Volume 2024 | No. 2
SURVEYOR
FROM THE PROGRAM DIRECTOR
In nutritional services, standard 24.01.09 Lighting, ventilation, and temperature control also ticked upward from three years ago, moving from a deficiency rate of 23% to 35%. The intent here is to mitigate the risk of food-borne illness through effective management of food preparation and storage areas. Noncompliance with this standard closely correlates with deficiency citations for 07.02.01. If your organization was cited for 24.01.09, it is highly likely that you also will be cited for the broader infection prevention standard. The third of these regrettable “upwardly mobile” standards is 25.01.03 Security of medications . Here the increase was from 30% in 2021 to 51% in 2024. This was the largest change in the wrong direction. Surveyor comments focused on inadequately secured drugs and ineffective disposal of unused medications, both situations creating opportunities for diversion. I also want to call special attention to standard 15.01.08 which was numbered 15.01.17 in 2021. The frequency of citation then and now was within one percentage point, but the importance of recognizing patients at risk of harm to self or others and implementing effective mitigation measures is of critical importance as we see more workplace violence occurring in hospitals across the country. Four additional standards ( 10.01.16, 15.02.08, 15.02.17,
Standard 06.03.08 Policy requirements: Food preparation and storage in patient care areas focuses on coordination between nutritional services and the unit-based staff through effective policies. This standard was also noted as a deficiency in many acute care hospitals. In both settings, Surveyors observed a failure to segregate patient-assigned food, to label and remove expired items, and to consistently monitor storage temperatures for refrigerated or frozen items. Standard 18.02.01 Risk mitigation measures for infection prevention , dominated last year’s chart at 100% and, like its equivalent for acute care hospitals, (07.02.01), it is again most prominent in this year’s results. The expansiveness of its scope, which encompasses all areas of the CAH, makes it especially challenging. The last of the top three (an undesirable distinction) is 17.01.06 Evacuation . This standard ties to the emergency operations plan and specifically to identifying how the needs of varying patient populations will be managed, including a strategy for those who may refuse evacuation. We know that many facilities are still recovering from operational challenges brought on by the pandemic, but ACHC’s hospital team is invested in supporting your success. Take advantage of our monthly Coffee Chats, the growing list of free webinars, new master classes, and other resources through ACHCU. And don’t forget about ACHCU Academy! It will be in Dallas, in March 2025 and offers a fantastic opportunity to learn face-to-face with our team and with your peers from other hospitals. I hope to see you there.
The 2020 merger of ACHC and HFAP included significant efforts to provide a smooth transition for continuing customers and a warm welcome to new and transitioning organizations. This year’s Surveyor represents a milestone for the Acute Care Hospital and Critical Access Hospital Quality Review Edition . The data now span a period that allows comparison with survey results reported in 2021. This comparison is relevant as a progress check for the cohort of hospitals that were surveyed as HFAP became part of ACHC. Physical Environment and Life Safety Results You’ll find the most frequent deficiencies in these areas in separate charts on page 20 for acute care hospitals and page 38 for critical access hospitals. Acute Care Hospital Clinical and Administrative Results In 2021, 12 standards were identified as not compliant on at least 20% of the surveys analyzed. Those 12 divided neatly in thirds, with eight (2/3) showing improved performance in 2024 data. This is commendable for the cohort of renewing hospitals. Four topics (staff competency assessment, product recall management, QAPI Program scope, and emergency preparedness in nutritional services) improved such that they fell below the threshold for inclusion in this year’s Quality Review . The four others ( 07.05.04, 08.00.03, 18,00.08, 24.01.08 ) remain above 20% and are covered on the following pages. My comments here will focus on the remaining three that saw declining compliance and one standard with an essentially unchanged percentage. Standard 07.02.01 remains the most often cited deficiency and unfortunately, the frequency of this finding increased from 2021 to 2024 (60% to 65%). The data demonstrate consistency in Surveyor evaluation because the percentages are quite consistent for this overlapping group of hospitals. By contrast, last year almost 90% of the acute care hospitals surveyed were cited for this standard. To improve, hospitals must seek commitment from every individual in every department to find, report, and correct issues related to cleanliness and maintenance of the facility.
15.03.02 ) are new to the report this year. Critical Access Hospital Clinical and Administrative Results
For CAHs, we are taking a close look at 14 clinical and administrative standards that were cited on at least 30% of the surveys performed. In 2021, only five standards rose to that level, but another nine were noncompliant on 27% of the surveys analyzed that year for a similar overall count. Comparing years, however, only three standards appear on both lists (05.05.03, 06.03.08, 18.05.04), and each was more frequently cited in 2024 than in 2021. Of the three standards that received the highest number of deficiencies, only one is a carry-over from 2021.
Deanna Scatena, RN Associate Program Director
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