ANNUAL COMPLIANCE PLAN: BRONZE

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:

• Annual Visit – 2 days
  • Does not include travel expenses

KEY COMPLIANCE AREAS:

Governance:

• Review Governing Body Meeting Minutes
• Ensure Credentialing and Privileging are Completed in a Timely Manner.
• Review Completed Peer Review Semi-Annually.

Human Resources:

• Assist with Onboarding of New Employees
• Training New Employees
  • Admin
  • Nursing
  • Surg Tech
• Review Annual Competency Reviews
• Review Annual Performance Evaluation
• Review Staff Meetings Minutes

Accreditation Compliance:

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

Quality Improvement:

• Review Quality Improvement Meeting Minutes
• Review QI Studies and Benchmarking

Audits:

• Review of Internal Audits and Completed Risk Assessments Reviewed  

MONITORING AND REPORTING:

• Semi-Annual Compliance Check-Ins
• Action Plan and Follow-Up

CONTINUOUS IMPROVEMENT:

• Implement best practices from industry benchmarking
• Regularly updated policies to align with new standards