ANNUAL COMPLIANCE PLAN: GOLD

PURPOSE:

The purpose of this Accreditation Annual Compliance Program is to ensure compliance with all accreditation requirements and industry standards. This program establishes a structured approach to monitor, assess, and improve compliance throughout the year.

SCOPE:

This program applies to all departments, employees, and stakeholders involved in maintaining accreditation standards.

ONSITE VISITS:

• Quarterly Onsite Visits – 2 days
  • Does not include travel expenses

 

KEY COMPLIANCE AREAS:

Governance:

• Conduct Governing Body Meetings and completing Governing Body Meeting Minutes
• Ensure Credentialing and Privileging are completed in a timely manner.
• Ensure Peer Review is completed semi-annually.

Human Resources:

• Onboarding New Employees
• Training New Employees
  • Admin
  • Nursing
  • Surg Tech
• Annual Competency Reviews Assistance
• Annual Performance Evaluation Assistance
• Assistance with Staff Meetings and Meetings Minutes

Accreditation Compliance:

• Regulatory and Accreditation Standard Adherence
• Policy and Procedure Updates
• Documentation and Recordkeeping Compliance

Quality Improvement:

• Continuous Quality Improvement Meetings and Meeting Minutes
• Assistance with QI Studies and Benchmarking

Audits:

• Internal Audits and Risk Assessments Completed

MONITORING AND REPORTING:

• Monthly Compliance Check-Ins
• Action Plan and Follow-Up

CONTINOUS IMPROVEMENT:

• Conduct staff feedback sessions
• Implement best practices from industry benchmarking
• Regularly updated policies to align with new standards