Craft Your Compliance Competency
Health care facilities managers oversee the health care physical environment and ensure compliance with associated regulatory requirements in a way that ensures patient care and safety is the foremost priority for the entire facility management team.
This is demonstrated through, but not limited to, possessing a comprehensive working knowledge of health care physical environment-related regulatory requirements for accreditation at the federal/state/local levels, as well as an understanding of the actions required to ensure compliance through:
- Policy/procedure development
- Documentation of integrated life safety inspection
- Compliance-related testing, maintenance and documentation of facility-related systems
- Identification of the responsible facility authority for medical gas systems
- Maintaining the appropriate permits for work programs (ex. above ceiling, medical gases, hot work, etc.)
Featured Resources
Understanding Health Care Compliance: The Facilities Manager’s Handbook
A comprehensive overview of health care facilities compliance that maps the complex regulatory landscape and shares best practices in compliant facilities management.
Physical Environment Survey Readiness
Leverage continuous code compliance and reduce survey mistakes. Explore upcoming dates for Life Safety, Emergency Management and The Care Environment modules.
Hazard Vulnerability Assessment Tool
Use this tool to score your emergency preparedness using the all hazards approach and identify the potential hazards that need the most attention for exercise, mitigation and/or planning.
Training and Resources
Compliance Education
NFPA 101: Chapter 43 Building Rehabilitation
24/7 on demand
Understand Chapter 43 of NFPA 101, which provides clarification on levels of building renovations and when compliance with new construction would be required.
Medical Gas Cylinder Storage
e-Learning
Understand the storage and use of medical gas cylinders with the 2012 Edition of NFPA 99 in mind.
NFPA 99 - Medical Gas and Vacuum Systems
e-Learning
Learn NFPA 99’s (2012 edition’s) minimum health care facilities requirements related to medical gas and vacuum systems, covering a broad spectrum of applications.
Major Proposed Changes to NFPA 101 - 2024 Edition
Webinar
CMS currently enforces the 2012 Edition of NFPA 101 — explore the changes in the 2015, 2018, 2021 Editions, and anticipated changes in the 2024 Edition.
Managing Life Safety Program
e-Learning
Experts provide advice on how to protect patients, staff and visitors from fire-related hazards by correctly applying NFPA 101 code requirements.
CMS Conditions of Participation (CoP) and Codes
Video
Get a step-by-step explanation of how the Conditions of Participation for Hospitals, the State Operations Manual and accrediting organizations standards all tie together.
Compliance Publications and Tools
Physical Environment Provisions of USP <797>
Monograph
Review the certification process and ongoing requirements for the physical environment provisions of compounded sterile preparations (CSPs) in USP.
ANSI/ASHRAE/ASHE Standard 170-2021, Ventilation of Health Care Facilities
Guide/Report
Standard 170 offers ventilation guidance, regulation and mandates to designers and operators of health care facilities.
Managing Hospital Electrical Shutdowns
Monograph
Improve your hospital’s electrical infrastructure, power system reliability, and staff training with the utility management program approach.
Hospital CMS Tag Checklists and Crosswalks
Tool
These tools outline how accreditation standards and codes applicable to most hospitals align with CMS’s Conditions of Participation and Code of Federal Regulations.
Health Care Facility Manager's Guide to Smoke Control
Monograph
Get insights into the regulatory requirements and maintenance recommendations for smoke control systems in hospitals.
Focus on Compliance: Fire door checklist
Tool
This checklist can help health care facilities professionals inspect fire doors to ensure compliance with The Joint Commission standard LS.02.01.10.