1. MAINTAINING COMPLIANCE DOCUMENTATION DOUG STRINGFIELD, CHFM GEORGE VOLZ, CHFM

3. Maintaining Compliance Documentation

4. CAST Centers for Medicare & Medicaid Services (CMS) Healthcare Facilities Accreditation Program The Joint Commission Det Norske Veritas

5. MORE CAST State Fire Marshal Title 153 HHS - Title 175 NDOL- Chapter 48 NDEQ – Chapter 46

6. AND STILL MORE CAST City Agencies Board Physicians Department Patient & Families

7. AND STILL MORE CAST SWPPP - Title 119 Waste Water - Title 123 Waste - Chapter 126 Hazardous waste Title 128 And others too numerous to mention………………….

9. STAR OF THE SHOW YOU

10. WHAT Compliance Process What applies to your facility? What is the desired performance? What documentation is required? What improvements should be made?

11. WHAT Centers for Medicare and Medicaid Services (CMS) CFR 42 624 pages Chapter 482.41 Conditions of Participation Broad range of coverage

12. WHAT State Fire Marshal—Title 153

13. WHAT State Fire Marshal—Title 153

14. WHAT State Fire Marshal—Title 153

15. WHAT State Fire Marshal—Title 153

16. WHAT State Fire Marshal—Title 153

17. WHEN NOW Compliance Daily Weekly Monthly Annually

18. READ AND DO How do you know if you comply? TJC CMS DNV HFAP

19. HOW TJC Environment of Care EC.01.01.01 Someone manages the risks

20. HOW TJC Environment of Care EC.02.01.01 Hospital manages Safety and Security

21. HOW TJC Environment of Care EC.02.02.01 Hazardous Materials and Waste

22. HOW TJC Environment of Care EC.02.03.01 EP 4 Unobstructed exits

23. HOW TJC Environment of Care EC.02.03.01 EP 9 Written Fire Plan

24. HOW TJC Environment of Care EC.02.03.05 Fire Safety Equipment

25. HOW TJC Environment of Care EC.02.05.01 EP 2 Utility Inventory

26. HOW TJC Environment of Care EC.02.05.01 EP 3 Utility Maintenance

27. HOW TJC Environment of Care EC.02.05.01 EP 4 Utility Maint. Intervals

28. HOW TJC Environment of Care EC.02.05.01 EP 6 Ventilation Systems

29. HOW TJC Environment of Care EC.02.05.01 EP 9 Utility Disruptions

30. HOW TJC Environment of Care EC.02.05.03 EP 2 Using Emergency Power

31. HOW TJC Environment of Care EC.02.05.03 EP 4 Elevator Power

32. HOW TJC Environment of Care EC.03.01.01 The Role of People

33. HOW TJC Life Safety LS.01.01.01 EP2 Statement of Conditions

34. HOW TJC Life Safety LS.01.01.01 EP3 PFI

35. HOW TJC Life Safety LS.01.01.01 EP4 Other Inspections

36. HOW TJC Life Safety LS.01.02.01 Interim Life Safety

37. HOW TJC LIFE SAFETY LS.02.01.35 FIRE EXTINGUISHING

38. Panel Discussion

39. THE END