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Top 5 Areas of Compliance to Watch for Healthcare Facility Managers

Compliance is a critical concern in every aspect of the healthcare industry, and in particular, in the maintenance of facilities. When accrediting organizations, like The Joint Commission, arrive onsite for surveys, they examine everything and anything that impacts patient care and that includes facilities-related elements such as cleanliness, clearly marked and accessible exits, the facility's ability to minimize the effects of smoke and heat, safety equipment maintenance and so much more. Every day of the year, healthcare facilities management teams must be proactive about these compliance concerns. Once an inspection or survey is underway, it’s already too late to address facilities-related deficiencies.

Compliance for Healthcare Facility Managers


How can you remain prepared at all times for prickly inspectors from the Joint Commission while also completing your daily tasks? Here we discuss the top 5 areas of compliance to watch in order to stay compliant among the flurry of shifting priorities and regulations in the healthcare facilities management sector.


Healthcare Facilities Management Software for Compliance


1. Be Prepared for an Emergency

With the increase of events such as natural disasters due to climate change, emergency preparedness procedures have become a top compliance concern. So much so that the Joint Commission recently rewrote its Emergency Management chapter.

Now more than ever, it is imperative that healthcare organizations take stronger steps to provide a safe and resilient space not only for patients, but also for staff and visitors. Rather than waiting for an extreme whether event to occur, it is better to take steps now to draft a climate resilience plan so that your health facility keeps its lights on regardless of the conditions outside.

Learn more about how we can help you to become a climate resilient healthcare facility >


What to Watch:

Being prepared for any emergency is the key to equipping your staff with the knowledge and skills necessary to act quickly and efficiently when needed.

Benefits of FM Software on Emergency Preparedness:

  • Digitize and store emergency plans and procedures, so your team can easily access this information in a hurry. This eliminates the need to look for a binder or try to remember procedures at the last minute
  • Know what to test and when with automated preventive maintenance tasks and emergency-related work orders

Instead of hoping that an emergency situation doesn’t occur, be proactive and develop a plan. Having a plan in place ensures others on your facilities team are confident in their role in the event of an emergency. Instead of relying on stacks of binders and papers, use mobile technology to make your compliance-required emergency protocols accessible and actionable.


2. Infection Control

Your entire maintenance and operations team play a role in infection control and disease prevention. According to an article in Health Facilities Management Magazine, “the health facility manager’s role in infection prevention and patient care has become increasingly more important as health care associated infections (HAIs) have become a growing concern.”

Learn how this organization improved efficiency by implementing solutions by Intellis to manage and control disease prevention >

Effectively controlling the spread of infection in healthcare facilities requires optimal vigilance even when dealing with the smallest tasks. It is essential to ensure that you have the right protocols documented and a methodology in place in order to demonstrate that you are putting them through to action. Start by making sure that everyone on your team has access to the tools and training they need to track and manage compliance work so that you can mitigate risks.

A recent article in Health Facilities Management magazine identified the top four most common facility-related infection control risks that are critical because they present the highest risk to patients and have received an increased focus by regulatory agencies.

  1. Improper pressurization and ventilation of sensitive patient areas
  2. Dust and contaminants from construction sites
  3. Legionella growth in utility and potable water systems
  4. Contamination of sterile compounds in hospital pharmacies


What to Watch:

  • Housekeeping
    • Train your housekeeping staff on current infection control standards
  • Legionnaire's
    • Develop a water management plan with processes in place to protect it 
  • Hand hygiene
    • Promote good hand hygiene on your team and throughout your organization 

Read about how the physical maintenance and design of a healthcare facility can impact an organization's patient satisfaction score >


Benefits of FM Software on Infection Control:

  • Identify high risk patient areas with mapping technology and set parameters within your facility management system that requires the completion of an infection control risk assessment (ICRA) before work orders are assigned in those areas
  • Using FM software that incorporate mobile technology allows your team to snap photos of any areas of concern and attach images directly to work orders
  • Program your platform to prioritize Life safety related concerns
  • Set your FM system to schedule daily inspections in high priority areas.

Ultimately, compliance in regards to infection control, is primarily about fulling your healthcare facility's mission to promote health and save lives. There is a clear correlation between facility management practices and patient health, so it is crucial to set standards and to ensure that your team has the right tools in place for maintaining detailed documentation.

Implementing an efficient infection control strategy backed by facility management software will empower your team with the necessary tools to ensure a safe and healthy environment so that you are prepared for every compliance inspection.

See how our software helped NYC public schools improve the collection and transmission of information about asthma-related critical events >


3. Fire and Life Safety

Fire and life safety compliance is mandatory for Centers for Medicare and Medicaid Services (CMS). According to a recent article by Facilities Maintenance Decisions, "more than 100,000 fires occur in non-residential buildings every year... costing organizations billions of dollars in damages." Violations in this area, and all areas of compliance, can equal fines, lack of reimbursements and even result in facilities being shut down in extreme cases.

Further new standards and regulations are constantly updated by the Joint Commission, CMS, and OSHA, and it can be challenging to remain up-to-date. Therefore, this area is a top priority for protecting both patients and staff. Following compliance codes and integrating them into your daily work orders and preventive maintenance plan will make inspections easier and keep you prepared for any issues.

Fire and life safety directly impacts the protection of patient health and safety as well as the health and safety of staff. Technology can help you stay in control of growing demands.


What to Watch:

  • CMS K-Tag violations
  • Interim Life Safety Measures (ILSM)
    • Ensure you have ILSMs in place and make improvements to stay current with evolving codes 
  • NFPA codes and standards
    • Stay up-to-day on changes in NFPA codes and ensure you pass these on to your team

Benefits of FM Software on Fire and Life Safety

  • Quickly generate reports on all activities related to life or fire safety assets on demand for key stakeholders including CMS, AO, and hospital administration
  • Test and track life and safety protocols during mock compliance surveys
  • A facility management system that incorporates mobile technology, like FOUNDATION, allows your team to easily and efficiently track inspections, take photos and start maintenance work right away


4. Medical Gas and Vacuum Systems

Your medical gas and vacuum systems need constant supervision to ensure that they are functioning properly and not putting anyone in danger. The ongoing operation and maintenance of these systems for health facilities is vital to ensuring that they remain safe and dependable for patients who rely on them for survival. Training all members of staff to be aware of compliance with these volatile systems will result in improved compliance as well as better care and safety for patients.


What to Watch:

  • CMS standards
    • Familiarize your team with current information on the storage, temperature, disposal and management of medical gas
  • Staff Training
    • Keep your staff trained and up-to-date on new and evolving compliance codes around medical gas and vacuum systems

Benefits of FM Software on Medical Gas and Vacuum Systems

  • Simplify tracking, management, and inventory of medical gas and vacuum systems with recurring tasks, automated PM work orders, and digital record-keeping
  • Implement a mobile work management system so that you can connect compliance codes with specific work orders
  • Easily track mock compliance audits for equipment and processes for medical gas systems

See how our software helped to reduce pest infestations and significantly lower the use of toxic pesticides in New York City's public housing buildings >


These systems can mean life or death for patients who rely on them. This is aspect of healthcare operations greatly depends upon the ongoing monitoring and regular maintenance of these of systems. With the implementation of innovative technology like facility management software, maintaining compliance will be easier, more efficient, and streamlined.


5. HVAC and Utilities Maintenance

The management of your HVAC systems is critical to your operations and to compliance. When you can better manage the condition of your heating and cooling systems and make data-driven decisions about how to maximize their performance, you'll be better prepared for compliance inspections.


What to Watch:

  • HVAC Maintenance
    • Track the maintenance of your HVAC systems
    • Manage air handling
    • Make decisions around repairing vs. replacing equipment components
  • Utility Systems Codes

Ensuring that your HVAC systems are more compliant and efficient will reduce the numbers on costs, calls, and complaints. Using technology solutions gives you the power to increase your efforts in regards to HVAC and utility systems maintenance, making the work and reporting easier and more thorough.


Benefits of FM Software on HVAC Maintenance:

  • Track and document maintenance for better decision-making
  • Use facilities management software, such as FOUNDATION, to monitor all maintenance, testing, and inspections for your HVAC systems
  • Monitor PM tasks
  • Generate reports on the health of your systems and share with key stakeholders
  • Make decisions backed by data about repairing versus replacing equipment

The maintenance, testing, and inspection of your HVAC and utility systems is critical, and there is no room for error in terms of meeting current health compliance codes and standards.

Learn how facilities management software can make the maintenance, testing, and inspection of HVAC and utility systems easier >


The Role of Technology in Healthcare Facilities Management

Technology and software solutions such as facilities management systems offer healthcare facility managers many opportunities to improve equipment uptime and increase levels of operational readiness. With tools like FOUNDATION, a facility management and capital planning system, you can let technology do the busy work and long-range planning for you such as monitoring compliance codes, documenting compliance-related tasks, developing renewal and replacement plans, and implementing mobile communication in order to increase efficiency across the board.

Mobile-enabled solutions, like FOUNDATION, are transforming healthcare facilities management. Traditionally when a facility issue occurred and was reported, the facilities manager was required to make a trip to the site where the issue occurred, review the issue, and schedule the maintenance work in order to resolve it. Today, mobile technologies, like tablets and smartphones, make it easy to simply take a photo of a problem such as a cracked ceiling tile. This technology saves time for the facilities team because personnel can easily view an image of the issue within their facilities management system and quickly evaluate the urgency of the issue without having to take extra time to visit the physical site.

Our FOUNDATION Solution is an innovative platform that employs cutting-edge data collection, analysis, evaluation, and planning to equip your team with the right data and insights that empower you to ensure compliance among the shifting healthcare facilities regulations and give you the right insights so you can improve your organization's patient safety score.

Ready to learn more?




Connors, Bryan, “Facility Managers’ Role in Infection Control,” Health Facilities Management Magazine,

Chrisman, Mark, "Fire Protection: Inspection, Testing and Maintenance", Facilities Maintenance Decisions,

Hrickiewicz, Mike, "Emergency management tops October health care facility compliance news," Health Facilities Management Magazine,

National Fire Protection Association, List of NFPA Codes and Standards,

SAI Global, "Healthcare Compliance Benchmark Study,”

Stymiest, David, "A Look at CMS K-tag Requirements," Health Facilities Management Magazine,

The American Society for Health Care Engineering of the American Hospital Association, Air Filtration Compliance,

The Joint Commission, Utility Systems EC.02.05.01,

Willard, Jonathan, "What Recent CMS Changes Mean for Medical and Gas System Regulations," Health Facilities Management Magazine,