1. FROM AN INTEGRATORS PERSPECTIVE
THE JOINT COMMISSION
FROM AN INTEGRATORS PERSPECTIVE

2. Joint commission - Brief history
An independent, not-for-profit organization, The Joint Commission accredits and certifies nearly 21,000 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards.
The Joint Commission is the nation's oldest and largest standards-setting and accrediting body in health care. To earn and maintain The Joint Commission’s Gold Seal of Approval™, an organization must undergo an on-site survey by a Joint Commission survey team at least every three years. (Laboratories must be surveyed every two years.)
Originally Founded in 1910 – now based out of Chicago Suburb

3. CMS and The joint Commission
Hospitals must meet eligibility standards established by the federal government in order to receive reimbursement from the federally funded programs, Medicare and/or Medicaid. CMS has been designated as the organization responsible for certification of hospitals, deeming them certified and meeting established standards.
The Joint Commission sets its standards and establishes elements of performance based on the CMS standards. CMS has approved The Joint Commission as having standards and a survey process that meets or exceeds the established federal requirements. The Joint Commission is one of several organizations approved by CMS to certify hospitals. If a hospital is certified by The Joint Commission, they are deemed eligible to receive Medicare and/or Medicaid reimbursement. Hospitals must be a member and pay a fee to The Joint Commission to be included in their survey process.

4. General overview
From the overall view of owner to T.J.C. the response is that they are accommodating and working relationship is respectful
Each organization is assigned an Advisor – this person is not the actual person doing the Survey
One of the challenges is that there is no real open communication channel to speak directly with T.J.C. Life Safety Engineer(s) that did survey.
Preparation is key
Window of time is known in advance of when survey may take place – but actual arrival date and time is unannounced.

5. Preparing for survey
Work with facilities directors to make sure they know you can be a resource to assist them in preparing for their survey
REVIEW LIFE SAFETY AND ENVIRONMENT OF CARE – DOCUMENT LIST AND REVIEW TOOL (EXTENDED WORKBOOK AVAILABLE ON WEBSITE)
Accurate documentation is one of the paramount factors for successful survey.
“If it isn’t documented, it didn’t happen” –ANTIQUATED BUT APPLICABLE

6. SURVEY PROCESS Unannounced but somewhat predictable
Documentation Review generally first
Site survey can last anywhere from 1-10 days
Escort/Scribe/Safety/Project Services/Facilities
Survey Findings published on site – preliminary
Exit Conference to outline findings
Posting of Accreditation on Website
** Life Safety Surveyor generally quite knowledgeable when it comes to fire alarm requirements

7. Common citations during surveys
Anti-ligature Risks in ED/Mental Health Areas
Interim Life Safety Measures – Especially in Facilities that remodel frequently. If Fire Alarm Control Panel is showing in trouble – what is your ILSM until corrected?
Fire Stopping measures and procedures
Documentation and full inventory of all devices on system(s) EC
Magnetic Door Holders
Notification Devices
Dampers

8. How to handle citations
Conditional Accreditation – issued in most cases when items are found during survey
90 Days to Correct
Return visit unannounced for corrections needed
Can challenge citations – will need code reference in order to challenge (limited time to challenge)

9. documentation
Documentation of maintenance testing and inspection activities for EPs 1-20 and 25 includes: activity name; date; inventory of devices, equipment or other items; frequency; contact info for person performing activity; NFPA standard; activity results
How do you accurately track this information?
Barcoding
Software Programs to inventory and produce reporting
Building Reports, InspectionOps, eVance (Honeywell)
When asked to show that a particular device was tested and the date it occurred along with status – how to best produce this? NFPA Forms don’t always achieve results needed.