All Rights Reserved. As AAAHC begins our fifth decade of service to ambulatory health care centers, we continue to build on our mission and vision to improve health care for patients one facility at a time. Life Safety Documentation Requirements Revision: 2; 7-28-17 Based on the 2012 edition of the Life Safety Code, for Ambulatory Surgical Centers Date Assessment: _____ The Accreditation Handbook for Ambulatory Health Care, v41 is designed for ambulatory care organizations seeking AAAHC accreditation or Accreditation with Medical Home or Dental Home. 2023 Accreditation Association for Ambulatory Health Care, Inc. AAAHC will inform you of the accreditation decision. Methods for providing feedback, including complaints is posted. Review infection control risk assessment and practices to ensure they align with CDC recommendations for managing COVID-19 Assess how much personal protective equipment is in stock and monitor potential alternatives in the marketplace Implement contactless vendor services to ensure vendors and staff are protected 3. Initial accreditation surveys apply to organizations currently not accredited by AAAHC and have been providing services for at least six months before the onsite survey, or organizations with expired AAAHC accreditation that are again seeking accreditation through AAAHC. Food and drink only in designated areas:
* No evidence of it in patient areas, hazardous chemical storage area, laboratory specimen area, or any area where cross contamination may occur. Items are to be assessed primarily by surveyor observation, with interviews used to provide additional confirming evidence of observations. Final days for Early Bird: Register for Achieving Accreditation today! Please enter in a search term to continue. An organization is considered for accreditation by AAAHC on an individual basis and is eligible for accreditation if it meets all of the following criteria. CLIA waiver exists for staff performed blood and urine tests. Pre treatment of instruments is observed prior to delivery to CS: Instruments are in good working order and not bent or broken: Instruments requested for surgery are present prior to patient entry to OR: Instruments have all paramenters met and are confirmed by OR staff prior to patient entry to OR: Steris recycle bins and Biohazard instrument disposal bins are not overflowing: CS staff are wearing proper attire to transport dirty instruments: CS department equipment is in proper working order and/or work orders in progress: Vendors are adhering to policies and procedures with regard to requests: AAAHC accreditation is current and posted for viewing in a public area. Not expired. The AAAHC Quality Roadmap provides a thorough analysis of data from previous surveys conducted using current Standards, and helps support ongoing quality improvement throughout your accreditation cycle. Controlled substances are secure/policies are followed. Kershner QI Awards recognize excellence in quality improvement methodology and outcomes for AAAHC-accredited organizations in both the surgical/procedural and primary care space. Please enter in a search term to continue. The best way to achieve accreditation is to delegate tasks. Initials of person completing check are present. AAAHC denies accreditation to an organization when it concludes that the organization is not in substantial compliance with AAAHC Standards and/or policies and procedures. Immediate Implementation: CMS COVID-19 Vaccination Tracking. All Rights Reserved. Please note that the login you may have used to purchase items will not work for the Online Application for Survey. Able to promptly deliver requested logs and materials required for review. These requirements provide guidance on COVID-19 vaccination tracking. Please take the opportunity to look more closely at these survey findings and take advantage of the broad portfolio of educational programs and quality improvement resources that we offer here. AAAHC expert faculty will discuss the new CMS QSO-22-07 requirements impacting your organization. Microsoft Word - AAAHC Readiness Checklist v41 - MDS - Client 022021 v4 Author . No outer shipping carton boxes in patient care areas. AAAHC Grows Surveyor Talent with Intensive Training and Development August 17, 2022 Press Releases AAAHC Calls for 2022-23 Bernard A. Kershner Innovations in Quality Improvement Award Submissions August 9, 2022 Press Releases AAAHC Unveils Winners of the Bernard A. Kershner Innovations in Quality Improvement Award August 2, 2022 Press Releases Staff address mock survey team, smile and are helpful? AAAHC offers tools, resources, and education throughout your pre-survey planning. AAAHC provides tools and resources designed to assist ambulatory health care organizations in the pursuit of ongoing quality improvement.
*. You have just activated six months of membership as a pre-accredited practice. Final days for Early Bird: Register for Achieving Accreditation today! "Scrub the hub"-vial tops wiped and hubs scrubbed prior to administration(alcohol:15 secs, CHG 30 secs). Please enter number of files reviewed, missing items and due date. AAAHC holds deeming authority from the Centers for Medicare & Medicaid Services (CMS) to conduct deemed status accreditation for ambulatory surgical centers (ASCs). Open: Tue - Sun: 09am - 07pm, Sun: closed 1611 Linden Avenue 407, New York 01-382-4311, 301-461-9678 You may also use the wildcard character, %, if you are not sure of the exact organization name.
* Patient information is not discussed in public areas.
* Labels and PHI are obliterated before discarding in the trash. 2023 Accreditation Association for Ambulatory Health Care, Inc. Access education on our Learning Management System. AAAHC determines the length of the onsite visit and the number of surveyors based on your Application for Survey and supporting documents. In the final column, staff can indicate whether or not the correct documentation is present. Documentation is present for actions taken to correct out of range temps. The Joint Commission Life Safety & Environment of Care Document List and Review Tool 2021 Page 2 of 17 Legend: C=Compliant; NC=Not compliant; NA=Not applicable; IOU=Surveyor awaiting documentation STANDARD - EPs C See Legend Document / Requirement Yes No NC NA IOU LS.01.01.01 Buildings serving patients comply w/ NFPA 101 (2012) Application fees are non-refundable. Cookie Policy. These factors determine your survey fee. Fire extinguishers have been inspected monthly.
* Random sampling extinguisher tags checked. Author: Frank White Created Date: 5/14/2020 3:41:54 PM . AAAHC delivers up-to-date Standards for a variety of program types, along with interactive, engaging education and tools conveniently accessible to our clients. Any additional comments regarding positive or suboptimal issues observed during the tracer. AAAHC Publishes Medication Reconciliation Benchmarking Study Findings. AAAHC surveyor(s) conduct the survey. Organizations may receive a three-year term with intracycle activities required for continued assessment of ongoing compliance with the Standards. Medication errors account for 3.5 million physician office and 1 million emergency room visits per year. Use EP Tool and Appendix Z for guidance. Instructions: The following is a list of items that must be assessed during the on-site survey, in order to determine compliance with the infection control Condition for Coverage. Final days for Early Bird: Register for Achieving Accreditation today! Accreditation Handbook for Ambulatory Health Care, v42 - Print, Accreditation Handbook for Medicare Deemed Status, v42 - Print, Medical Home Onsite Certification Handbook - Print, Accreditation Handbook for Medicare Deemed Status v42 - Combo, 2018 Certification Handbook for Advanced Orthopaedics - Print, Accreditation Handbook for Ambulatory Health Care v42 - Combo, Accreditation Handbook for Medicare Deemed Status, v42 - PDF, Accreditation Handbook for Ambulatory Health Care v42 - PDF, Medical Home Onsite Certification Handbook - PDF, Accreditation Handbook for FEHB Health Plans v41 - PDF, Accreditation Handbook for Health Plans v41 - PDF, Accreditation Handbook for Medicare Deemed Status v41 - PDF, Accreditation Handbook for Ambulatory Health Care v41 - PDF, Certificates of Accreditation and Certification. COVID-19 Health Care Staff Vaccination Tracking, Immediate Implementation: CMS COVID-19 Vaccination Tracking, Patient-Centered Medical Home Certification, AAAHC Governance Unit Application Process, CMS COVID-19 Vaccination Tracking FAQs (PDF), CMS COVID-19 Vaccination Tracking Self-paced Module. Patient-Centered Medical Home Certification, AAAHC Governance Unit Application Process, Become familiar with award-winning QI studies, AAAHC Achieving Accreditation to Highlight New Standards with Interactive Participant Engagement, AAAHC 2022 Quality Roadmap Offers New Insight into Surveyor Findings in Ambulatory Settings, AAAHC Prepares Clients for v42 Standards at Achieving Accreditation, Diverse Medical Leaders Join AAAHC Board as New Officers, Directors, Elevate Your Quality Improvement Journey at the Live December Achieving Accreditation Conference, AAAHC Grows Surveyor Talent with Intensive Training and Development, AAAHC Calls for 2022-23 Bernard A. Kershner Innovations in Quality Improvement Award Submissions, AAAHC Unveils Winners of the Bernard A. Kershner Innovations in Quality Improvement Award, Tenured AAAHC Faculty and Expert Surveyors to Lead Virtual Conference for Ambulatory Practices, March Achieving Accreditation Conference to Provide Deep Dive into AAAHC Standards, AAAHC Hosts Winter Conference to Highlight Excellence in Ambulatory Care, AAAHC Announces New Board Officers and Directors. No expired items.
* Random sampling of supplies and equipment checked. Email: hrsaaccreditation@jointcommission.org. Separation of clean vs. dirty supplies & equipment:
* Clearly marked
* Clean items if stored in soiled utility are covered & clearly marked, Biohazard Waste:
* Discard in Red Bags with a biohazard symbol
* Not overfilled
* Covered when transported
* Chemo is handled and disposed of in proper collection bin, Wipes:
*Staff can speak to proper drying times of various wipes and use correct wipes on surfaces
*Proper drying time between case turnover and patients is witnessed, Sharps Waste:
* Placed in appropriate puncture resistant sharps container.
* Disposed of when 2/3 full or "full" indicator
* Mounted appropriately
* Recycling used instrument storage bin does not have items sticking out of bin
* Sharps waste has proper items in correct bin, General Cleanliness:
* Observe surfaces for high dust & residue, floors, stairwells, nutritional area, med prep areas, pt rooms & bathrooms
* No blood or bodily fluids. Congratulations! Reaccreditation surveys apply to AAAHC-accredited organizations and seek continuation of accreditation following a three-year term. American Association for Accreditation of Ambulatory Surgery Facilities 1. . Kershner QI Awards recognize excellence in quality improvement methodology and outcomes for AAAHC-accredited organizations in both the surgical/procedural and primary care space. Copyright © 2023 Becker's Healthcare. Linking and Reprinting Policy. The AAAHC Institute for Quality Improvement (Quality Institute) analyzes accreditation performance results for trends and compliance to AAAHC Standards, provides consolidated and curated research that informs standards development, and assists organizations with . We are facing the future together1095 Strong! The 2017/2018 Accreditation Handbook for Medicare Deemed Status Surveys will include the revised Physical Environment Checklist (PEC) from 2016 to reflect adoption of the 2012 editions of NFPA 99 and 101 by CMS and the new CMS requirements for emergency preparedness. Patient Bedside:
*. Linking and Reprinting Policy. All medications, needles and syringes are secured in locked cabinet or locked room or under constant surveillance. No extension cords are being used. The organization has a policy to ensure test results are reviewed and acknowledged in writing by the ordering physician or qualified designee. Dosimetry badges are worn, testing has been completed quarterly and results are maintained. Surveyors found that the areas with the highest deficiencies included: Infection prevention/safe injection practices Browse and order AAAHC tools and publications. Achieving Accreditation is an interactive, immersive event designed to help you learn and prepare for your AAAHC survey while developing a deeper understanding of AAAHC Standards. While accreditation standards may change over the years, our mission to improve the quality of health care through accreditation remains the same. Kershner QI Awards recognize excellence in quality improvement methodology and outcomes for AAAHC-accredited organizations in both the surgical/procedural and primary care space. The checklist below lists the standard number, the element of performance number, the item to be documented, and the accreditation program applicability for the required documentation. Discretionary surveys are conducted for cause, when concerns have been raised about an accredited organizations continued compliance with AAAHC Standards. Staff can state, identify, find or know about the following: * KP Learn
* UO Reporting: Culture of Safety and Reporting
* Red Rule/2 Patient Identifier
* Look alike-Sound alike drugs * Policies and Procedures. Patient care supplies:
* Not expired, damaged, soiled. If necessary, this meeting may be by conference call rather than in person. We are facing the future together1095 Strong! Effective, hands-on healthcare policy management will reduce risk, keep things running smoothly and make sure every staff member and provider is equipped (and fully licensed) to serve patients. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. AAAHC SurveyLink ACCREDITATION ASSOCIATION for AMBULATORY HEALTH CARE assisting ambulatory health care organizations improve the quality of care provided to patients Welcome to the AAAHC Staff Website! NCQA Government Recognition Initiative Program. Click below to download AAAHC Readiness Checklists. C-arms and U/S. 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