Crosswalk of 2014 HFAP Standards against HFAP Standards Acute Care Hospital Manual
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1 Operations Plan Hazard Vulnerablity Analysis (HVA) Safety & Security New Name Supplies (a)(2) Utilities ; Decontamination Personal Protective Equipment (PPE) Nutritional Services Score under Communication Incident Command Center Triage Evacuation Volunteer Management Business Continuity Exercises ; Chapter 9 Management Page 1
2 Education ; Chapter 9 Management Page 2
3 Condition of Participation: Physical Environment Condition of Participation Required Plans & Performance s Periodic Monitoring for Safety Issues Building Safety Safety Team / Committee Safety Team / Committee Facilitator Safety Officer Teams Appinted for Specific Areas Safety Team / Committee Functions Review of Safety Policies & Procedures Smoking / Tobacco Products Building Security Security Management Chapter 11 Physical Environment Page 3
4 Local Security Support Security Sensitive Areas Security Incident Procedures Hazardous Materials & Waste Program (b)(6) Storage & Disposal of Trash Program Minimizes Exposure Labels, Inventory & MSDS Personal Protective Equipement Hazardous Materials Routine Monitoring (b)(7) Written Fire Control Plans Fire Drill - Quarterly Fire Drill - Critique (b)(8) Approval by State & Local Fire Agencies Minimize the Risk of Danger from Fire Chapter 11 Physical Environment Page 4
5 Medical Equipment & Systems - Maintenance Medical Equipment Inventory Patient Call System Safe Medical Device Act (SMDA) Medical Equipment Procurement (a)(1) Power & Lighting Power Electrical System ; Generator Inspection ; Generator Monthly Load Test ; Generator 3-Year Load Test ; ; Automatic Transfer Switch Test Potable Water Medical Gas Shut- Off Valves Chapter 11 Physical Environment Page 5
6 Plant Equipment & Systems - Maintenance ; Plant Equipment Inventory Medical Gas Systems - Maintenance Water Temperature Control (c); (c)(2); (c)(3) Adequate Facilities and Supplies (c)(1) Facilities Located for Safety of Patients (c)(4) Ventilation, Light, & Temperature Control Americans with Disabilities Act Occupational Safety & Health Act (OSHA) Assessing Risk Prior to Construction Monitoring the Physical Environment Fire Response - Staff Training Chapter 11 Physical Environment Page 6
7 Crosswalk of 2014 HFAP s against HFAP s (b)(1)(i); (b)(2); (b)(3) Life Safety Code Compliance ; ; Alternative Life Safety Measures - Policy Alternative Life Safety Measures - Implementation January Notification of Response Forces January Facility Demographic Report (FDR) ; Testing & Inspection - Definition of Time Testing & Inspection - Documentation Corridor Door Latching ; Door Locks January Corridor Width Suites Exit Signs Exit Discharge Corridor Projections January January January January Chapter 13 Life Safety Code Page 7
8 Crosswalk of 2014 HFAP s against HFAP s Path of Egress Obstructions Fire Alarm System - Installation Fire Alarm System - Testing Fire Alarm Systems - Transmitting Signal January Fire Alarm Systems - Technician Qualifications January Water-Based Fire Protection System - Installation Water-Based Fire Protection System - Testing & Inspection Water-Based Fire Protection System - Control Valves, Piping and Hangers January Fire Pumps - Weekly Test January Fire Pumps - Annual Test January Alternative Fire Suppression systems - Installation & Testing January Chapter 13 Life Safety Code Page 8
9 Crosswalk of 2014 HFAP s against HFAP s Water-Based Standpipes & Hoses - Inspection & Testing Water-Based Fire Department Connections - Inspection Portable Fire Extinguishers - Installation. Inspection and Maintenance Fire Rated Barriers January January January Smoke Compartment Barriers Fire & Smoke Damper - Testing January Overhead Rolling / Horizontal Sliding Fire Doors - Testing January Construction Types January Separation of Occupancies January Fire Rated Door Assemblies January Hazardous Areas Ceilings Corridor Walls January January January Chapter 13 Life Safety Code Page 9
10 Crosswalk of 2014 HFAP s against HFAP s Fireplaces Elevator Recall January January Trash & Linen Chutes January Decorations January Trash Receptacles January Portable Heaters To be Scored January Life Safety Drawings (b)(9)(ii) Alcohol Based Hand-Rub Dispensers ; ; Definition of New Construction and Existing Conditions January (b)(2) CMS Waiver of Life Safety Code Fire Safety Evaluation System January Chapter 13 Life Safety Code Page 10
HFAP Acute Care Hospital Manual Crosswalk of Standards against 2014 Standards
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Agency for Health Care Administration
Page 1 of 98 ST - Y0000 - INITIAL COMMENTS Title INITIAL COMMENTS Type Memo Tag These guidelines are meant solely to provide guidance to surveyors in the survey process. Based on the LSC surveyor's determination
Public Health Fax: Web Site:
State of Alabama Department of Public Health Fax: 334-206-5890 Web Site: www.adph.org.facmgmt Mike Free Building Construction Specialist Technical Services Unit Office of Facilities Management 334-206-5221