Changes and Guidance on Your Facility Demographic Report

A comprehensive and essential document, the Facility Demographic Report (FDR) is completed and submitted with each application for Accreditation Commission for Health Care (ACHC) Ambulatory Surgery Center Accreditation. The FDR is then expected to be used as a living document that is reviewed at least annually and updated to reflect facility changes as they occur.

The intent of the FDR is to help the organization provide a high level-but-meaningful overview of its healthcare buildings. The information it conveys helps shape how the Life Safety building tour and document reviews will be performed during an accreditation survey.

Item 17 on the Ambulatory Surgery Center FDR has prompted repeated questions:

Based on a documented Risk Assessment conducted by the organization, please identify which NFPA 99-2012 Building System Category has been determined for the respective building services:

• Gas and Vacuum Systems
• Electrical Systems
• HVAC Systems
• Electrical Equipment
• Gas Equipment

The Building System Category refers to definitions found in NFPA 99 Health Care Facilities Code, 2012 Edition, Chapter 4.

Gas and Vacuum Systems and Electrical Systems are defined in their respective chapters of NFPA 99-2012. Showing the result of a risk assessment for these on the FDR usually makes sense to both the facility manager and the accreditation Surveyor.

Expectations for HVAC Systems, Electrical Equipment, and Gas Equipment are not as clear, so we are providing additional guidance. Organizations must continue to comply with these chapters in NFPA 99-2012. However, treating HVAC, electrical, and gas equipment as “systems” is problematic. Updates to the FDR and guidance for completing it provide clarity.

Download our Quick Reference Guides to help with categorizing HVAC, electrical, and gas equipment.

To access the updated FDR, find the update in the latest ACHC ASC Standards Manual, or log in to your customer portal, open an application, and go to Step 3 – Supporting Documents.

Here to Help

ACHC is more than an accreditor. We are your partner. For help completing your FDR or finding answers to your questions about any accreditation topic, contact your Account Advisor, or email [email protected], or call (855) 937-2242.