Accreditation & Regulatory Journal
September 2023

News You Can Use

September’s Compliance Tip of the Month

Common Findings With Generator Testing
by Billy Kinch, MHA, HACP-PE
Have you ever wondered what the common findings are during a survey. We are going to be discussing what some of those common findings are related to generator testing.
Weekly Testing
NFPA 110 has a list of tasks that must occur during the weekly inspection. These tasks can be found in a table that is in the Annex section of this code. Most organizations are good at performing the weekly inspection task however, where they fall short is documenting all the required elements. During the weekly inspection the facility must document that the following areas are being addressed:
  • Fuel system
  • Lubrication system
  • Cooling system
  • Exhaust system
  • Battery system
  • Electrical system
  • Prime mover
  • General condition of the generator
Monthly Testing
When it comes to monthly testing there are a couple of things that organizations tend to struggle with. The first is when the test must occur each month. The most stringent code is NFPA 99 which states that generators must be tested 12 times a year with the timing between tests being no sooner than 20 days and no greater than 40 days.
Another issue is organizations documenting the duration of the test. Generators are required to be tested monthly for 30 minutes. After the generator runs for the 30 minutes there is a cool-down period. Some organizations are documenting the start and stop time of this test using the hour meter located on the generator. Here is a common mistake that organizations do when documenting this way. Let’s say they initiate the test at an hour meter reading of 145.0. The conclusion of the test occurs at hour meter 145.5. According to these readings, the generator ran for 30 minutes. However, in discussion with some organizations they indicate that this also includes the cool-down time. The cool-down time is not part of the 30-minute load bank requirement for the generators. Therefore, the documentation should indicate the additional cool-down period. The correct way to document this monthly test would be to indicate the time as being from 145.0 to 145.6.
Monthly Transfer Switch Testing
This test can be one of the more common findings during a document review. All transfer switches are required to be tested monthly. What a lot of organizations do is document the transfer switch that is being used to initiate the test and then there is no documentation on all the other switches.
As you can see a lot of these issues are easily resolved. It is not that the organizations are not performing the required tests and inspections, it is more around the documentation showing or proving to a surveyor that they are meeting the requirements. These are what we call low-hanging fruit and can be frustrating for a hospital when cited. Make sure your documentation doesn’t fall into these categories and your survey should go smoothly.
Annual Testing
When organizations are cited around annual testing, the main reason is around the required load that must be administered during the test. Organizations are required to perform an annual load bank test when they cannot achieve the 30% load requirement during the monthly generator test. When the annual load bank test is conducted it must be at a minimum of 50% load for 30 minutes followed by a minimum of 75% load for 60 minutes which would be a total of 90 minutes. Many times, when organizations are cited it is due to the minimum loads not being obtained for appropriate amount of time. For example, the percentage of load was 45% followed by 70%.
Triennial Testing
The same issues as was discussed during the annual testing comes up during the triennial testing. The appropriate load is not maintained for the entire duration of the test. Additionally, sometimes the testing vendor documentation will come up a little short in how long they had load. The test is cut off too short and does not show 4 continuous hours of run time. For example, the test started at 0900 with the 30% load in place and the last documented input was at 1245. The timing should have extended an additional 15 minutes and had a final input at 1300 with 30% load still in place.

CIHQ Accredited Hospital Extranet Site Gets a Facelift

The accreditation division of CIHQ is always working behind the scenes to improve our systems and more importantly our client’s experience. As a result, the hospital’s extranet site has undergone a facelift and will now begin a beta testing period. Once the testing period has been conducted, everyone will be switched over to the new site.
While the look and feel may be a bit different the content and information remain unchanged. Below is a snapshot of what a hospital will see in the current version and then what it will look like in the new version.
New Version
Current Version
So, what is different?
In the new version access to information has been relocated to the blue navigation bar at the top of the page instead of having all the boxes and sections of the site to navigate.
Your online standards and resources are now accessed via the following:
Lists & Archives – Quick Links, Contains Accredited Hospital Listing, Notification Archive, Past Survey Report Archive and ARS Mock Survey Requests
Standards & Resources – Online Standard Manuals, Glossary, Standards Interpretation and Download Standards, Policies & More
Libraries – What’s New on the Website, Resource Library, Reference Library, Regulatory Alert Library and Survey Preparation Library
Education – Webinar Center, Continuing Education Center and Staff Training Library
Partners & Sponsors
The quick links button on the navigation bar under Lists & Archives will provide you with all the resources in a list on the screen and you will be able to enter each one from there if you wish.
What you will see on your extranet landing page is:
  • Important Actions Required. This will still turn red when you have a corrective action plan to enter.
  • Standards, Policies & More – Policies and Survey Tools, Survey Activity Guides and Center of Excellence and Disease Specific Manuals and Information
  • Past Survey Reports – This will contain any survey information for the past 18 months. Any surveys done prior to that they are located under the Lists & Archives under Past Survey Report Archive
  • Miscellaneous Important Notifications – This will contain all notifications posted for the past 90 days. Any notification posted prior to the 90 days can be accessed under Lists & Archives under Notification Archive
There is also a new and improved site directory at the bottom of the screen to help you navigate your extranet page. As always, we welcome your feedback so when you begin to use the new site, please provide us any ideas, suggestions, or comments to Traci at

2023 CIHQ Accreditation and Regulatory Summit September 26-28, 2023

The 2023 CIHQ Accreditation and Regulatory Summit is fast approaching, and registration will be closing on September 18th, 2023. If you have not already registered and wish to attend now would be the time to get your registration in. The summit will be held in Allen, Texas at the Marriott Hotel & Convention Center.
There will be tons of education, networking and even a murder mystery dinner theater. You won’t want to miss it. This will be the biggest conference ever hosted by CIHQ. We will have over 35 Sponsors/Partners for you to explore as well.
Here is what one attendee had to say,
“I am the Director of Quality Management at Texas Rehabilitation Hospital of Keller and attended the CIHQ Summit for the first-time last year. The Summit was an awesome experience that I thoroughly enjoyed. Some of my highlights from the Summit included –
  • Meeting and getting to know the CIHQ team who was very personable, approachable, caring, and friendly.
  • Great topics of interest presented by subject matter experts.
  • Collaborating and networking with other attendees and exhibitors.
  • The scheduling and format of the Summit being conducted in a manner that kept everyone engaged.
  • Being in a location and space that was intimate and inviting.
  • Being surrounded in an atmosphere and climate of learning.
  • Leaving the Summit with a wealth of new knowledge that I was able to share with my colleagues.
  • The fabulous food.
“I am registered for the upcoming Summit in September. This year, CIHQ has further expanded the topics to include various tracks, choices, and a Murder Mystery Dinner Theatre. I am excited about attending and have no doubt that I will leave the Summit with greater knowledge and ideas/ways to help my organization achieve excellence.”
De-Andre Warren
Director of Quality Management

2023 HACP Courses Prio to the Accreditation and Regulatory Summit

On September 25th CIHQ will be provided our Healthcare Accreditation Certified Professional course in person at the Marriott Hotel & Convention Center in Allen, Texas with the exam being offered on the morning of the 26th. These certifications are must haves in the industry and afford certified individuals HACP to their name/credentials.
We now offer three different certifications:
  • HACP – CMS
  • HACP – Physical Environment
  • HACP – Infection Control (NEW)
This will be the debut of our newest certification in infection prevention and control. If you would like to register to attend any of the certification courses, go to , select the program you wish to attend and follow the easy online instructions.

CIHQ Now a CMS Approved Accrediting Organization for Critical Access Hospitals

On May 22, 2023 CMS published the approval of the CIHQ Critical Access Accreditation Program. This was the initial application and is applicable from June 1, 2023 to June 1, 2027. CIHQ is extremely grateful to the facilities that acted as our pilot survey and to Frio Regional Hospital that graciously allowed us to conduct our observation survey with CMS in attendance. You can find this exciting announcement in the Register at

CIHQ Applications to CMS as an Accrediting Organization and Expansion of Accreditation Programs - Update

CIHQ is expanding its accreditation programs to Acute Psychiatric Hospitals. The application has been approved and the virtual office review has been completed. The final decision to accept the application was published in the Federal Register on May 22, 2023. We are excited about welcoming Acute Psychiatric Hospitals to the CIHQ family of accredited organizations. You can find this exciting announcement in the Register at
  • Next steps will be the standards and process review. We have completed the five pilot surveys and wish to thank them for allowing us to pilot our process in their hospital.
    • Griffin Memorial Medical Center
    • SD Human Services Center
    • Adventist Health Vallejo
    • East End Behavioral Health Hospital
    • Glendora Hospital – A College Behavioral Health Hospital
  • A virtual office review was conducted from June 21 – 23, 2023
  • An observation survey was conducted in July. A huge thank you to the State of Oklahoma and Northwest Center for Behavioral Health for volunteering to be our CMS observation survey.
  • Publication in the Federal Register will occur on or by October 19, 2023

CIHQ Sponsors and Speaks at the 60th Annual Conference

CIHQ’ own Billy Kinch will be presented at ASHE as part of the 60th Annual Conference & Technical Exhibition. This was the first time we CIHQ had been invited to speak. Billy provided an update on CIHQ’ adventures and shared top findings in the physical environment.
Before the ASHE Conference kickoff, CIHQ' Michelle Shaffer participated in a volunteer opportunity at the San Antonio Food Bank with the of Texas Association of Healthcare Facilities Management ( group. The Food Bank appreciated the generous donation, a gift of time early on a Saturday morning. The group helped sort and compile 18,834 pounds of food for those in need. A special thanks to Taylor Vaughn of Children's Health, TAFHM President Elect, for the invitation to volunteer.

Upcoming Conferences and Sponsorships

Discovery, connection, and enrichment
Healthcare and community care professionals from across the continuum attend CareForum every year because it offers unmatched opportunities to learn from the industry’s top experts and gain skills to take back to their organizations and put into action.
CareForum is attended by more than 1,000 healthcare executives and leaders from various end markets across health and community care.
CIHQ to Speak at WellSky’s Care Form
Richard Curtis, CEO was accepted to speak at WellSky’s Care Forum in Austin, September 10-13. He’s speaking on Monday, September 11th on Collaborating with the Medical Staff for Successful Regulatory Compliance.

2023 Fall Educational Conference & Expo
CIHQ appreciates the work of rehabilitation hospitals, and will be attending AMRPA’s conference October 15-18, 2023 in Dallas. AMRPA hosts an IRF Boot Camp before the conference to provide rehabilitation managers and medical directors with fundamental knowledge.
The conference program will focus on innovative strategies to keep rehabilitation professionals ahead of the curve and providing the highest quality of care, advocacy efforts in the interest of inpatient rehabilitation hospitals and units, outpatient rehabilitation centers, and other rehabilitation providers.