maintaining compliance documentation doug stringfield, chfm george volz, chfm
DESCRIPTION
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. - PowerPoint PPT PresentationTRANSCRIPT
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
HOWTJC
Environment of Care
EC.02.03.05
Fire Safety Equipment
HOW
TJC
Environment of Care
EC.02.05.01 EP 2
Utility Inventory
HOWTJC
Environment of Care
EC.02.05.01 EP 3
Utility Maintenance
HOWTJC
Environment of Care
EC.02.05.01 EP 4
Utility Maint. Intervals
HOWTJC
Environment of Care
EC.02.05.01 EP 6
Ventilation Systems
HOW
TJC
Environment of Care
EC.02.05.01 EP 9
Utility Disruptions
HOWTJC
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
HOWTJC
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
HOWTJC
LIFE SAFETY
LS.02.01.35
FIRE EXTINGUISHING
Panel Discussion
THE END
