3^rd Floor Conference Center

Rooms 301/302

Zoom link: https://nyph.zoom.us/j/99051058772

Presentation Topic:

Healthcare Regulatory Compliance Services

Presented By PROEDGE FM specializes in healthcare regulatory compliance services:

Presenters:

Larry Lacombe, CHFM-SVP Facility Compliance Services

Ken McGraw-Director Facility Compliance Services

On December 2013, CMS released the hospital equipment maintenance requirements for facilities to expand their equipment inventories to include all equipment. While the requirements applied to both utility systems and medical equipment, this presentation will focus on the requirements for hospital utility equipment inventories as well as inspection, testing and maintenance (ITM) practices.

Additionally, CMS introduced an alternate equipment management (AEM) program for those hospitals that wish to deviate from the manufacturer’s recommendations. This program is “evergreen” in that it requires facilities to monitor their inventories continually and make appropriate changes as needed.

The presentation will focus on the following:

The Joint Commission (TJC) requirements for the following Standards:

• 02.05.01 EP’s 3, 4, 5, 6, 7, 8
• 02.05.05 EP’s 1, 4, 5, 6

NFPA 99 2012 Chapter 4 Risk Categories

Outcomes:

Attendees will be provided:

• Understanding of the TJC requirements for the Utility Inventory
• Understanding the differences between the inventory and an AEM
• Example policies and risk assessment for determining “High-Risk”, “Infection Control” and “Non-High-Risk” equipment.
• What surveyors are looking for.
• Questions

Mr. Larry Lacombe, CHFM, is the Senior Vice President of Regulatory Compliance for PROEDGE FM, a Facility and Regulatory Compliance Services company.  Larry has over 35 years of experience in providing Healthcare Organizations with regulatory and facilities operational expertise in their accreditation survey readiness process.  Larry’s responsibilities include the development of Programs, Operations Management, and Regulatory Consulting to facilitate Survey Readiness for its healthcare customers within The Joint Commission’s Physical Environment.

Prior to joining PROEDGE FM, Larry was the Vice President of Compliance, Support, and Program Development/Management for Medxcel LLC.  In this role, he created, supported, and trademarked Medxcel’s Unit Operating System, FMOS™, which provided facilities programs and processes for operational and regulatory compliance for Ascension Healthcare’s portfolio of 162 hospitals encompassing 58 million square feet.  In this capacity, Larry was responsible for successful accreditation surveys, approximately 55 surveys per year, under The Joint Commission’s Physical Environment Standards.

Before Medxcel LLC, Larry owned Facility Compliance Solutions LLC which provided regulatory consulting to healthcare organizations.

Larry is a U.S. Navy Veteran and a member of ASHE, ASHRAE, and NFPA.

Mr. Ken McGraw completed his studies in the disciplines of Environmental Technology and Engineering, and Business Administration. Thereafter, Ken embarked on a career in Healthcare that spanned over 35 years. Initially at the operations level and the last 25 years at the Director and Administrative levels. During his tenure, Ken worked in acute care hospitals ranging in size from 200 to 1000 beds primarily in positions with responsibilities in the areas of Facilities Management, Support Services, Construction Management, and Healthcare Compliance. During this time Ken had responsibilities for compliance to ensure success during Joint Commission Surveys, OSHA inspections, and CMS Validation Audits.

Additionally, Ken worked with The Joint Commission for approximately five (5) years as a Life Safety Code Specialist.

Working as a consultant for the past 10 years Ken has specialized in not only assessing client compliance with standards and requirements set forth by The Joint Commission, CMS, AOA, CARF, and DNV, but also implementing processes to ensure of sustainable programs for compliance. This includes identification of educational opportunities and establishing educational sessions when requested to ensure that clients are kept fully aware and educated on any and all changes to standards/code requirements.

Management Skills:

Staff Motivation Systems and Operations

Fiscal Responsibility

Organizational Skills

Communication Priorities