Necessity to Hire Contractors for Completion of Physical Environment Checklist

The following article appeared in the Feb. 2011 issue of Connection, the e-newsletter from the AAAHC. Q: When preparing for my AAAHC/Medicare deemed status survey, do I need to hire contractors to help me complete the Physical Environment Checklist (PEC) and the attestations? Bill Lindeman, WEL Designs PLC, Physical Environment Consultant to the AAAHC: The deemed status survey process is predicated on organizations being primarily responsible for their facility’s compliance with applicable National Fire Protection Association (NFPA) standards. The AAAHC Physical Environment Checklist (PEC) was written to enable an organization to effectively verify that design and construction professionals who worked on their facilities applied and conformed to the NFPA standards. While CMS has accepted this approach, the AAAHC is nonetheless required to validate each organization’s good faith effort in determining its compliance hence the wording of the introductory section of the PEC, and the requirement that surveyors randomly check a variety of PEC items with each survey.

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The introductory section of the PEC identifies four categories of regulatory focus in the PEC, and asks for descriptions of the qualifications of the personnel who completed each section of the document. However, the PEC never defines what those qualifications must or should be. The intent is simply that whoever answers each question should understand its meaning; and that the subject matter tends to fall into four categories that may or may not require different people to meaningfully assess each of them.

Most items in the PEC are narrative compilations of the most easily understood, and freely visible, manifestations of compliance with far more complex technical issues. As such, expertise in design or engineering of ASCs should not be required. What is necessary are individuals able to carefully read each given item, and truly/critically evaluate the particular aspect of the given facility. The greatest challenge is to not jump to the desired conclusion, such as: “It wasn’t a problem last time,” or “We hired experts to design it,” or “Prior surveyors didn’t say it was a problem . . . so it MUST be right;” but instead determine if the facility demonstrates what the PEC item describes (just like a surveyor will do).

The PEC enables organizations to double-check for themselves the work of those involved with the design, construction and/or maintenance of their facility. It is entirely possible that the best people for the job are those working in the facility every day, as they routinely deal with the operational aspects of the facility and train for emergency preparedness.

 

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Read more from AAAHC:

 

12 Findings on Colonoscopy From the AAAHC Institute

 

AAAHC Introduces New Handbook for Organizations Seeking Medicare Deemed Status

 

AAAHC Releases Changes to 2011 Accreditation Standards Handbook

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