Top FAQs

Hospital Accreditation
September 30, 2015

Donna Tiberi ,RN, BS, MHA

Standards Interpretation &
Accreditation Manager

Objectives
Review of actual HFAPs
frequently asked questions (FAQs)
Increase awareness and
understanding of Acute Care
standard compliance
2

PLEASE NOTE
All Allied Health Professional
requirements have been deleted
from Chapter 2 and are now
located in Chapter 3 Medical
Staff.

FAQs
We thought it would helpful to review frequently asked questions
submitted by hospitals to provide clarification.
Often times accreditation organizations are told that there is
inconsistency with their FAQ responses. Organizations report that
they ask the same questions, but receive different answers. This
can be true. However, one reason why FAQs are answered differently
is because questions were phrased differently. Its not uncommon
for organizations to call in to AOs many times or submit the same
question multiple times for the same issue. Even one word can
change the answer!
Its important to remember that based on how a question is written
or asked will determine how our Standards Interpretation
department will respond to your question.

01.00.07
Governing Body Responsibilities
Q: The Acute Care standard (01.00.07)
requires that the governing board
bylaws address the responsibilities for
the physical plant. I do not understand
how to implement this. Do I need a
statement in the bylaws that speak to
what our current process entails?
5

01.00.07
Answer:

Governing Body
Responsibilities

The bylaws of the governing body must state that the governing body is
responsible for the "provision for the adequacy of the physical plant." This
statement establishes the role and responsibilities of the governing body to
ensure a safe environment for patients, visitors, and staff.
It is the responsibility of the governing body to review safety reports,
inspections, and other reports of the physical condition and take corrective
action, including the release of funds as necessary.
Be sure the committee minutes at each level, especially the governing
body, reflect the review of these reports and any corrective actions taken
as indicated.
The Governing Body must have a mechanism in place for the review of
the governance bylaws no less than every three (3) years, and must
complete a performance evaluation of itself within the past 12 months.

01.01.01
Categories Eligible for
Appointment
Mid-level Practitioners
Q: The Acute Care standard states that
the number of allied health
professionals that may be supervised
by a single physician is limited in some
states.
Where can I find the ratio so that I am
within the state limitations?
7

01.01.01
Categories Eligible for Appointment
Supervision of Allied Health
Answer:
Practitioners
You may refer to your state's Advanced Nurse
Practice Act and the Physician Assistant Practice
Act to identify whether there is a limit.
Governing Body defines AHP requirements
Remember that this information must be made
available to the surveyor at time of survey.
8

10.01.02
Information in Medical
Records
Q: The Acute Care standard (10.01.02)
states that parts of the medical record that
are the responsibility of the physician must
be authenticated by the physician.
The standard also stipulated that it is up to
the institution to define the rules &
regulations for authentication/delegation.
Are all history & physicals (H&Ps) subject to
co-signature?
9

10.01.02
Answer:

Information in Medical
Records

Medical staff policies identify those portions of the medical

record, if any, that may be delegated to a non-physician
practitioner. Medical staff policy, consistent with State law defines:
The portions of the medical record that may be delegated to nonphysician practitioners, such as:
Medical History
Physical Examination
Progress Notes
Operative Report
Discharge Summary

The requirements for co-signature and/or authentication, consistent with

State law for non-physician practitioners, especially:
Nurse Practitioners
Physician Assistants
Certified Registered Nurse Anesthetists (CRNA)
Certified Nurse Midwifes
10

03.01.15
Required Application and Reapplication:
Information to be Reviewed
Criminal Background Checks
Q: What type of criminal background checks are required to
run on employees? Per Indiana state law, we are required to
obtain limited criminal background history.
We are not obtaining: 1) social security trace; 2) county
criminal check for all counties lived; 3) multi-state, multi
jurisdiction search; and 4) all 50 states sex offender registries.
During our last survey, we were not cited but were questioned
about our searches. The surveyor mentioned that statewide
searches are pulled differently than multi-state searches.
Are our current searches acceptable?
11

03.01.15
Required Application and Reapplication:
Information to be Reviewed
Answer:
HFAP is not prescriptive. Criminal background
checks is often a state requirement and varies
greatly, state to state. There are many types of
searches to consider. Your human resources
department should develop this policy in collaboration
with the legal department.
The hospital will conduct criminal background
investigations based on information provided in the
application or as required by federal and state
regulations
12

03.01.15
Required Application and
Reapplication: Information to be
Reviewed
(continued )

The hospital will conduct criminal background checks

as allowed by State law for all potential new hires
This policy should establish how extensive the
criminal background check will be in terms of:
The number of years to be searched
Whether the search will be limited to your state or beyond. Some
facilities have implemented finger-printing for new employees, but
again this is not an HFAP requirement
Certain states have more extensive requirements for those employed
in nursing homes, behavioral health or mental health facilities

13

03.01.15
Required Application and
Reapplication
Q: Employment verification from former
employers has been increasingly difficult
and a time consuming task. We would
like to know what other means would
meet the standard?
We currently conduct skills checklists on
clinical staff and all new hires have a
background check.
14

03.01.15
Required Application and
Reapplication
Answer:
We would suggest developing a policy in collaboration with your
legal department outlining your process for obtaining reference
information.
This policy should specify the number of attempts that will be made
to obtain references. Perhaps you will mail two requests and send a
third as "certified mail."
The policy should also outline documentation expectations, e.g.,
"No response received from letter mailed on July 1, xxxx. Second
letter mailed to xxxx on July 17, xxxx."
Your facility may also consider the use of electronic means to
request this information. For some facilities, this has been an
effective means used by the Medical Staff officers to obtain
references in a timely manner.
15

03.01.15
Required Application and Reapplication:
Information to be Reviewed

Answer:

(continued)

At time of survey, your facility should be

able to speak to the requirements
established by your state and be able to
explain your policy & procedures.
The hospital must be able to speak to the
application request information regarding
any criminal history
16

03.01.18
Temporary Privileges

Q: What are the standard

requirements for assigning
temporary privileges to a
physician?
17

03.01.18
Temporary Privileges

Answer:

It is not permitted to grant temporary

privileges until such time as the appointment or
reappointment process can be completed.
All applicants requesting privileges must go
through the entire credentialing and privileging
process for approval.
For those that cannot wait, this means that an
ad hoc or Medical Executive Committee
meeting should be scheduled sooner than
planned.
18

03.01.18
Temporary Privileges
(continued)

Answer:
The medical staff bylaws should clearly define the process for granting
temporary privileges. Of course, your medical staff may prefer to wait until
all 3 references before the application is submitted to the chief/department
chair and CEO. Temporary privileges should be temporary and time-limited.
Inappropriate granting of temporary privileges could be a violation of the
Acute Care standard (03.01.12) Uniform Application of Membership Criteria)
that requires a uniform application of membership criteria. It is not
permitted to grant temporary privileges until such time as the appointment
or reappointment process can be completed. Please review the Acute Care
standard (03.01.18) for additional information.
All applicants requesting privileges must go through the entire
credentialing and privileging process for approval. For those that
cannot wait, this means that an ad hoc or Medical Executive
Committee meeting should be scheduled sooner than planned.
19

04.00.05
Competency

Q: Can you provide a

description of the scope of
practice for Licensed Practical
Nurses (LPNs)?

20

04.00.05
Competency
Answer:
The scope of practice for LPNs is defined
through your facility's policies & procedures
and in accordance with your state law.
The job descriptions must reflect the scope
of practice and how this individual will
function within your organization, including
supervision requirements in certain settings of
care.
21

04.00.05
Code Blue

Q: Is there a requirement for

conducting a mock Code Blue
(emergency code) exercise?
There is a requirement for fire,
but not sure about Code Blue.
22

04.00.05
Answer:

Competency
Code Blue

HFAP standards are not prescriptive. There is no standard that

speaks to hospital codes. However, the Acute Care standard
(04.00.05) speaks to staff competency per hospital policy.
Staff must be qualified and competent to perform their duties
as assigned. Conducting a mock "Code Blue" may be one
example your facility has defined as a policy to ensure staff
competence via practice.
If staff is required to be certified in Advanced Cardiovascular
Life Support (ACLS), Pediatric Advanced Life Support (PALS), Basic
Life Support (BLS), etc., the staff must also maintain certification
every two years as required per certification. Again, there is
no HFAP requirement for conducting a mock Code Blue.
23

04.00.09
Evaluation of Competence
Q: The Acute Care standard (04.00.09)
indicated that competence evaluations
should be at least on an annual basis.
Our organization is considering a change
in the timeline, but will maintain on an
annual basis. With this change, some
evaluations may be earlier or later than
the last evaluation. Is this acceptable?
24

04.00.09
Evaluation of Competence
Answer:
Yes, such proposed changes would be
acceptable. However, be sure to
memorialize your plan and the details of all
changes.
Also, be sure to document these changes
in your Leadership meeting minutes.
25

04.00.09
Evaluation of Competence
Q: Our leadership staff is considering
allowing Cath Lab Technicians to insert
Peripherally Inserted Central Catheters
(or PICC lines).
Is there a standard requirement about
who should be inserting intravenous
lines?
26

04.00.09
Evaluation of Competence
Answer:
Your facility defines the duties and responsibilities of each
discipline through a job description.
The Acute Care standard (04.00.09) requires that staff must be
competent in knowledge, skills and ability to perform their
responsibilities.
There must be an objective process performed at defined intervals
for assessing and evaluating the competence of all employees.
As long as your staff have completed appropriate training and
passed competency assessments, staff may perform procedures or
services within their scope of practice and in accordance with
hospital policy, state law & regulations.

27

04.00.10
New Employee Orientation &

04.00.11
Required Orientation Curriculum

Q: Are hospital-employed
physicians and hospitalists
held to the same standard for
orientation and ongoing
educational requirements?
28

04.00.10
New Employee Orientation &

04.00.11
Required Orientation Curriculum
Answer:
The Acute Care standards (04.00.10 and 04.00.11) require
orientation for all employees, including hospital-employed
physicians and non-employed physicians (hospitalists).
Orientation for non-employed physicians may be modified;
however, it must include all elements defined in the standard
(04.00.11). Orientation may be provided by either the medical
staff office, physician services department, or the human
resources department.
Your facility should have a policy that outlines the
orientation plan for your physicians. The orientation provided
is to be documented in the credentials files for each physician.29

04.00.10
New Employee Orientation
Contract Employee Records

Q: What is required of an
employee file, and maintaining
proper documentation for a
contracted employee?

30

04.00.10
New Employee Orientation
Contract Employee Records

Answer:

The facility is responsible to ensure that all employees, including

contracted employees, are competent. Maintenance of such
competence is in the design of your facilitys policy & procedures.
Competency assessment is an ongoing process. The facility will
define the competencies to be assessed annually, and those
competencies to be assessed at shorter defined time intervals.
The facility is also responsible to provide contracted employees an
orientation to the facility.
The orientation curriculum addresses specific information and
individual scope of service. You may review the following Acute Care
standards for more detail: 01.01.06, 04.00.05, 04.00.09, 04.00.10,
04.00.11, and 04.00.12.
31

07.01.02 & 24.01.16

Infection Control
Q: Does HFAP require the same titers
and immunizations for volunteers as
for in-house employees? If so, please
provide the related references.

32

07.01.02 & 24.01.16

Answer:

Infection Control

Yes, volunteers must meet the same requirements.

See Acute Care standard (24.01.16), Infection Control,
item D, states that
"employee health policies regarding infectious
diseases and specifically those infected or ill
employees, including contract workers and
volunteers, must not render food service and/or
must not report to work."
See - Acute Care standard (07.01.02) Infection
Prevention. Explanation: Measures to evaluate staff and
volunteers exposed to patients with infections and
communicable disease.
33

07.02.04
Preparing, Assembling, Wrapping, Storage of,
& Distribution of Sterile Equipment & Supplies

Q: Is there a standard that

address storage of sterile
instruments?
What is the recommended
temperature for all sterile
storage areas?
34

07.02.04

Preparing, Assembling, Wrapping, Storage of, &

Answer:Distribution of Sterile Equipment & Supplies
The Acute Care standard (07.02.04) addresses the requirements for storage and
distribution of sterile equipment. You may also want to review the CDC, AORN, AMII
guidelines as well for additional information. The following link will also provide you with
some additional insight as well:
http://www.infectioncontroltoday.com/articles/2011/05/infection-control-and-the-centralsterile-supply-department.aspx.
The recommended temperature for all sterile storage areas is 24C (75F). These areas
require at least 4 air exchanges per hour in a controlled relative humidity that does not
exceed 70%. Sterile items should be stored on or in designated shelving, counters or
containers.
Sterile items should be stored: 18" below the ceiling (or level of sprinkler head) because
adequate space is needed for air circulation and to ensure the effectiveness of sprinkler
systems. 8-10" above the floor to prevent contamination during cleaning and 2" for outside
walls because of condensation that may form on interior surfaces of outside walls.
The bottom shelf should be solid or contain a physical barrier between the shelf and the
floor. Heavy instruments packages should not be stacked due to the possibility of
compression. Outside shipping containers and corrugated cardboard boxes are exposed to
unknown and potentially high microbial contamination and should never be allowed in the
sterile storage area.

35

10.01.01
Content of the Record

Q: What is required in terms

of documentation in the
medical records for short
stays?
36

10.01.01
Content of the Record
Answer:
The medical record must reflect the
patient's entire care during his/her inpatient
or outpatient treatment.
The medical record must contain
information to justify admission, continued
hospitalization, support the diagnosis, and
describe the patient's progress and response
to medications and treatment services.
37

10.01.02
Information in Medical
Records

Q: Does HFAP recognize the

ability of mid-level practitioners,
such as Physician Assistants
(PAs), to co-sign for physicians
that have delegated the
performance of medical service
to this individual?
38

10.01.02
Information in Medical Records
Answer:
Yes - HFAP recognizes the ability of mid-level
practitioners co-sign for physicians.
Medical staff policies identify those portions of the medical record,
if any, that may be delegated to a non-physician practitioner.
Under standard 10.01. 02 it states that the Medical staff policy,
consistent with State law defines the portions of the medical record
that may be delegated to non-physician practitioners, such as:

Medical History
Physical Examination
Progress Notes
Operative Report
Discharge Summary
Also refer to standard 30.00.10 History & Physical.
39

10.01.02
Information in Medical
Records
Answer:

(continued)

The requirements for co-signature and/or

authentication, must be consistent with State law for
non-physician practitioners, especially:
Nurse Practitioners
Physician Assistants
Certified Registered Nurse Anesthetists (CRNA)
Certified Nurse Midwifes

40

10.01.05
Pre-printed Orders, Order Sets
& Protocols

Q: In regards to the Acute Care

standard (10.01.05), item #3,
what is the required frequency
for reviewing preprinted
orders, order sets and
protocols?
41

10.01.05
Pre-printed Orders, Order Sets
& Protocols

Answer:

All medication standing orders or routine protocols

are subject to annual review and/or revision
All protocols and practice guidelines for
patient care must be reviewed on an annual basis
to ensure all information is up-to-date with current
practice guidelines. The Medical standing orders
and protocols are to be reviewed by the professional
medical staff via its committee structure
42

10.01.18
Discharge Summary

Q: Is it a requirement to
have a list (or template) of
what to include in a
discharge summary?
43

10.01.18
Discharge Summary

Answer:

Your facility should have a policy approved by the medical staff that
outlines the expectations for the discharge summary, including
timeliness for completion and content. Please refer to the Acute Care
standard (10.01.18) Discharge Summary, for the entire requirement.
The medical records must contain a discharge summary with outcome
of hospitalization, disposition of case, and provisions for follow-up care.
The discharge summary requirement would include outpatient
records. For example:
1. The outcome of the treatment, procedures, or surgery
2. The disposition of the case
3. Provisions for follow-up care for an outpatient surgery patient or an
emergency department patient who was not admitted or transferred to
another hospital

*Discharge summaries must be completed within 7 days of discharge.

The medical record must be completed with in 30 days.
44

15.01.03
Complaints and Grievances
Q: If the governing body has
delegated the process for
resolution of complaints and
grievances to a committee or
department, does that committee
or department need to report back
to the governing body?
45

15.01.03
Answer:

Patient Grievances

Yes, the committee for complaints/grievances would need to

report back to the governing body. Communication reporting should
always go up to all leadership levels.
Please remember that the hospital's governing body is responsible
for the effective operation of the grievance process. This includes
the hospital's compliance with all of the CMS grievance process
requirements.
A written complaint is always considered a grievance and
information obtained from patient satisfaction surveys usually does
not meet the definition of a grievance.
Data collected regarding patient grievances, as well as other
complaints must be incorporated in the hospital's Quality
Assessment and Performance Improvement (QAPI) Program.
46

18.00.10
Conscious Sedation

Q: When performing
conscious sedation, the nurse
providing the sedation is also
monitoring the patient and
should not be the circulating
nurse. Is this correct?
47

18.00.10
Moderate Sedation: Assisting With
the Procedure

Answer:

Yes, this is correct. Standard 18.00.10 states that the proceduralist shall
have an assistant assigned whenever moderate sedation is administered; this
assistant may be another physician, RN, LPN/LVN, or technician.
The "monitoring" RN may be counted as the "RN planning and supervising
nursing care for the patient.
During survey the surveyors will review to determine that policy
requires moderate sedation cases to have a minimum of two (2) staff:
one (1) to monitor
one (1) to assist the physician

The nurse administering sedation cannot be the nurse assisting with the
procedure or be the circulating nurse in the room.
Please review the Acute Care standard (18.00.08 Moderate Sedation) for
additional information

48

19.00.13
Qualified Personnel

Q: What staffing
qualifications are required
to assist and provide
moderate sedation during a
bronchoscopy?
49

19.00.13
Answer:

Qualified Personnel Staff

Qualifications/Competency

Your medical staff will need to define the qualifications for staff that can assist with
patients receiving moderate sedation.
Hospitals are expected to regularly reassess staff competency and to provide
periodic training needed to keep staff skills up-to-date.
The hospital must document training completion dates and evidence of satisfactory
competence.
Staff that complete training but cannot demonstrate satisfactory competence must
not be permitted to use radiologic equipment and/or administer procedures
The qualifications should be written in either the job description or approved policy.
It is recommended that the education department prepare a training program with a
post-test to ensure competency. Both training program and post-test must be
submitted to the director of anesthesia for approval. You may review the Acute Care
standards (19.00.13/20.00.07/15.02.30) for additional information.
The Association of periOperative Registered Nurses (AORN) is a valuable
resource and may offer examples: (https://www.aorn.org/education/curriculum/confidencebased_learning/moderate_sedation.aspx). Also, the American Society of Anesthesiologists

(ASA) website provides guidelines relative to moderate sedation.

50

25.01.03
Security of Medications
Q: Our crash cart and Omni
medication system is located in an
alcove by the nurses' station. Do
they have to be behind locked
doors?

51

25.01.03
Security of Medications
Answer:
The crash cart and Omni medication system
must be maintained in an area that allows for
sufficient staff traffic to notice anyone
attempting to access cart when not authorized.
Staff must be able to view the cart from the
station or floor area. It is recommended that
your facility conduct a risk assessment to
determine potential unauthorized access to the
cart.
52

30.00.05
Surgical Privileges

Q: Does a hospitalemployed First Assist need

to be credentialed and
privileged?
53

30.00.05
Surgical Privileges, RN first
assistants
Answer:
Yes, the first assistant must be credentialed and privileged, whether
employed by the hospital, a physician or other entity, or a contracted
provider.
The First Assist, also known as Certified Surgical First Assistant CSFA)
Must be considered a medical professional who assists surgeons during surgeries.
The practitioner is individually credentialed based on their own individual
qualifications. You may wish to refer to the Acute Care manual standard (30.00.05)
for more detail on Allied Health Practitioner categories. If the hospital utilizes RN
First Assistants, surgical PA, or other non-MD/DO surgical assistants, the hospital
must establish criteria, qualifications and a credentialing process to grant specific
privileges to individual practitioners based on each individual practitioners
compliance with the privileging/credentialing criteria and in accordance with
Federal and State laws and regulations. This would include surgical services tasks
conducted by these practitioners while under the supervision of an MD/DO.

54

30.00.05
Surgical Privileges

Q: Does hospital-employed
Surgical Assistants and
Surgical Technicians need to
be credentialed through the
medical staff process?
55

30.00.05
Answer:

Surgical Privileges

Your facility may choose to use either the medical staff or human
resources department process in accordance with federal and state laws &
regulations. Your facility must:
Have medical staff approved qualifications that details the expectations regarding
education, training, experience, certification/license as appropriate to the position.
Have medical staff approved privileges that detail the surgical tasks that are
appropriate for the position. This may be in the form of either a job description or list
of privileges.
Have a process to credential/validate the qualifications of the individual, including
education, training, experience, certification/license as appropriate to the position.
Have a process for the ongoing evaluation of competency of the individual. Should
your facility determine these individuals are to go through the medical staff
credentialing process, they must follow the same procedures as the medical staff
personnel.
56

30.00.05
Surgical Privileges
Answer:

continued

Credentialing and privileging criteria requirements apply to all categories of

practitioners utilized in the facility. The granting of surgical privileges is a function of
governance upon the recommendation of the Professional Medical Staff. Initial and
revised / renewed privileges are copied to the surgical services.
Requirements apply to all categories of practitioners utilized in the facility. The granting
of surgical privileges is a function of governance upon the recommendation of the
Professional Medical Staff. Initial and revised / renewed privileges are copied to the
surgical services
If the hospital utilizes RN First Assistants, surgical PA, or other non-MD/DO surgical
assistants, the hospital must establish criteria, qualifications and a credentialing process
to grant specific privileges to individual practitioners based on each individual
practitioners compliance with the privileging/credentialing criteria and in accordance with
Federal and State laws and regulations. This would include surgical services tasks
conducted by these practitioners while under the supervision of an MD/DO.
When practitioners whose scope of practice for conducting surgical procedures requires
the direct supervision of an MD/DO surgeon, the term supervision would mean the
supervising MD/DO surgeon is present in the same room, working with the same patient.

57

30.01.00
Condition of Participation:
Medical Leadership for Anesthesia
Services

Q: We were informed that

hospitals will be cited for not
having an Anesthesia Rescue
Capacity policy. What needs to
be included in this policy for
compliance?
58

30.01.00
Condition of Participation:
Medical Leadership for Anesthesia
Services
Answer:
The hospital must demonstrate that its emergency services are
integrated into its other departments. The integration must be
such that the hospital can immediately make available the full
extent of its patient care resources to assess and render
appropriate care for an emergency patient.
A facility must be able to respond to any life threatening
patient emergency based on hospital services provided in
accordance with their patient population (i.e., neonatal,
pediatrics, adults etc.).

59

30.01.00
Condition of Participation:
Medical Leadership for Anesthesia
Services

continued
Answer:
Rescue Capacity: Because the level of sedation of a patient receiving

anesthesia services is a continuum, it is not always possible to predict how

an individual patient will respond. Further, no clear boundary exists between
some of these services. Hence, hospitals must ensure that procedures are in
place to rescue patients whose level of sedation becomes deeper than
initially intended, for example, patients who inadvertently enter a state of
Deep Sedation/Analgesia when Moderate Sedation was intended .

Rescue from a deeper level of sedation than intended requires an

intervention by a practitioner with expertise in airway management and
advanced life support.
The qualified practitioner corrects adverse physiologic consequences of the
deeper-than intended level of sedation and returns the patient to the
originally intended level of sedation. (Rescue capacity is not only required as
an essential component of anesthesia services, but is also consistent with
the requirements.
60

30.01.03
Moderate Sedation
Q: The Acute Care standard (30.01.03) limits
privileges only to a list of providers that can
administer deep sedation.
In our emergency department (ED), the
physicians are credentialed to give deep
sedation and to supervise. Our registered
nurses are also trained to give IV deep
sedation in unusual circumstances. Is this
practice acceptable?
61

30.01.03
Moderate Sedation
Answer:

(Conscious Sedation)

The Acute Care standard (30.01.03) requires that anesthesia is furnished

in a well-organized manner and limited to qualified individuals.
Anesthesia services must be delivered in a manner that is consistent
with the needs and the resources of the hospital.
Should your facility determine, as appropriate, to administer IV deep sedation in
the ED or areas other than surgery, the ED physicians must be granted privileges
approved by the medical executive committee and the governing body. The ED
physician requesting this privilege must demonstrate competency.
The credentials committee, with input from the director of anesthesia, is
responsible to determine the training requirements and the method to be used to
evaluate competency.
Facilities will define competency, training requirements, and methods to
evaluate all staff that is permitted to administer sedation of any type.
Competency is to be reassessed with each reappointment.
62

Employee Education File

Retention
Q: How long should we keep
educational records on staff
education requirements,
e.g., education on restraints
or CPR?
63

Employee Education File

Retention

Answer:

HFAP has no standard regarding the length of time for saving these staff education
files. You may want to seek direction from your facility's Risk Management and/or legal
counsel regarding the preferred practice. You may also wish to contact your state to
obtain additional information as some states may have retention requirements. You
may wish to review Civil Rights Act of 1964 and FLSA- se below:
Under the Civil Rights Act of 1964, Title VII, and the ADA, employers with at least
fifteen employees must retain applications and other personnel records relating to
hires, rehires, tests used in employment, promotion, transfers, demotions, selection for
training, layoff, recall, terminations of discharge, for one year from making the record
or taking the personnel action. - See more at: http://corporate.findlaw.com/humanresources/the-how-long-must-employers-retain-employeerecords.html#sthash.tFnv4QFG.dpuf

2015 - Under the FLSA, the record-keeping requirements are either two years or three
years depending on the type of record involved: - See more at:
http://corporate.findlaw.com/human-resources/the-how-long-must-employers-retainemployee-records.html#sthash.tFnv4QFG.dpuf
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Direct Access Law

Q: Does HFAP have statespecific guidelines for states
that allow direct access
(without a physician
order)to physical therapy?
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Direct Patient Access Law

Answer:
HFAP will survey to ensure compliance to state law &
regulations for physical therapy access.
Some states do not allow direct access and require a
physician's order, plan, and signature to proceed with
treatment
Some states allow for up to 21 days of care within
scope of PT practice guidelines to provide services
before obtaining physician order and signatures.
You may wish to refer to the following website: 2015http://www.apta.org/uploadedFiles/APTAorg/Advocacy/State/Issues/Direct_
Access/DirectAccessbyState.pdf. ( please review 31.00.11 Orders for
Outpatient Services).
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Monitoring End Tidal CO2

Q: Is there a requirement
for monitoring End Tidal
CO2 levels during
moderate sedation?
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Monitoring End Tidal CO2

Answer:
HFAP standards are not prescriptive; however, your
facility is required to follow current ASA (American
Society of Anesthesiologists) practice guidelines to
ensure patient care is delivered in a safe and effective
manner.
You may wish to review the ASA guidelines and other
information at:
www.asahq.org/For-Members/Standards-Guidelines-and-Statements.aspx
www.ncbi.nlm.nih.gov/pmc/articles/PMC3167153;
www.dremed.com/medical_equipment_news/meet-new-asa-standards-with-wavelinetouch-monitors
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QUESTIONS?
Please submit questions to:
Donna Tiberi
Standard Interpretation
Dtiberi@hfap.org
or
info@hfap.org
or
Please call 312-202-8073

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