Patient Care Facility Accreditation Guide

ABC’s Facility Safety and Management Standards address facility safety, safety management, and environmental safety.

FS.1

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

Tip

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

FS.1.1

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

Tip

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

FS.2

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 

FS.2.1

Each patient care location must provide dedicated, private treatment areas that are properly equipped for patient evaluation and care.

Tip

A private treatment area that provides visual and auditory privacy.

FS.3

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

Tip

Annual training should include any changes to 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

FS.3.1

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.

Tip

Your emergency evacuation plan should include an evacuation route and the specific duties of staff in an emergency. These duties might cover who calls fire and other emergency personnel and who ensures all patients have safely evacuated the premises. Your drill also needs to include testing of the fire suppression and/or alarm systems, if applicable.

FS.3.2

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.

FS.3.3

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.

Tip

Fires are not the only emergency you must be prepared for. Other events such as natural disasters (e.g., flood, tornado, hurricane, ice or windstorms) or widespread, 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 to continue operations in the event of a disaster or contracts and/or agreements with other companies to assist with patients

FS.4

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) bloodborne pathogen regulations
• Centers for Disease Control (CDC) guidelines
• World Health Organization (WHO) hand hygiene protocols

Tip

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

FS.4.1

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.

Tip

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