Health Care compliance is not the easiest concept to grasp. Just when you think you have all the items covered something changes or you missed a small detail. These changes and details are also the items that surveyors can zero in on during inspections. Here are a few compliance issues that you may be missing:
Main Drain Test Comparison – Each main drain test should be compared to the original test, or the oldest test that you have, to see if anything within the system has changed. Comparing the testing to only the previous year may not catch a problem that is developing slowly over time. See Chapters 6 and 12 of the 2002 edition of NFPA 25.
Code Reference and Frequency for Testing – In June of 2010 The Joint Commission required all testing documentation to have the Code reference and testing frequency included in the documentation. Review all of your testing documentation to ensure that all code references and testing frequencies are added. See EC News.
CMS Waivers – In August of 2013, CMS released a document outlining the acceptable requirements from the 2012 Edition of the Life Safety Code that can now be used by Health Care facilities. These are beneficial waivers that should at least be reviewed by all health care facilities. See S&C: 13-58-LSC for further information.
Ensuring that you facility is meeting these compliance items will go a long way in helping to show inspectors that you have your facility’s compliance under control.