Patient Care Facility Accreditation Guide

October 2023


Facility Safety and Management (FS)

ABC’s Facility Safety and Management Standards are designed to ensure the location and environment of patient care is appropriate for the items and services provided. These Standards address three critical categories: facility safety, safety management and environmental safety.

1. Facility Safety                                                                                                                                                                  The Standards require your facility to appropriately accommodate patients and provide an office space to adequately fulfill your patient care and business activities. Further, the Standards require that your facility comply with all appropriate health, fire and occupancy codes, including appropriate requirements of the Americans with Disabilities Act (ADA).

2. Safety Management                                                                                                                                                      Safety management requires that accredited facilities implement processes designed to maintain and improve the quality of the patient care environment. You are expected to establish a safety management program commensurate with the scope and complexity of the items and services provided in order to assure a continued safe physical location and environment. The Standards also require that a Safety Officer be appointed to oversee the program, carry out inspections and perform an evaluation of those inspections. In addition, you must develop specific plans to respond to potential emergency situations, including fires and disasters common to your geographical location. Personnel must be trained to carry out duties and responsibilities specified in the contingency plans. Finally, you must have a plan to facilitate the continuation of patient care services in the event of a disaster (including power outages and technical malfunctions) affecting the facility, the region or a larger area.

3. Environmental Safety                                                                                                                                                Facilities should implement policies and procedures that minimize patient and staff exposure to health and environmental risks. The Standards require adoption of appropriate infection control procedures, including the use of universal precautions and other aspects of OSHA’s blood borne pathogens regulations. In addition, you are required to administer an equipment management program that is designed to assure proper performance of your equipment and is supported by appropriate preventive maintenance programs.


You must have a written safety management program designed to:

  • Provide a physical environment free of hazards
  • Manage staff activities to reduce the risk of injuries

Your written safety management program must include, but is not limited to:

  • Information concerning specific procedures to be followed by staff
  • Provisions for the management of patients
  • Provisions for compliance with relevant OSHA standards
  • Access to Safety Data Sheets (SDS) for any on-site chemicals
  • Evaluation of the results of the safety inspection


You must have written policies and procedures that reduce the risk of injury to employees and patients. The policies must include specific procedures to be followed by staff and specific requirements for the management of patients. You may find the OSHA website (link) helpful in developing your safety management program.


Your safety management program must describe and document annual safety inspections of your facility and operations.


You must prove that you conduct annual safety inspections of the facility and document any corrective actions taken as a result of the inspection.


The interior and exterior of your buildings and grounds must be appropriate to the nature of the services provided and to the patient population served. In compliance with applicable laws, your facility must be designed to accommodate the needs of the physically challenged, including but not limited to:

1. Appropriate exterior handicap access; including the path from the parking lot to the facility

2. Ramps and/or elevators that comply with federal, state and local requirements for handicap access

3. Interior areas for patient use including restrooms that are wheelchair accessible as well as designed and equipped to meet the needs of disabled persons

4. A patient waiting/reception area, as applicable

5. Compliance with state and local health codes and occupancy classifications for your location

6. Ensuring there is adequate space to manage the business 


Each of your patient care locations must provide specific dedicated private treatment areas that are properly equipped for patient evaluation and care.


A private treatment area is one that provides visual and auditory privacy.


You must annually conduct and document a safety management orientation for all staff that addresses:

1. General safety management issues

2. Safety plans

3. Emergency preparedness

4. Emergency plans

5. Special hazards related to assigned duties

6. Safety practices

7. Changes in your safety management program


The annual training should include any changes in the safety management program since the last training. You should have training guides or employee handbooks to use in conducting safety management orientations for employees. You must document this staff training with sign in sheets, program agendas or course certificates


If you utilize specialized emergency equipment such as an Automatic External Defibrillator (AED), your staff must be trained in the proper use of that equipment. You must document this training.


You must document this staff training with sign in sheets, program agendas or course certificates. 


You must have a written emergency evacuation plan that addresses appropriate staff response to fires or other emergencies. Based upon occupancy classification, the program includes provisions for appropriate fire alarm and fire suppression systems.


Your emergency evacuation plan should include an evacuation route as well as the duties of specific staff in the event of an emergency. These duties might cover who is responsible for calling fire and other emergency personnel and who is responsible for checking that all patients have safely evacuated the premises. Your drill also needs to include testing of the fire suppression and/or alarm systems, if applicable.


You must conduct an annual emergency evacuation drill in accordance with the evacuation plan. The drill(s) must be done for all staff on all shifts.


                                                                                                                                                                                      You must write an evaluation of the effectiveness of the emergency evacuation plan and                annual drill. Results of the evaluation must be included in your performance management            plan.


Your evaluation might include items such as timeliness of the evacuation, confirmation that all staff and patients exited the premises, all staff gathered at the predetermined meeting location and that the all clear procedures for returning to the facility were followed. The written evaluation should be kept in your emergency preparedness files. Use the Fire Emergency Drill Documentation form in the online Resource Kit to document your drill.


You must have a written disaster preparedness program designed to manage the consequences of natural disasters or other events that threaten your business’s structural integrity, infrastructure, including electronic records and/or ability to serve your patients.


Fires are not the only emergency for which you must be prepared. Other events such as natural disasters (e.g., flood, tornado, hurricane, ice or windstorms) or widespread and lengthy power outages could also disrupt your ability to serve your patients. You must provide documentation that you have a plan to manage the consequences of a disaster or interruption. This should include a process for data backup and/or restoration in order to continue operations in the event of a disaster or contracts and/or agreements with other companies to assist with patients


You must have policies and procedures that prohibit the use of smoking materials within your facility.


This policy should be included in staff orientation and training as well as posted in a location visible to all staff and patients. 


You must have policies and procedures for the use of universal precautions to minimize the risk of transmission of infection when caring for patients. As appropriate, these policies include procedures to comply with:

  • Occupational Safety and Health Administration (OSHA) blood borne pathogen regulations
  • Centers for Disease Control (CDC) guidelines
  • World Health Organization (WHO) hand hygiene protocols


A copy of this policy should be placed in your policy manual and be available to all staff. You must document that staff has been trained on these policies and procedures with sign in sheets, program agendas or course certificates. 


You must maintain suitable cleanliness of your facility and equipment used in patient care. You must have appropriate hazardous waste disposal procedures in accordance with the services you offer.


Staff training should include what is appropriate cleaning of the facility and equipment, even if you use an outside cleaning service, and a process to respond to pest infestation. You must have a process to ensure that your staff is trained and consistently follows appropriate hazardous waste disposal procedures. Hazardous waste disposal monitoring should be part of your performance management plan.