Maintaining Compliance documentation Doug Stringfield, CHFM George Volz, ChfM

1. Maintaining Compliance documentationDoug Stringfield, CHFMGeorge 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. State Fire Marshal—Title 153 What

16. State Fire Marshal—Title 153 What

17. WHEN • Compliance • Daily • Weekly • Monthly • Annually NOW

18. Read and do TJC CMS How do you know if you comply? HFAP DNV

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. TJC Life Safety LS.01.01.01 EP4 Other Inspections how

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

37. TJC Life Safety LS.02.01.35 Fire Extinguishing HOW

38. Panel Discussion

39. THE END