ■ Evidence of malpractice insurance and history. ■ Employment history. ■ Identification of sanctions or disciplinary actions taken. ■ Professional references. ■ Evidence of clinical activity (e.g., procedure logs) ■ Evidence of attendance at required meetings (for reappointment consideration). ■ Regularly review a sample of credentialing files for inclusion of all required documentation. ■ Review “core privileges” documents to ensure that they are relevant to the department/specialty for which they are being used. ■ Train credentialing staff to immediately return applications that are missing peer references, clinical procedure logs, evidence of current malpractice insurance, etc. Applications should not be advanced to the MEC or the governing body without all required elements.
Nerd Newbies (understand the requirement)
Overview of the requirement: Each practitioner participates in ongoing practice evaluation as defined by the medical staff. The results of this evaluation are factored into the decision to continue, revise, or revoke an existing privilege. Comment on deficiencies: Compliance is assessed through review of the medical staff bylaws and credentialing files. Surveyor findings identified specific files that were missing OPPE data.
Examples of ACHC Surveyor findings:
■ Clinical indicators were missing from some files. ■ OPPE data was not sent to the Credentialing Committee to provide evidence that OPPE factored into privileging decisions. ■ OPPE indicators were not specific to provider specialties. Compliance tips for:
Nerd Apprentices (audit for excellence)
OPPE is the process by which the medical staff monitors the competency of its members. In aggregate, data are used for trending. Individually, data are used to inform privileging decisions for practitioners seeking renewal of their medical staff membership. ■ Audit renewal applications for inclusion of OPPE data. ■ Audit performance measures approved by the medical staff to ensure that they include aspects of practice specific to evaluation of each specialty. ■ Review the OPPE plan to ensure it addresses 12 required elements and identifies roles that can access and review the data. ■ Confirm security of individual practice evaluation data.
Nerd Newbies (understand the requirement)
Nerd Trailblazers (prepare the path for others)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
achc.org | (855) 937-2242 | 9
8
Volume 2025 | No. 2
SURVEYOR
ACUTE CARE HOSPITAL
CHAPTER 07: INFECTION PREVENTION & CONTROL AND ANTIBIOTIC STEWARDSHIP 07.02.01 Risk mitigation measures for infection prevention Frequency of the citation: 90% Overview of the requirement: The hospital has identified and implements mitigation strategies to minimize transmission of infectious disease within the organization and from the facility to other settings. Strategies address at least: maintenance of a sanitary physical environment, measures to reduce risks to/from staff, measures related to patients presenting with infection, measures to reduce risk of healthcare-associated infections. Comment on deficiencies: Compliance is assessed through direct observation, interview, and document review. Most findings relate to observable, unmitigated infection risks. Similar findings are noted at standards in other chapters as well. In some cases, surveyors noted that facility practice did not align with policy. Examples of ACHC Surveyor findings: ■ In surgical services: Inadequate dwell time for disinfection of mattresses, dust/dirt accumulation in ORs. Carts carrying used OR instruments were observed to also transport sterile trays to the clean ORs creating risk of cross contamination. ■ In sterile processing: Surgical instruments in peel packs had surgical tape that was broken, chipped, or lifted. Surgical instruments were noted to be sterilized in the closed ratchet position. ■ In endoscope processing area: No demarcation between the clean and dirty areas. ■ In pharmacy: Visible debris in medication storage bins. ■ In materials management: Supplies, including intravenous catheters, gloves, gowns, and PPE, were stored in the staging area and pulled for distribution from corrugated shipping boxes. The facility's corrugated cardboard risk assessment states that there must be a delineation between the staging and clean areas and that outside shipping boxes should not be used for storage. Practice was not following the result of the risk assessment. ■ In housekeeping: Employee food items were stored alongside supplies. ■ The Director of Respiratory Services stated during an interview that hospital ventilators are not wiped down, not covered, and tubing is not always removed until brought to the respiratory department for decontamination. The policy for infection control for the pulmonary services department does not address cleaning locations or proper transport of dirty ventilator equipment throughout the hospital.
Compliance tips for:
The intent of the standard is that all staff are engaged with infection prevention and control efforts. Everyone “owns” facility cleanliness by following policies and alerting housekeeping/environmental services to problem areas where static dust buildup, dirt, and debris are frequently noted. ■ Make sanitary condition rounding a team activity that includes department staff, environmental services, and infection preventionists. ■ Conduct periodic audits of instruments in sterile peel packs looking for surgical tape, closed ratchets, and other issues. ■ Train environmental services/housekeeping to observe for and report rusted equipment, and damaged floors, walls, and doors when cleaning rooms. ■ Conduct periodic training for cleaning, sterilization, and storage of equipment. ■ Create infection control quality goals related to a sanitary environment by collecting and trending data from environmental rounds. Develop action plans for high-frequency issues. ■ Address variance from approved policies and procedures across all departments with team-building training.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
achc.org | (855) 937-2242 | 11
10
Volume 2025 | No. 2
SURVEYOR
ACUTE CARE HOSPITAL
Compliance tips for:
07.04.03 Processing flexible and semi-rigid endoscopes Frequency of the citation: 26%
The goal of the standard is to ensure that reusable endoscopes are decontaminated, cleaned, and stored according to recognized standards to mitigate the risk of contamination and damage. ■ Audit policy for inclusion of all required elements. ■ Audit inventory for relevant classification. ■ Audit storage for compliance with time-sensitive reprocessing expectations. ■ Engage a collaborative team with representatives of surgical services, endoscopy, sterile processing, respiratory services, facilities, QAPI, and infection prevention to review and make recommendations regarding policy and procedures.
Nerd Newbies (understand the requirement)
Overview of the requirement: The hospital adopts nationally recognized guidelines for classifying endoscope inventory as critical, semi- critical, or non-critical and establishes cleaning, disinfection, and sterilization processes in accordance with classification guidelines. Comment on deficiencies: Compliance is assessed through observation, interview, and review of policy and process documentation. Surveyor citations focused on policies that lacked required elements and processing practices that diverged from policy requirements. Examples of ACHC Surveyor findings: ■ Scopes located outside the endoscope drying cabinets were tagged as reprocessed within seven days in accordance with hospital policy. The scope cleaning log lacked evidence of the processing as recorded on the tags. ■ The latest processing date for bronchoscopes, ready to be used, was noted to be more than 14 days prior to survey. This is not consistent with hospital policy which states "Remove and reprocess the endoscope before use if seven-day storage time has been exceeded." ■ Elements were missing from the policy: ٝ Point of use treatment: Does not discuss time frame within which scope cleaning has to start. ٝ Transporting: No mention of the number of scopes that can be transported in bin at one time. ٝ Leak testing: No mention of space requirement. ٝ Decontamination/cleaning: No delayed cleaning procedure. ٝ Safe storage: Policy states scopes should be hung horizontally instead of vertically. ٝ Personnel education, training, and competency verification. ٝ Classification of the endoscope inventory. ٝ Unidirectional workflow for device processing: Section needs expansion and clarification. ٝ Required lighting and magnification for scope inspection. ٝ Water quality plan. ■ The scope processing area lacks a dual sink, and the hospital lacked evidence of a consistent process for using freshly cleaned containers for leak testing, manual cleaning, and rinsing, compromising the cleaning of the scopes.
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
CHAPTER 08: MATERIALS MANAGEMENT 08.00.03 Safe storage of supplies Frequency of the citation: 45%
Overview of the requirement: Storage of items that support patient care is appropriate to their use and protects from damage or loss. Comment on deficiencies: Compliance is assessed through observation. Deficiencies noted commingled storage of medications and supplies, shelving that did not meet requirements, and inadequate efforts to limit access to supplies.
Examples of ACHC Surveyor findings: ■ Clean supplies were stored in the dirty utility room in a patient care area.
■ Materials management: Containers of clean supplies were observed on the floor of a storage room. ■ The hospital's risk assessment for storage lacked evidence of reasonable attempts to segregate supplies, review by the infection preventionist, and review and approval by the Infection Control Committee. ■ Laboratory storage did not meet requirements for a minimum distance of six inches above the floor for lowest shelving height and a solid protective barrier. ■ Multiple departments stored cleaning supplies and patient supplies together. ■ The phlebotomy room door was propped open and left unattended allowing access to needles, syringes, and other venipuncture supplies.
achc.org | (855) 937-2242 | 13
12
Volume 2025 | No. 2
SURVEYOR
ACUTE CARE HOSPITAL
Compliance tips for:
Examples of ACHC Surveyor findings: ■ The hospital’s policy “Consents for Medical Procedures” lacked required elements. ■ The process for obtaining consent in/after an emergency situation was not completed per hospital policy. ■ Surgical consents were not written in a language the patient understood. ■ Surgical consent for a patient whose primary language was Spanish lacked evidence that an interpreter was provided to assist in understanding the consent. Compliance tips for:
The standard is designed to support the integrity and cleanliness of supplies and to prevent diversion and other forms of loss.
Nerd Newbies (understand the requirement)
■ Audit storage for appropriate segregation of items. ■ Audit storage spaces for the minimum six-inch floor clearance for non- sterile supplies and food items and eight-inch floor clearance for sterile supplies and a solid surface for bottom shelves. ■ Audit for locked doors/storage cabinets where medications, sharps, or other items subject to diversion risk are kept. ■ Add expectations for storage in various locations to the environmental rounding audit tool. ■ Review risk assessments to ensure that they result in a recommendation which is followed.
Nerd Apprentices (audit for excellence)
Informed consent means the patient or their representative is provided the information needed to agree to a procedure or treatment. This means the hospital identifies procedures/treatments that require consent in a policy that also describes the process. Documentation to be signed by the patient must use language accessible to a non-medical professional. ■ Audit medical records of patients who underwent a procedure requiring consent for a signed form. Check for the use of simple terms to describe the treatment/procedure. ■ Audit consent forms for all required signatures. ■ Audit surgical consents for completion prior to the procedure. ■ Compare consent forms to policy to ensure alignment. ■ Educate relevant staff on the informed consent policy at regular intervals. ■ Train all staff that confirming comprehension is the goal, and it is achieved through a consistent, defined process.
Nerd Newbies (understand the requirement)
Nerd Trailblazers (prepare the path for others)
Nerd Apprentices (audit for excellence)
CHAPTER 10: MEDICAL RECORDS 10.01.16 Informed consent 30.00.11 Surgical informed consent
Nerd Trailblazers (prepare the path for others)
Frequency of the citation: 10.01.16 35%, 30.00.11 29%
Overview of the requirement: The medical records standard focuses on the requirement that medical staff policies identify the procedures and treatments that require informed consent, the process for obtaining it, and the elements that must be included. Medical records document the patient’s informed consent including, at least, the required elements. The surgical informed consent standard requires that the consent form be in the medical record prior to the procedure except in the case of emergency. This standard also requires disclosure of sensitive examinations that may be used for educational or training purposes. Comment on deficiencies: Compliance is assessed primarily through review of informed consent policies and patient medical records. Most deficiencies noted the failure to use simple language for consent forms. Other citations focused on issues with the policy itself or for patients presenting in the ED and transferred to inpatient status.
achc.org | (855) 937-2242 | 15
14
Volume 2025 | No. 2
SURVEYOR
ACUTE CARE HOSPITAL
CHAPTER 12: QUALITY ASSESSMENT & PERFORMANCE IMPROVEMENT 12.00.01 Data collection and analysis: Program scope Frequency of the citation: 32% Overview of the requirement: The hospital’s QAPI Program includes measurable quality indicators for every department and service including contracted services that are used to monitor the effectiveness and safety of care provided. Comment on deficiencies: Compliance is evaluated through review of the annual QAPI plan with a focus on frequency and detail of data collection.
CHAPTER 15: PATIENT RIGHTS AND SAFETY 15.01.02 Notice and promotion of patient rights Frequency of the citation: 26%
Overview of the requirement: A document of patient rights is developed to include 24 required elements and posted or otherwise available to patients. Comment on deficiencies: Surveyors review the patient rights document to confirm compliance. Findings focused on documents that lacked specific required elements. Examples of ACHC Surveyor findings: ■ Posted statements of patient rights were not congruent with the hospital’s Patient Rights and Responsibilities policy. ■ The patient rights poster does not include the required language that the hospital will not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identity, sexual orientation or disability. ■ Patient rights documents are missing the following elements: ٝ The right to know the reasons for any proposed change in the professional staff responsible for his/her care. ٝ The right to know the reasons for his/her transfer either within or outside the hospital. ٝ The right to be informed of the source of the hospital's reimbursement for his/her services, and of any limitations which may be placed upon his/her care. ٝ The patient's family has the right of informed consent for donation of organs and tissues.
Examples of ACHC Surveyor findings: ■ The hospital lacked metrics for contracted patient care services. ■ Frequency of data reporting was not identified in the annual QAPI plan.
■ The facility policy, “Sentinel Events,” states that the risk manager will provide quarterly aggregate reports on the number, type, and outcome of sentinel events to the Process Improvement Committee. PI Committee minutes do not reflect that this information is communicated. ■ External data are not used to benchmark program effectiveness and identify opportunities for improvement related to quality indicators selected for each department. ■ Patient care and patient-care associated contracted services lacked qualitative metrics/ benchmarks identified in their contracts, and the required approval of the governing body.
Compliance tips for:
QAPI is an organization-wide program that tracks quality across all departments and locations of the hospital. This standard focuses on the establishment of these metrics: what they are, how and when they are to be collected and analyzed against external benchmarks and prior organizational performance. ■ Inventory all patient care services, including contracted services to ensure that metrics are established for each. ■ Educate contract owners on data collection requirements and reporting frequency. ■ Place contracted services quality monitoring on a reporting schedule for QAPI Committee review and discussion. ■ Research external benchmarks to create goal targets for performance.
Nerd Newbies (understand the requirement)
Compliance tips for:
This standard focuses on the presence, completeness, and accessibility of a patient rights document. Compliance should be simple: every required right is spelled out in the ACHC standard. The language can be copied directly.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
■ Audit for the presence of a patient rights posters in all departments.
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
■ Add patient rights education to annual staff training.
Nerd Trailblazers (prepare the path for others)
achc.org | (855) 937-2242 | 17
16
Volume 2025 | No. 2
SURVEYOR
ACUTE CARE HOSPITAL
15.02.14 Violent restraints and/or seclusion: One-hour face-to-face assessment 15.02.15 Violent restraints and/or seclusion:
15.02.07 Restraint or seclusion: Modification of the plan of care Frequency of the citation: 32% Overview of the requirement: An order for the use of restraint or seclusion requires a modification to the individualized plan of care. Comment on deficiencies: Compliance is evaluated by reviewing medical records of patients who required restraint or seclusion. Examples of ACHC Surveyor findings: ■ Based on review of closed records for the use of violent restraints, one of two care plans identified the use of non-violent restraints instead of violent restraints and did not note discontinuation of restraints until seven days after they were no longer in use. ■ In four of five records where restraint use was documented, the plan of care was not modified to reflect that restraints had been discontinued. ■ Hospital policy requires that initiation of restraint use and plan of care updates are completed by the end of the shift. One file reviewed was missing a timely entry.
One-hour face-to-face assessment components
Frequency of the citation: 15.02.14 26%, 15.02.15 29%
Overview of the requirement: These closely related standards identify who must perform a one-hour face-to-face assessment and what that assessment must include when restraint or seclusion is used to manage violent or self-destructive behavior. Comment on deficiencies: Compliance is based on interview and review of hospital policy and medical record documentation. Examples of ACHC Surveyor findings: ■ Violent restraint records did not have a dated or timed face-to-face evaluation completed within the one-hour time frame requirement. ■ Documentation was missing for a face-to-face assessment within one hour by the physician or a trained RN. In one case, an assessment was conducted two hours after the initiation of chemical restraint, in another, there was no assessment noted. Hospital policy requires a physician assessment/in-person evaluation completed within 30 minutes of notification of the event. ■ The facility's restraint/seclusion policy states that the face-to-face evaluation will "evaluate the patient's immediate situation, response to the intervention, medical and behavioral condition, and the need to continue or terminate the restraints." The physician evaluation was missing:
Compliance tips for:
■ When restraint or seclusion is ordered, the plan of care must identify the rationale for their use, the intervention(s) selected, and the plan for patient monitoring including the frequency of reassessment of vital signs, safety, comfort, mental status, skin integrity/circulation checks, hydration, toileting, and readiness for release. ■ Audit records of patients for whom restraint or seclusion was ordered to ensure the plan of care includes all required information, including the discontinuation of the intervention. ■ Train staff on documentation to ensure that the plan of care modification reflects a process of assessment, intervention, and that ongoing evaluation data are included in progress notes.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
ٝ The patient's behavioral condition. ٝ The need to continue the restraint.
Nerd Trailblazers (prepare the path for others)
achc.org | (855) 937-2242 | 19
18
Volume 2025 | No. 2
SURVEYOR
ACUTE CARE HOSPITAL
Compliance tips for:
Compliance tips for:
When restraint (physical or chemical) or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within one hour after the initiation of the intervention by a qualified practitioner within their scope of practice. That face-to-face assessment must address: the patient’s immediate situation, their reaction to the intervention, their medical and behavioral condition, and the need to continue or terminate the intervention. ■ Audit violent restraint records for one-hour, in-person assessments. ■ Ensure the records address the four required elements.
Hospital policies are expected to guide staff in determining the type of restraint or seclusion used and appropriate intervals for assessment and monitoring based on the individual needs of the patient. Surveyors look for evidence that the policies are put into practice for all restrained or secluded patients. ■ Audit medical records for entries related to monitoring schedules.
Nerd Newbies (understand the requirement)
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
■ Train staff qualified to provide monitoring on the required time frames. The ACHC Standard provides suggested parameters but hospitals should not blindly write these into policy without committing to enacting procedures to ensure compliance.
Nerd Trailblazers (prepare the path for others)
Nerd Apprentices (audit for excellence)
■ Confirm that practitioners performing face-to-face assessments for violent restraints or seclusion have been appropriately privileged.
Nerd Trailblazers (prepare the path for others)
15.03.01 Identifying patients at risk 15.03.02 Environmental safety risks
15.02.17 Monitoring of the patient Frequency of the citation: 42%
Frequency of the citation: 15.03.01 32%, 15.03.02 35%
Overview of the requirement: A patient who is restrained or secluded is monitored by a trained professional to prevent injury or death, and to ensure that the intervention is ended at the earliest possible time. Comment on deficiencies: The standard is evaluated through document review. Most deficiencies noted variance between policy and actual practice related to the frequency of monitoring. Examples of ACHC Surveyor findings: ■ The facility restraint policy does not address the frequency of monitoring or assessments of patients for either violent or non-violent restraints. ■ Non-violent restraint records lacked evidence of assessment every two hours. ■ Based on medical record review, records lacked evidence of monitoring documentation for a patient in violent restraints every 15 minutes as required by hospital policy. ■ For four-point violent restraint episodes, documentation is required every 15 minutes with specific assessments. ‘Physical discomfort' was absent for entire episode of restraints, and two checks lacked 'psychological status' as required by hospital policy. ■ Based on interview with the day shift ED manager, patients who are in seclusion are periodically monitored by staff. Hospital policy is silent on the frequency of monitoring and assessment for seclusion.
Overview of the requirement: These closely related standards require that all inpatients and Emergency Department patients are screened for risk of harm to self or others and that patient care areas undergo at least annual environmental risk assessments for ligature points, and access to sharps, harmful substances, cords or tubing, breakable glass, etc. Comment on deficiencies: Compliance is assessed through direct observation, and review of documentation. Surveyors noted patient screening policies that omitted required elements or were not followed in actual practice. Many citations noted missing environmental risk assessments or failure to take mitigating action identified by existing risk assessments. Examples of ACHC Surveyor findings: ■ Hospital policy allows family members to provide 1:1 observation. During interview, staff noted that a family member could be responsible for performing 1:1 monitoring for a suicidal patient. This is in violation of policy and regulatory requirements. ■ The adult and adolescent BH unit had adopted screening, identification, and assessment processes. The methods outlined in the policy were not congruent with current nationally recognized tools. The policy did not clearly identify risk levels or interventions to be implemented based on risk. ■ No evidence of staff training on hospital policy regarding patient-at-risk screening, removal of at- risk items from patient room, and implementation of a 1:1 sitter.
achc.org | (855) 937-2242 | 21
20
Volume 2025 | No. 2
SURVEYOR
ACUTE CARE HOSPITAL
CHAPTER 16: NURSING SERVICES 16.00.10 Plan of care Frequency of the citation: 26%
■ Medical records lacked documentation of screening to identify risk for self or others. ■ One of three ED medical records for patients assessed at high risk for self-harm had a one-and-a- half-hour delay for initiating 1:1 observation as required by facility policy. ■ The hospital lacked evidence of a policy related to an annual environmental risk assessment. ■ The hospital lacked evidence of an environmental risk assessment for the emergency department, ICU, med-surg, OB and pediatric units. ■ The environmental risk assessment did not identify any environmental safety risks or strategies to minimize risks. ■ The adult BH unit was found to have multiple ligature and/or risk points (more than 40 items) in the environment. These include hospital-style beds in some rooms, chairs, tables, sink faucets, door handles, electronic equipment, power cords, and two open nurses' stations accessible to patients via a low counter with access to items that can easily be thrown (computer, chairs, rolling carts, printers, etc.), office supplies, and telephone cords. The hospital’s environmental risk assessment listed these items and documented a mitigation strategy to increase levels of observation/ intervention according to assessments for suicidality. Medical record review of patients admitted with a diagnosis of suicidal ideation lacked evidence of required interventions for suicidal patients as identified on the environmental risk assessment.
Overview of the requirement: Each patient has an individualized nursing care plan based on assessment of treatment goals, physiological and psychosocial factors, and discharge planning. The care plan is kept current through updates and revisions in response to ongoing assessments. Comment on deficiencies: Hospital policy and medical records are reviewed to determine compliance. Most findings noted care plans that did not reflect assessment data or were inconsistent with medical care plans. Examples of ACHC Surveyor findings: ■ Hospital policy requires a nursing care plan initiated within eight hours of admission. Medical records lacked evidence of care plan implementation within this time frame. ■ Medical records lacked evidence of an established nursing care plan once a risk was identified on admission, as required by policy. ٝ Two of 30 nursing care plans lacked evidence of skin interventions required as indicated by the admission risk assessment; One of 30 nursing care plans lacked evidence of pain interventions required; Seven of 30 nursing care plans lacked evidence of VTE interventions. ■ Records did not contain care plans consistent with the physician's assessment for medical care. ٝ The physician identified diabetic care and respiratory (CPAP) needs, which were not reflected in the care plan. ٝ The physician identified that seizure care was required, which was not reflected in the care plan. ٝ The physician identified airway protection needs that were not reflected in the care plan. ٝ The physician identified coagulation needs that were not addressed in the care plan.
Compliance tips for:
These two standards work together for the safety of patients and others. Although all risks cannot be eliminated, hospitals are expected to: 1. Identify patients at risk for intentional harm to self or others.
Nerd Newbies (understand the requirement)
2. Identify environmental safety risks for such patients. 3. Provide education and training for staff and volunteers.
■ Audit patient records for inclusion of screening assessments. ■ Audit for annual environmental risk assessments for each patient care department. ■ Train staff on screening process to include risk of self-harm and risk of harm to others. ■ Bring awareness to what constitutes a ligature risk point and train staff on required mitigation actions when an at-risk patient is present.
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
Compliance tips for: Nerd Newbies
Each patient has an individualized plan of care. This standard focuses on the nursing care component, ensuring that it is consistent with the physician’s plan for medical care but addresses patient goals and other factors, as well as discharge planning. ■ Audit records of nursing care plans to ensure they are congruent with assessments and medical care plans.
(understand the requirement)
Nerd Apprentices (audit for excellence)
■ Promote integrated, multidisciplinary care and communication by developing the nursing care plan in coordination with other disciplines.
Nerd Trailblazers (prepare the path for others)
achc.org | (855) 937-2242 | 23
22
Volume 2025 | No. 2
SURVEYOR
ACUTE CARE HOSPITAL
16.01.02 Pain assessment and reassessment Frequency of the citation: 35%
16.02.02 Patients at risk Frequency of the citation: 29%
Overview of the requirement: Patient pain is managed through assessment, intervention, and reassessment. Policies and procedures identify standardized tools (pain scales) and define the means and frequency of monitoring. Comment on deficiencies: Compliance is evaluated through interviews and document review. Most deficiencies noted policies that did not require a quantitative or visual analog scale as a measurement for pain. Reassessment after medication administration was another frequent citation. Examples of ACHC Surveyor findings: ■ Records reviewed lacked evidence of a qualitative reassessment for pain after medication administration. Records lacked identification of a pain location as required by hospital policy. Records indicated Tylenol for pain; but pain was documented as zero in the medical record. ■ The hospital’s pain management policy requires a quantitative pain reassessment after the intervention has reached peak effect and documented evaluation and response within specific time frames. Medical records in the ICU lacked documentation of the effect of PRN pain medications. Medical records in the telemetry unit lacked reassessment after IV dantrolene PRN. ■ Records lacked a quantitative pain reassessment after pain medication administration. ■ ED patient records lacked documentation of a pain reassessment after administration of Toradol 30 mg IM. The hospital’s policy states, "reassessment must be completed within an hour." ■ ED records documenting patient pain levels of 5 and 6 had no additional documentation of actions taken to address the pain.
Overview of the requirement: The hospital assesses patients for risk of pressure ulcers, DVT, aspiration, malnutrition, and falls. Comment on deficiencies: Compliance is evaluated through document review. Deficiencies noted policies and records that were inadequate with regard to required assessments, either missing specific elements or failing to define actions taken based on the results of the assessment. Examples of ACHC Surveyor findings: ■ Hospital admission policies lacked the required risk assessment and reassessment for DVT/VTE. ■ DVT/VTE risks were documented, and patients were placed in low, medium, or high-risk categories. Interventions do not change with medium or high-risk categories (ambulation, SCDs and TED hose. Interventions do not include the need for a review of anticoagulation usage. ■ Three out of five nursing assessments reviewed lacked the fall risk assessment defined in hospital policy.
Compliance tips for:
The medical complications associated with risks identified in this standard are avoidable with proactive assessment. An admission assessment policy is expected to include the five items with a process of intervention to be implemented for at-risk patients. ■ Review policy for inclusion of all required elements. ■ Audit medical records for the presence of assessment results at admission and periodically (as defined by the hospital) during a patient stay.
Nerd Newbies (understand the requirement)
Nerd Apprentices (audit for excellence)
Compliance tips for:
Patients have a right to pain management. This standard requires consistent use of a standardized pain scale tool appropriate to the age and condition of the patient. Assessment is followed by medication and/or non-medication interventions and subsequent reassessment for effectiveness. ■ Review policies for inclusion of all required elements. ■ Audit patient records to confirm compliance with assessment and reassessment requirements. ■ Train staff to use the appropriate pain scale and the defined frequency based on the intervention chosen.
Nerd Newbies (understand the requirement)
■ Ensure annual review of the Falls Prevention Program.
Nerd Trailblazers (prepare the path for others)
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
achc.org | (855) 937-2242 | 25
24
Volume 2025 | No. 2
SURVEYOR
ACUTE CARE HOSPITAL
CHAPTER 24: NUTRITIONAL SERVICES
Compliance tips for:
Food products must be maintained to ensure safety and quality. This includes processes to identify expiration/discard dates and remove supplies prior to expiration. Products are stored at least six inches off the floor in a sanitary environment. All food preparation areas and equipment are maintained in sanitary condition and refrigerator and freezer temperatures are logged within specified ranges. ■ Ensure that food items are labeled and include expiration dates. ■ Rotate stock and supplies to use oldest products first. ■ Assign responsibility for daily temperature logging of unit-based refrigerators and freezers. ٝ Identify acceptable range temperature range. ٝ Educate staff to immediately report equipment maintenance issues. ■ Unit-based food products are the responsibility of nutrition services, but all staff can be trained to observe for and discard expired items. ■ Educate staff to avoid commingling patient-assigned food, staff food, and medications. ■ Include kitchen areas in environmental rounding for assessment of cleanliness and properly working equipment.
Nerd Newbies (understand the requirement)
24.01.03 Policy requirements: Food preparation and storage in patient care areas 24.01.08 Physical Environment Frequency of the citation: 24.01.03 61%, 24.01.08 39% Overview of the requirement: These two standards are closely related. The first addresses the requirement for written policies developed collaboratively by the food service department and patient care teams and reviewed by the Infection Control Committee for food storage and preparation in patient care areas. The second focuses on similar requirements in the hospital kitchen(s) and extends to include specific expectations for a sanitary environment. Comment on deficiencies: This standard is frequently cited for noncompliance. Evaluation involves direct observation, policy review, and review of temperature logs. Many deficiencies were the result of poor temperature management. Freezer/refrigerator logs were missing or temperatures logged were out of range without corrective action documented.
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
Examples of ACHC Surveyor findings:
CHAPTER 25: PHARMACY SERVICES/MEDICATION USE
■ Products (produce, proteins, dairy) lacked “use by” dates. ■ The walk-in freezer log was missing daily temperature checks for four of 20 days in August. The walk-in freezer’s daily temperature checks were outside the acceptable range on 15 of 20 days with no documentation of corrective action. ■ The dry food storage area had a buildup of dust and debris. ■ The dietary policy on cleaning had not been reviewed within the time frame required by the organization’s policy. ■ Significant dust and grease build-up was observed on the cooking hood and cooler fans.
25.01.03 Security of medications Frequency of the citation: 61% Overview of the requirement: Medication is secured to prevent unauthorized assess.
Comment on deficiencies: The standard is evaluated through observation, interviews, and document review. Most deficiencies noted the presence and easy accessibility of frequently diverted drugs. Examples of ACHC Surveyor findings: ■ The hospital allows patients to bring their medications from home; however, it has no process to secure them. ■ CT contrast media are stored in an unsecured cabinet (no locking mechanism). Anesthesia carts in four ORs were found to contain unlocked inhalant anesthetic (Sevoflurane).
■ Twenty-two desserts in the freezer were expired by nine days. ■ Food bins were stored directly on the floor of the freezer. ■ There was standing water on the floor of the dish room. ■ The walk-in freezer had ice buildup on the coil.
achc.org | (855) 937-2242 | 27
26
Page 1 Page 2-3 Page 4-5 Page 6-7 Page 8-9 Page 10-11 Page 12-13 Page 14-15 Page 16-17 Page 18-19 Page 20-21 Page 22-23 Page 24-25 Page 26-27 Page 28-29 Page 30-31 Page 32-33 Page 34-35 Page 36-37 Page 38-39 Page 40-41 Page 42-43 Page 44-45 Page 46-47 Page 48-49 Page 50-51 Page 52-53 Page 54-55 Page 56-57 Page 58-59 Page 60-61 Page 62-63 Page 64Made with FlippingBook - PDF hosting