MAINTAINING COMPLIANCE DOCUMENTATION

DOUG STRINGFIELD, CHFMGEORGE VOLZ, CHFM

Maintaining Compliance

Documentation

CAST

•Centers for Medicare & Medicaid Services (CMS)•Healthcare Facilities Accreditation Program

•The Joint Commission•Det Norske Veritas

MORE CAST

•State Fire Marshal Title 153•HHS - Title 175•NDOL- Chapter 48•NDEQ – Chapter 46

AND STILL MORE CAST

•City Agencies•Board•Physicians•Department•Patient & Families

AND STILL MORE CAST

• SWPPP - Title 119•Waste Water - Title 123•Waste - Chapter 126• Hazardous waste Title 128• And others too numerous to mention………………….

STAR OF THE SHOW

YOU

WHAT

Compliance Process

What applies to your facility?

What is the desired performance?

What documentation is required?

What improvements should be

made?

WHAT Centers for Medicare and Medicaid Services

(CMS)

• CFR 42

• 624 pages

• Chapter 482.41

• Conditions of Participation

• Broad range of coverage

WHAT State Fire Marshal—Title 153

WHAT State Fire Marshal—Title 153

WHAT State Fire Marshal—Title 153

WHAT State Fire Marshal—Title 153

WHAT State Fire Marshal—Title 153

WHEN

NOW Compliance

DailyWeekly

MonthlyAnnually

READ

AND DO

How do you know if

you comply?TJCCMS

DNVHFAP

HOW

TJC

Environment of Care

EC.01.01.01

Someone manages the

risks

HOW

TJC

Environment of Care

EC.02.01.01

Hospital manages Safety and

Security

HOW

TJC

Environment of Care

EC.02.02.01

Hazardous Materials

and Waste

HOW

TJC

Environment of Care

EC.02.03.01 EP 4

Unobstructed

exits

HOW

TJC

Environment of Care

EC.02.03.01 EP 9

Written Fire

Plan

HOW

TJC

Environment of Care

EC.02.03.05

Fire Safety

Equipment

HOW

TJC

Environment of Care

EC.02.05.01 EP 2

Utility

Inventory

HOW

TJC

Environment of Care

EC.02.05.01 EP 3

Utility

Maintenance

HOW

TJC

Environment of Care

EC.02.05.01 EP 4

Utility Maint.

Intervals

HOW

TJC

Environment of Care

EC.02.05.01 EP 6

Ventilation

Systems

HOW

TJC

Environment of Care

EC.02.05.01 EP 9

Utility

Disruptions

HOW

TJC

Environment of Care

EC.02.05.03 EP 2

Using Emergency

Power

HOW

TJC

Environment of Care

EC.02.05.03 EP 4

Elevator Power

HOW

TJC

Environment of Care

EC.03.01.01

The Role of People

HOW

TJC

Life Safety

LS.01.01.01 EP2

Statement of

Conditions

HOW

TJC

Life Safety

LS.01.01.01 EP3

PFI

HOW

TJC

Life Safety

LS.01.01.01 EP4

Other Inspections

HOW

TJC

Life Safety

LS.01.02.01

Interim Life Safety

HOW

TJC

LIFE SAFETY

LS.02.01.35

FIRE

EXTINGUISHING

Panel

Discussion

THE END