| Course | AFT2 Accreditation Audit |
|---|---|
| Task | Task 1 |
| Paper type | Accreditation compliance action plan |
| Length | About 1,100 words, 5 pages |
| Format | APA 7 |
| School | Western Governors University (WGU) |
| Program | BS Healthcare Administration |
| Updated | September 2026 |
Free sample paper for AFT2 Task 1
Three Findings Before the Surveyors Arrive: An Executive Summary, Corrective Action Plan and Justification After a Composite Community Hospital's Mock Accreditation Survey
Student Name
Leavitt School of Health, Western Governors University
AFT2: Accreditation Audit, Task 1
Course Instructor
Month Day, Year
Three Findings Before the Surveyors Arrive: An Executive Summary, Corrective Action Plan and Justification After a Composite Community Hospital's Mock Accreditation Survey
Executive Summary
Bayview Community Hospital, a composite 150-bed hospital, is due for its triennial accreditation survey in about five months. Last month an outside consulting team conducted a three-day mock survey using accreditation-style tracer methods, following patients and processes through the hospital. The survey found the hospital largely compliant but identified three deficiencies that would likely be cited in a real survey and that carry genuine patient risk.
Finding 1: Medication management. In two of four procedure rooms observed, syringes of medication drawn up for use were left unlabeled on the procedure tray. In three of 18 automated dispensing cabinets inspected, surveyors found expired medication vials, including one vial of a high-alert medication that had expired six weeks earlier.
Finding 2: Infection control. In the endoscopy suite, logs for high-level disinfection of flexible endoscopes were missing the required daily minimum effective concentration test results for the disinfectant solution on 11 of the 30 days reviewed. Staff could not show that the disinfectant was effective on those days.
Finding 3: Record documentation. In a sample of 60 inpatient records, 13 (22%) contained verbal or telephone orders that had not been authenticated by the ordering practitioner within the 48-hour period required by hospital policy. Federal Conditions of Participation require hospitals to authenticate verbal orders within the timeframe set by state law or, where there is none, by hospital policy (42 C.F.R. ยง 482.24).
Each finding reflects a process that depends on individual memory rather than on a reliable system. The corrective action plan below addresses each finding with system changes, named owners, deadlines and measures, and the justification explains why each action is required and likely to work.
Corrective Action Plan
The plan assigns each action to one owner, sets a completion date well before the survey window opens and defines how compliance will be measured.
| Finding | Action | Owner | Due | Measure |
|---|---|---|---|---|
| 1a. Unlabeled syringes | Require labeling of every medication and solution on and off the sterile field; stock preprinted labels and a label printer in every procedure room; add a labeling check to the procedural time-out | Director of perioperative services | 30 days | Weekly observation of 10 procedures per area; target 100% labeled for 8 consecutive weeks |
| 1b. Expired medications in cabinets | Pharmacy audit of every cabinet pocket monthly; expiration dates entered into the cabinet software so it alerts before expiry | Director of pharmacy | 45 days | Expired doses found per audit; target zero for 3 consecutive months |
| 2. Missing disinfectant test results | Electronic reprocessing log that will not release an endoscope for use until the day's concentration test is recorded; competency validation for all reprocessing staff | Infection prevention manager with endoscopy nurse manager | 60 days | Days with complete test results; target 100% on weekly review |
| 3. Unauthenticated verbal orders | EHR queue that shows each practitioner their unsigned orders at login; daily report to department chiefs of orders older than 24 hours; policy limiting verbal orders to urgent situations | Chief medical information officer with medical staff president | 45 days | Percentage of verbal orders authenticated within 48 hours; target 95% on monthly audit of 60 records |
The hospital's accreditation steering committee, chaired by the chief nursing officer, will review progress on every action every two weeks until the survey. Each owner will bring measurement data, not just a status report, and any action that misses its target for two consecutive reviews will be escalated to the chief executive officer. Evidence for each finding, including revised policies, training records and audit results, will be kept in a survey readiness binder so staff can show surveyors what has changed.
Justification
Finding 1a. Labeling every medication and solution in procedural areas is an accreditation requirement, and the risk it guards against is real. In an observational study of 277 operations, 5.3% of 3,671 perioperative medication administrations involved a medication error or adverse drug event, and more than a third of the errors led to an observed adverse drug event (Nanji et al., 2016). An unlabeled syringe on a crowded tray is an opportunity for exactly that kind of error. Preprinted labels and a check in the time-out make labeling the easy default rather than an extra step.
Finding 1b. Expired medications may lose potency or stability, and their presence suggests the cabinets are not being checked reliably. When one academic medical center tested different audit schedules, monthly audits of all cabinet pockets reduced the rate of expired doses, with one fully audited cabinet containing no expired doses at the final check; a full audit of a cabinet with about 340 pockets took about an hour (Nanni et al., 2020). Monthly full audits are therefore both effective and affordable, and software alerts add a second safeguard.
Finding 2. Minimum effective concentration testing is how staff confirm that a reusable disinfectant is still strong enough to kill organisms. Research on endoscope reprocessing found that reusable high-level disinfectants commonly failed concentration tests before the end of their labeled use periods, and that failures stemmed from product issues, process complexity and staff not following guidelines and manufacturer instructions (Ofstead et al., 2020). On the 11 days without test results, Bayview cannot show that its endoscopes were properly disinfected. An electronic log that blocks release without a recorded test replaces reliance on memory with a hard stop, the kind of engineered safeguard the research recommends.
Finding 3. Authentication confirms that the practitioner actually gave the order as recorded, protecting patients from transcription errors and the hospital from legal and billing risk. The Conditions of Participation make timely authentication a federal requirement. A 22% failure rate indicates a system problem, not a few careless individuals. A login queue makes unsigned orders visible to the practitioner every time they use the record, and daily reports to department chiefs add accountability without burdening nurses with repeated reminders.
Conclusion
The mock survey gave Bayview something valuable: a clear view of three weaknesses before surveyors, or a patient, found them. Each finding traces to a process that depends on someone remembering. The corrective action plan replaces memory with systems, assigns clear ownership and measures results, so that when the survey team arrives the hospital can show not only that it corrected the problems but that it can prove they stay corrected.
References
Nanji, K. C., Patel, A., Shaikh, S., Seger, D. L., & Bates, D. W. (2016). Evaluation of perioperative medication errors and adverse drug events. Anesthesiology, 124(1), 25-34. https://doi.org/10.1097/ALN.0000000000000904
Nanni, A. N., Rana, T. S., & Schenkat, D. H. (2020). Screening for expired medications in automated dispensing cabinets. American Journal of Health-System Pharmacy, 77(24), 2107-2111. https://doi.org/10.1093/ajhp/zxaa318
Ofstead, C. L., Hopkins, K. M., Buro, B. L., Eiland, J. E., & Wetzler, H. P. (2020). Challenges in achieving effective high-level disinfection in endoscope reprocessing. American Journal of Infection Control, 48(3), 309-315. https://doi.org/10.1016/j.ajic.2019.09.013
What the AFT2 Task 1 instructions ask
The first AFT2 task asks you to respond to accreditation audit findings as an administrator would. You will usually write an executive summary for leadership, a corrective action plan with owners, dates and measures, and a justification that explains why each action matters. The findings are often supplied by the course. Evaluators look for a summary that a busy executive could act on, actions that address the cause of each finding rather than the symptom, owners assigned by role, measures that would show compliance and justifications tied to the standard and to patient safety. A plan that lists fixes without owners or measures will not meet the core aspects. The timeline should leave room to check results before surveyors arrive. Most scenarios give you a hospital, a survey date and several findings drawn from a mock survey report.
How this AFT2 Task 1 example is built
The plan begins with an executive summary that states the survey date, the three findings and the overall readiness in a few sentences. The corrective action plan is presented as a table so each action, owner, due date and measure can be read across a row. Actions address causes, such as missing label stock in procedure rooms, rather than simply retraining staff. A note explains how the steering committee will track progress and escalate delays. The justification section takes each finding in turn and explains the standard behind it, the risk it addresses and how the action reduces that risk. The conclusion treats the mock survey as useful early warning rather than a failure.
Where the AFT2 Task 1 rubric puts the marks
AFT2 Task 1 aspects are rated competent, approaching competence or not evident. One aspect asks whether the summary gives leaders what they need in a few lines. A corrective action aspect rewards actions with owners, dates and measures. A cause aspect looks for actions aimed at why each finding happened. A justification aspect asks for the standard and the patient safety reason behind each action. A monitoring aspect wants a way to track progress before the survey. Evaluators notice when measures include audits that would show sustained compliance, and they expect accreditation standards and safety sources to be cited where requirements are described. Clear tables help, since evaluators read the plan quickly and look for gaps in each row.
AFT2 Task 1 help: what sends it back
Action plans come back most often when every action is retraining. Ask what in the environment or process allowed the finding and fix that as well. Second, owners are departments rather than roles. Name the position responsible. Third, measures are completion of the action rather than evidence of compliance. Use audits that show the standard is met, such as a weekly check of labeled syringes. Fourth, timelines end at the survey date. Finish early enough to confirm results. Finally, write the executive summary last, after the plan is complete, so it reflects what the plan actually does. Keep the justification specific to each finding rather than repeating a general statement about quality.
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AFT2 Task 1 questions, answered
How many findings should AFT2 Task 1 address?
Follow your course scenario, which usually supplies the findings. The sample addresses three, each with its own actions, owners, dates, measures and justification. Addressing fewer findings in more depth usually scores better than covering many briefly.
What belongs in an AFT2 executive summary?
The survey timeline, the findings in plain terms, overall readiness and what leadership must approve or support. The sample keeps it to a few sentences leaders can act on.
Why do AFT2 actions need measures?
Because surveyors look for evidence of sustained compliance, not completed tasks. Measures such as weekly audits show whether the standard is actually being met. A plan without measures cannot show surveyors that problems have been fixed.
Is the AFT2 hospital in the sample real?
No. Bayview Community Hospital and its mock survey are hypothetical. The accreditation requirements and patient safety sources described are real. Use your course's facility and findings when you write your own plan.
Where can I find a free AFT2 Task 1 sample paper?
The AFT2 Task 1 example above is the complete accreditation compliance action plan, and every section has a note on its AFT2 purpose. A free first AFT2 draft built on your own Task 1 details is available once you send the instructions.