MAINTAINING COMPLIANCE DOCUMENTATION DOUG STRINGFIELD, CHFM GEORGE VOLZ, CHFM.
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Transcript of MAINTAINING COMPLIANCE DOCUMENTATION DOUG STRINGFIELD, CHFM GEORGE VOLZ, CHFM.
![Page 1: MAINTAINING COMPLIANCE DOCUMENTATION DOUG STRINGFIELD, CHFM GEORGE VOLZ, CHFM.](https://reader035.fdocuments.in/reader035/viewer/2022062421/56649cf05503460f949bf4b9/html5/thumbnails/1.jpg)
MAINTAINING COMPLIANCE DOCUMENTATION
DOUG STRINGFIELD, CHFMGEORGE VOLZ, CHFM
![Page 2: MAINTAINING COMPLIANCE DOCUMENTATION DOUG STRINGFIELD, CHFM GEORGE VOLZ, CHFM.](https://reader035.fdocuments.in/reader035/viewer/2022062421/56649cf05503460f949bf4b9/html5/thumbnails/2.jpg)
![Page 3: MAINTAINING COMPLIANCE DOCUMENTATION DOUG STRINGFIELD, CHFM GEORGE VOLZ, CHFM.](https://reader035.fdocuments.in/reader035/viewer/2022062421/56649cf05503460f949bf4b9/html5/thumbnails/3.jpg)
Maintaining Compliance
Documentation
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CAST
•Centers for Medicare & Medicaid Services (CMS)•Healthcare Facilities Accreditation Program
•The Joint Commission•Det Norske Veritas
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MORE CAST
•State Fire Marshal Title 153•HHS - Title 175•NDOL- Chapter 48•NDEQ – Chapter 46
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AND STILL MORE CAST
•City Agencies•Board•Physicians•Department•Patient & Families
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AND STILL MORE CAST
• SWPPP - Title 119•Waste Water - Title 123•Waste - Chapter 126• Hazardous waste Title 128• And others too numerous to mention………………….
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STAR OF THE SHOW
YOU
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WHAT
Compliance Process
What applies to your facility?
What is the desired performance?
What documentation is required?
What improvements should be
made?
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WHAT Centers for Medicare and Medicaid Services
(CMS)
• CFR 42
• 624 pages
• Chapter 482.41
• Conditions of Participation
• Broad range of coverage
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WHAT State Fire Marshal—Title 153
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WHAT State Fire Marshal—Title 153
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WHAT State Fire Marshal—Title 153
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WHAT State Fire Marshal—Title 153
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WHAT State Fire Marshal—Title 153
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WHEN
NOW Compliance
DailyWeekly
MonthlyAnnually
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READ
AND DO
How do you know if
you comply?TJCCMS
DNVHFAP
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HOW
TJC
Environment of Care
EC.01.01.01
Someone manages the
risks
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HOW
TJC
Environment of Care
EC.02.01.01
Hospital manages Safety and
Security
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HOW
TJC
Environment of Care
EC.02.02.01
Hazardous Materials
and Waste
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HOW
TJC
Environment of Care
EC.02.03.01 EP 4
Unobstructed
exits
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HOW
TJC
Environment of Care
EC.02.03.01 EP 9
Written Fire
Plan
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HOW
TJC
Environment of Care
EC.02.03.05
Fire Safety
Equipment
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HOW
TJC
Environment of Care
EC.02.05.01 EP 2
Utility
Inventory
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HOW
TJC
Environment of Care
EC.02.05.01 EP 3
Utility
Maintenance
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HOW
TJC
Environment of Care
EC.02.05.01 EP 4
Utility Maint.
Intervals
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HOW
TJC
Environment of Care
EC.02.05.01 EP 6
Ventilation
Systems
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HOW
TJC
Environment of Care
EC.02.05.01 EP 9
Utility
Disruptions
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HOW
TJC
Environment of Care
EC.02.05.03 EP 2
Using Emergency
Power
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HOW
TJC
Environment of Care
EC.02.05.03 EP 4
Elevator Power
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HOW
TJC
Environment of Care
EC.03.01.01
The Role of People
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HOW
TJC
Life Safety
LS.01.01.01 EP2
Statement of
Conditions
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HOW
TJC
Life Safety
LS.01.01.01 EP3
PFI
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HOW
TJC
Life Safety
LS.01.01.01 EP4
Other Inspections
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HOW
TJC
Life Safety
LS.01.02.01
Interim Life Safety
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HOW
TJC
LIFE SAFETY
LS.02.01.35
FIRE
EXTINGUISHING
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Panel
Discussion
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THE END
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