MAINTAINING COMPLIANCE DOCUMENTATION DOUG STRINGFIELD, CHFM GEORGE 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 pages Chapter 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 Daily Weekly Monthly Annually
READ AND DO How do you know if you comply? TJC CMS DNV HFAP
HOW TJC Environment of Care EC Someone manages the risks
HOW TJC Environment of Care EC Hospital manages Safety and Security
HOW TJC Environment of Care EC Hazardous Materials and Waste
HOW TJC Environment of Care EC EP 4 Unobstructed exits
HOW TJC Environment of Care EC EP 9 Written Fire Plan
HOW TJC Environment of Care EC Fire Safety Equipment
HOW TJC Environment of Care EC EP 2 Utility Inventory
HOW TJC Environment of Care EC EP 3 Utility Maintenance
HOW TJC Environment of Care EC EP 4 Utility Maint. Intervals
HOW TJC Environment of Care EC EP 6 Ventilation Systems
HOW TJC Environment of Care EC EP 9 Utility Disruptions
HOW TJC Environment of Care EC EP 2 Using Emergency Power
HOW TJC Environment of Care EC EP 4 Elevator Power
HOW TJC Environment of Care EC The Role of People
HOW TJC Life Safety LS EP2 Statement of Conditions
HOW TJC Life Safety LS EP3 PFI
HOW TJC Life Safety LS EP4 Other Inspections
HOW TJC Life Safety LS Interim Life Safety
HOW TJC LIFE SAFETY LS FIRE EXTINGUISHING
Panel Discussion
THE END