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Stay Ahead: Expert Tips on Infection Control for Hospital Compliance

Blog_Hospital Compliance (1)

Managing a facility comes with its fair share of challenges, especially when it's your job to keep everything up to code and within the lines of countless federal and national regulations. On one hand, you've got safety codes, environmental guidelines, and labor laws, and on the other, the daily grind of keeping the facility running smoothly. While you're likely familiar with the regulations that affect your day-to-day, staying on top of new updates and changes can feel like an added weight to an already full load.

Compliance isn't just about following a set of rules. It's about staying sharp, being proactive, and understanding the bigger picture of keeping your facility safe, ethical, and on the right side of the law. 

Leading with Safety and Hospital Compliance in Mind

Modern facility management — particularly in a healthcare environment — is much more than overseeing daily operations. Managing the safety and health of your facility falls on your shoulders in addition to making sure that the facility is prepared to stand up to strict federal and state regulations and avoid non-compliance. To do this, your facility must take careful stock of data like maintenance schedules, air quality, infection control preparedness, and more. The more proactive you can be with factors related to patient and staff safety, the better equipped the entire facility is to stay healthy and compliant while offering top-tier patient care. 

Stay Current With Critical State and Federal Regulations

In the United States, rigid federal and state standards exist to protect levels of health and safety in medical facilities of all kinds. While regulations will vary depending on where your facility is located, you must be aware of and compliant with local and national guidelines to avoid penalties, maintain safety, and provide top-notch patient care.

The Importance of Aligning with Mandated Federal Laws 

At the heart of federal regulations, the Centers for Medicare and Medicaid Services (CMS) set the Condition of Participation (CoP) Interpretive Guidelines for Infection Control. These standards support the essential practices necessary to keep your facility clean and well-managed. 

Beyond just cleanliness, this includes having a dedicated infection prevention and control program. It's crucial to have a point person or a team focused on overseeing these efforts, ensuring your facility is proactive in preventing hospital-acquired infections (HAIs). Another critical aspect is having an active infection prevention program in place as well as a plan for systematic surveillance and logging of infections. The combination of these guidelines helps your facility to yes, stay compliant, but also to continually improve your infection control practices over time.

Stay up-to-date with State Laws & Local Regulations

State regulations add another layer to the infection control puzzle, especially around the public reporting of hospital-acquired infections, or HAIs. Currently, 27 states require transparency around how frequent HAIs are in their facility. Beyond the states that currently require public reporting, there are more that are in the process of creating this standard and more still that require private reporting to state regulatory agencies. The ultimate goal is to create more openness around the health and safety of healthcare centers and maintain a high level of care around the country. A facility with higher rates of HAIs may struggle to qualify for state funding, making it a significant financial concern when HAI rates are out of control. However, it isn’t only about hospital compliance — it’s also about trust. 

Keeping a handle on HAI rates encourages the trust of potential patients who may be choosing between several facilities to receive care. In these states where public reporting is required, it's used as a direct reflection of your facility's commitment to safety and quality care. 

What You Should Know About Other Regulatory Agencies

Beyond CMS, facilities must report to and engage with several regulatory bodies, including The Joint Commission, the National Fire Protection Association (NFPA), and the Occupational Safety and Health Administration (OSHA). Each of these organizations sets standards that impact various aspects of facility management, from healthcare quality and safety to fire safety and employee well-being. 

Centers for Medicare & Medicaid Services (CMS): Compliance with CMS regulations is a baseline for healthcare facilities to receive federal funding. Essentially, hospital compliance with CMS is the bare minimum required to participate in Medicare and Medicaid programs. 

The Joint Commission: Accreditation from The Joint Commission is a mark of quality and safety in healthcare, distinguishing a facility's commitment to high standards in patient care and operational efficiency. Recognition from The Joint Commission gives a boost to your facility’s reputation and provides ongoing encouragement to improve. 

National Fire Protection Association (NFPA): The NFPA focuses on minimizing risks related to fire, electrical, and related hazards in healthcare facilities. Specific codes, including NFPA 101 (Life Safety Code) and NFPA 99 (Health Care Facilities Code), are particularly vital for ensuring the safety of your facility’s patients, staff, and visitors.

Occupational Safety and Health Administration (OSHA): OSHA regulates the safety and well-being of healthcare employees, and by extension, benefitting patient care. By enforcing workplace safety standards, OSHA helps create a safer and more effective healthcare environment for both staff and patients.

What’s New in Hospital Compliance in 2024?

Between Federal and State agencies, the rules around hospital compliance programs are constantly being updated and refreshed to bring patients around the country the best possible care and hold healthcare facilities to a high standard.

 In 2024, here are a few trends and updates to stay on top of: 

Patient Data Security: With more patient info going digital, it's crucial to tighten up data security. Make sure you're using strong protection measures like encryption and secure data disposal. Keeping your team trained on data privacy is also key to avoid any breaches.

Post-COVID Changes: The pandemic has changed a lot of rules in healthcare. Stay updated on new infection control standards, telehealth regulations, and reporting needs to keep your facility compliant and safe.

Tech Advances: As AI and other tech become more common in healthcare, ensuring these tools meet compliance standards is vital. Keep in dialogue with tech vendors and stay informed on regulatory updates to use these innovations effectively and legally.

Training Needs: With new rules and tech comes the need for updated staff training. Make sure your team is always learning about the latest in compliance for hospitals to keep your facility on the right track.

5 Key Areas of Compliance for Hospitals  

1 4 3 2 5
Emergency Preparedness Infection Control Fire & Life Safety Medical Gas HVAC & Utilities


1. Emergency Preparedness

Natural disasters have become increasingly common over the years, and having a solid emergency plan is critical to keep your facility safe and maintain hospital compliance. The Joint Commission specifically outlines standards as to which kinds of preparedness plans are the most important for your facility to have as a minimum. However, it’s never a bad thing to have a plan in place should the worst happen. 

2. Infection Control

Infection control is one of the most significant battles that a facility manager will undertake. 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 healthcare-associated infections (HAIs) have become a growing concern.” 

The larger and busier a facility is, the more important it becomes to keep harmful particles, contaminated surfaces, and other dangers safely contained. To do this, tools like dust containment carts or anterooms can provide a helpful barrier against the spread of disease in your facility. 

3. Fire and Life Safety

Compliance for hospitals in fire and life safety is non-negotiable in modern healthcare facilities. Billions of dollars are spent on fire damage every year, according to the NFPA. Because of the severity of fire damage, the NFPA is particularly strict with its regulations and standards. Violations can lead to severe consequences, including fines and facility shutdowns. In the event of a fire emergency, very little can be done to protect your facility at the last minute outside of fire crew intervention, so you must take the necessary precautions ahead of time to prepare. 

For example, many facility managers make use of tools like STARC® FireblockWall™ to provide separation in the event of a fire to slow the progression and give patients and staff additional time to evacuate in the event of an emergency.

4. Medical Gas Systems

These systems require constant monitoring to ensure they function correctly and safely. Any lapses in this area can endanger patients and staff. It's essential to educate and continually update all staff members on the specific requirements and standards set by CMS, including the correct storage, handling, and disposal of medical gases, along with maintaining the optimal temperature and system management practices. 

Regular training on the latest CMS hospital compliance codes and operational protocols for these systems is your best defense against the dangers of mishandling medical gases.

5. HVAC and Utilities Maintenance

Efficient management of HVAC systems contributes significantly to a facility's compliance readiness. Utilizing high-quality filters and maintenance equipment can help in staying prepared for inspections.

Effective management of HVAC and utility systems is crucial for operational efficiency and meeting compliance standards within healthcare settings. Using high-quality filtration systems and staying on top of regular maintenance can help in staying prepared for inspections. Many facilities opt for the gold standard of High-Efficiency Particulate Air (HEPA) filters to do this. Whichever method you choose, it’s important to not only complete regular repairs but also to evaluate when a replacement is needed rather than a short-term fix. The higher quality and better maintained your equipment, the more effectively you can track and analyze areas of concern or potential improvements for better overall patient care and staff safety. 

Take on Hospital Compliance with Confidence 

Managing a modern healthcare facility is no small feat, especially with all the rules and standards to comply with. From making sure the air your patients breathe is clean, to managing daily operations and maintenance of HVAC systems, there's a lot on your plate.

HEPACART is your go-to partner in making these tasks more streamlined and effective. Our lineup of healthcare tools equips you to powerfully stay on top of everything from air quality to infection control. From solutions like top-notch air filters to dust containment systems, you can do healthcare better with industry-leading equipment from HEPCART. 

Unlock the full potential of your facility with our Ultimate Guide to Indoor Air Quality. Dive in now and transform your approach to hospital compliance programs and patient care today.


The Ultimate Guide to Indoor Air Quality in High-Risk Environments