Maintaining Compliance documentation Doug Stringfield, CHFM George Volz, ChfM

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

HOWTJC

Environment of Care

EC.02.03.05

Fire Safety Equipment

HOW

TJC

Environment of Care

EC.02.05.01 EP 2

Utility Inventory

HOWTJC

Environment of Care

EC.02.05.01 EP 3

Utility Maintenance

HOWTJC

Environment of Care

EC.02.05.01 EP 4

Utility Maint. Intervals

HOWTJC

Environment of Care

EC.02.05.01 EP 6

Ventilation Systems

HOW

TJC

Environment of Care

EC.02.05.01 EP 9

Utility Disruptions

HOWTJC

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

HOWTJC

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

HOWTJC

LIFE SAFETY

LS.02.01.35

FIRE EXTINGUISHING

Panel Discussion

THE END