Recovering The SelfA Journal of Hope and Healing


HFAP Reports: What Are the Top 5 Most Common Deficiencies in a Typical Healthcare Environment?

by Jenny Griffiths

The Healthcare Facilities Accreditation Program (HFAP) releases annual quality reports to illustrate commonly found deficiencies in healthcare environments. The purpose of these reports is not just to illustrate top deficiencies, but also to offer tips on how to overcome obstacles to achieve accreditation. Read on to find out about five common deficiencies in a typical healthcare environment.


1. Infection Control Issues

Infection control protocols include proper hand hygiene, sanitary environmental conditions, access to sufficient personal protective equipment, and the ability to isolate infected patients successfully to prevent the spread of disease. Patient Isolation Carts make it easier to comply with HFAP standards, but facilities and equipment must also be kept in sanitary conditions. This means keeping them free of dust, dead insects, and rust, and ensuring all surfaces are sanitized frequently to prevent the spread of disease.

2. Physical Environment Violations

Common physical environment violations of the HFAP guidelines include untested fire alarms, sprinkler systems, and emergency generators as well as insufficient access to emergency supplies. The rate of physical environment violations is highest in critical access hospitals, but acute care hospitals come in a close second. Resolving these issues requires the collaboration of facility managers, engineers, and clinical care supervisors.

3. Improper Documentation

Just under 70% of healthcare facilities have been cited for deficiencies in documentation. In some cases, patient allergies went undocumented. In others, dates were left off charts, assessments went uncompleted for a week or more after procedures, or patients’ medical records were not updated to reflect important changes. Improper documentation of patient or procedural information can lead to unnecessary risks, so healthcare facilities must educate employees to ensure they understand the importance of accurate and immediate documentation of changes in a patient’s condition.

4. Deficiencies in Emergency Management

Acute care hospitals and critical access hospitals are required by the HFAP to have a detailed Emergency Operations Plan (EOP) in place that meets local, state, and federal requirements, yet many facilities have failed to complete sufficient plans that meet HFAP standards. HFAP standards include ensuring that the EOP designates specific responsibilities and service capabilities, ensures sufficient access to medical supplies, assesses the specific needs of at-risk patients, and establishes nutritional service policies.

The first step facilities that have been found deficient in this area should take is to review the requirements for HFAP certification. Hospitals must evaluate and update their EOPs annually and provide accurate documentation of these evaluations to demonstrate their compliance with HFAP requirements.

5. Insufficient Development and Implementation of Quality Assessment and Performance Improvement Plans

Quality assessment and performance improvement (QAPI) plans are intended to provide a strong foundation for quality improvements in healthcare settings. They must identify areas of non-compliance and clearly designate what changes they will make to improve patient outcomes. QAPI plans must be broad enough to address all aspects of healthcare facilities’ operations, and many facilities are having difficulty demonstrating across-the-board improvements.

The Bottom Line

Compliance with HFAP standards helps to ensure patient and provider safety. It’s more important than ever that facilities take care to avoid deficiencies and ensure compliance with 100% of these regulations. Facility managers must ensure they meet and exceed all physical and administrative standards to avoid human error, reduce the risk of disease transmission, and ensure all patients receive the standard of care they deserve.

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