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Compliance News: Compliance Challenges in 2016

| David Stymiest

2016 brings a host of ongoing compliance challenges along with a few new ones.  The ongoing challenges often revolve managing and mitigating the myriad risks within our facilities: general safety hazards, utility risks, fire safety risks, and life safety risks.  Of concern is the accelerating pace of changes combined with increasing complexity of the impact of those changes on regulatory compliance.

The Joint Commission (TJC) and the American Society for Healthcare Engineering (ASHE) recently partnered to provide interpretations and compliance resources for some of the most problematic physical environment areas.  The November 2015 Compliance News issue discussed the progress of their joint initiative up to that time.

The ongoing challenges resulting from confusion between HVAC design requirements and related physical environment clinical practice recommendations were addressed in October 2015 Compliance News.

As it appears that the U.S. Centers for Medicare & Medicaid Services (CMS) continues to inch forward towards adoption of the 2012 codes, healthcare organizations are rightly becoming concerned about the mandatory references from the 2012 editions of NFPA 101 and NFPA 99 to dozens of substantially newer codes and standards.  The September 2015 Compliance News included a list of some of the more important updated codes and standards that would have an effect on hospital physical environment compliance.

And changes are not limited to NFPA codes and standards, since both the Facilities Guidelines Institute (FGI) and ASHRAE continue to issue new documents that get the attention of (and often later adoption by) Authorities Having Jurisdiction (AHJs).

The 2014 CMS changes to equipment inventory and Alternate Equipment Management / Maintenance (AEM) requirements with respect to equipment inspection, testing, and maintenance (ITM) are still creating challenges within healthcare facilities simply because of the scope of potentially required changes.  These issues were discussed within several articles, most recently the April 2015 Compliance News article.

Surveyors are generally very sophisticated in finding problem areas within healthcare organizations both because they know where to look and their fresh eyes often see violations that others miss.  This process is not expected to lessen.

The new challenges include an announcement in 2015 of increased enforcement within hospitals by the U.S. Occupational Safety and Health Administration (OSHA.)

In late 2015, the U.S. Department of Homeland Security urged enhanced vigilance towards potential terrorist activity by healthcare organizations.

Refer to the January 2016 Health Facilities Management (HFM) magazine article entitled “Codes and standards hot topics for 2016” for a more detailed discussion of these and other related issues.

Questions on this article may be addressed to the author at DStymiest@ssr-inc.com.

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