Accreditation Achieved: Facility Solutions That Deliver Results

A specialized healthcare provider recently underwent a comprehensive accreditation survey through the Accreditation Association for Ambulatory Health Care (AAAHC). The accreditation process, held every three years, includes detailed inspections by both medical and life safety surveyors, with a strong emphasis on compliance with National Fire Protection Association (NFPA) standards and AAAHC life safety guidelines.

The CFS team played a critical role in ensuring our client’s readiness for the survey with involvement extending across multiple areas of infrastructure, compliance, and documentation, including:

Preparation of the Life Safety Book and Opening Book, consolidating all documentation related to:

• Emergency management planning and hazard vulnerability analysis

• Fire drills, disaster drills, and generator testing schedules

• Fire safety systems (sprinklers, alarms, extinguishers, emergency lighting, exit signage)

• HVAC, medical gas systems, and electrical testing requirements

• Ongoing inspection logs for items like fire doors, eyewash stations, receptacles, and alarm systems

• Documentation around proper testing during installation

Support for Building Tour Inspections, ensuring:

• Physical compliance with clearances, proper signage, and labeling

• No penetrations in fire-rated walls and proper firestopping

• Functional emergency and exit lighting at all egress points

• Equipment documentation and placement, especially in operating and critical care areas

Finalizing accreditation:

• Wrap-up session and findings report for any cited issues

• Plan of correction

Through close collaboration with Advanced Urology leadership and clinical teams, the facility team ensured a successful survey outcome. Our proactive maintenance schedule, centralized documentation system, and in-depth knowledge of accreditation standards positioned Advanced Urology to maintain compliance and demonstrate a strong culture of safety and operational excellence.