MAINTAINING COMPLIANCE DOCUMENTATION DOUG STRINGFIELD, CHFM GEORGE VOLZ, CHFM
Dec 17, 2015
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