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Featured Article:

The Keys to Maintaining Joint Commission Accreditation

Primera Engineers, Ltd.

Written by:

Lourdes Gonzalez, AIA, LEED AP BD+C, ND, Senior Vice President and Architecture & Sustainability Lead
Rosa Lazebnik, PE, Vice President and Technology Manager
Amanda Beck, PE, CET, CFPS, Fire Protection Specialist
Primera Engineers, Ltd.

The rollout of the Affordable Care Act (ACA) is presenting a number of new challenges to healthcare providers and facility operators. One of the largest of these new challenges is keeping a facility continuously accredited by The Joint Commission (TJC) (formerly JCAHO). States rely on TJC accreditation and certification programs to oversee the quality of the healthcare facilities and programs. Additionally, various state agencies utilize TJC accreditation as a condition for Medicare payments. Specifically, the State of Illinois recognizes TJC accreditation as a condition of licensure and the receipt of Medicare and Medicaid service reimbursements. As such, continuous accreditation becomes even more critical in the present ACA environment as the population ages and hospitals rely more and more on Medicare and Medicaid reimbursements.

Each facility is subject to TJC inspections at a minimum of every 18-39 month intervals after their last inspection. During the inspection process, TJC surveys the facility and evaluates compliance with the published standards. The visits are unplanned and unannounced, which means that continual readiness of the facility and its personnel is critically important.

While TJC accreditation is voluntary, it is an ongoing process and accredited healthcare organizations have to constantly work on maintaining this certification. The more than 250 regularly updated TJC standards focus on patient safety and quality of care, infection control and preparedness for emergencies. However, the most important aspect of the survey is the evaluation of the facility’s compliance with life safety codes. TJC surveyors are certified and highly trained, and their team is usually comprised of experienced healthcare professionals and life safety specialists. The surveyors evaluate the organization’s patient experience, observe how doctors and nurses deliver patient care, and evaluate the overall condition of the facility as well.

For each item reviewed by TJC surveyors during the inspection, successful compliance with a particular item, or Condition of Participation, depends upon the matter and degree to which the provider satisfies the various standards within each Condition. When Conditions are not satisfied, The Centers for Medicare & Medicaid Services (CMS) cites deficiencies, classifying them at either Standard level or Condition level depending on degree of severity, criticality and extent of the lack of compliance.

  • A deficiency is defined at Standard level when it is of such nature that is does not limit a facility’s capacity to deliver adequate care and does not jeopardize or adversely affect the health or safety of patients.
  • A deficiency is defined at Condition level when non-compliance represents a severe or critical health or safety breach. When Condition level deficiencies are found, a follow-up TJC inspection (also unannounced) will occur within 45 days from the last survey with additional subsequent surveys if the deficiency persists. A full CMS survey will follow to review the facility for compliance with all Conditions of Participation.

The best way to deal with deficiencies, especially Condition level deficiencies, is to avoid them in the first place by conducting your own regular inspections that focus on the issues most often cited by TJC in inspection reports submitted to CMS. To aid in this process, the TJC releases a “Top Ten” list of the most frequently cited standards every six months. Several of the most frequently cited and routinely included Condition level deficiencies in the bi-annual TJC “Top Ten” list are, in fact, issues related to the Life Safety and Environment of Care standards. Below, we analyze some of the most common areas for deficiency and offer insights on how to correct or avoid the issue.

1. LS.02.01.10 – Building and fire protection features are designed and maintained to minimize the effects of fire, smoke and heat.

Citations for this standard typically relate to:

  • Missing or insufficient fireproofing of structural steel or of the openings thru fire rated walls
  • Proper operation of fire rated doors and door hardware: hold open devices, self-closing or automatic door openers or closers, positive door latches

The items for maintaining proper fire separations are best addressed during the initial construction of a facility or during any renovations that occur after the initial construction. Diligent oversight and completion of the design team’s punch list are critical even in new facilities. The issues with proper doors and hardware is an on-going challenge that needs to be addressed by the development of a process checklist for in-house trades and outside contractors. An assessment by a qualified team can identify these items early so that they can be addressed proactively by the facility.

2. LS.02.01.20 – The organization maintains the integrity of the means of egress:

  • Doors to patient rooms, egress doors, doors to diagnostic and treatment areas, especially in existing buildings are not compliant with NFPA 101 requirements for clear and unobstructed width
  • Non-functioning or non-compliant exit signs and emergency illumination devices

Means of egress is critically important to not only the TJC and its inspectors, but also the local municipal inspectors as well. They will also be making periodic inspection visits for compliance. Again, an assessment by a qualified team can address deficiencies proactively as well as address requirements during any planned renovation projects. A comprehensive maintenance program should be developed for lamp replacements to address exit signs and emergency lighting.

3. LS.02.01.30 – The organization provides and maintains building features to protect individuals from the hazards of fire and smoke.

Citations under this standard routinely include:

  • Penetrations thru smoke barriers – most frequently left without fireproofing after recent remodeling projects
  • Correct operation of smoke doors (swing, width, door edge treatments: undercuts or excessive gaps)
  • Smoke compartments and smoke suites – fire rating of partitions and doors between them, non-compliant penetrations or openings thru smoke barrier walls

Similar to the items above, construction phase oversight in addition to the implementation of design standards can minimize these issues. However, existing non-conforming conditions can be addressed proactively by an assessment team to minimize or eliminate Condition Level findings.

4. LS.02.01.34 – The hospital provides and maintains fire alarm systems.

TJC surveyors are indicating non-compliance with NFPA 101 (Life Safety Code) and NFPA 72 (Fire Alarm and Signaling Code) requirements for:

  • Locations and functionality of fire alarm initiating devices and notification appliances
  • Method of fire alarm signal transmission to the servicing Fire Department

Review of fire alarm systems should be undertaken on all systems that are 5 years or older to make sure they are in compliance with the appropriate version of NFPA 101 and 72. It is critical to maintain and test Fire Alarm systems in accordance with the applicable NFPA Code (NFPA 72) and maintain orderly and well-organized records of testing.

5. LS.02.01.35 – The organization provides and maintains systems for extinguishing fires.

Hospitals are often cited for this standard because of:

  • Condition of fire sprinkler systems
  • Installation of communication wiring above the ceilings with insufficient clearances to the sprinklers
  • Violation of 18” clearance between sprinklers and commodities in storage spaces
  • Absence of fire sprinklers within stretcher alcoves or wardrobes
  • Lack of Type K extinguishers and signage (or more than 30’ distance) at the grease producing equipment in food processing areas

These issues that can be cited for Standard or Condition level findings and can be examined in conjunction with smoke and fire barrier penetrations compliance. It is critical to maintain and test Fire Protection systems in accordance with the applicable NFPA Code (NFPA 13) and maintain orderly and well-organized records of testing.

6. EC.02.05.07 – The organization inspects, tests and maintains emergency power systems.

Emergency power systems equipment includes:

  • Generator(s)
  • Automatic Transfer switches
  • Associated power distribution equipment (paralleling gear, emergency power distribution switchboards, etc.)
  • Battery operated egress lighting

Emergency battery units or battery operated lights installed in electrical rooms or in operating rooms are not included in this standard, but the facility still needs to conduct periodic testing and maintain records.

7. EC.02.03.01 – The organization manages fire risks.

The common findings include:

  • Inappropriate storage of gas cylinders
  • Deficiencies in electrical systems installation, such as: open junction boxes, hanging wiring, non-working, damaged or improperly labeled electrical outlets

Items 6, 7 and 8 should be addressed by the Owner through the development and implementation of a comprehensive testing/records program. This information can also be critical to any Owner assist team that may be brought in to assess existing conditions.

8. EC.02.06.01: The organization establishes and maintains a safe functional environment.

Citation under this standard has a direct impact on the building HVAC and HVAC control systems. The monitored and evaluated parameters are:

  • Temperature and humidity levels in operating, procedure and delivery rooms, nursery, central sterile
  • Pressure differential in isolation rooms and operating rooms is also evaluated

Incorporating a retro-commissioning program, which can also be enhanced to search for energy savings potential through utility funded grant programs, can evaluate conformance to initial design requirements. From there, a fully robust building automation system (BAS) and monitoring can address on-going maintenance of standards.

To complicate matters further, upcoming changes to the CMS governing codes and procedures as well as TJC requirements can make the task of continually preparing for accreditation even more confusing for facility managers. In an effort to align its survey process with the requirements of the CMS, TJC recently announced changes to their survey decision reports effective July 1, 2014. Likewise, CMS is currently proposing the adoption of the NFPA Life Safety Code, 2012 Edition, and the NFPA 99 Health Care Facilities Code, 2012 Edition, as outlined in the proposed rule, “Medicare and Medicaid Programs; Fire Safety Requirements for Certain Health Care Facilities,” that was published in the Federal Register on April 16, 2014. Note that both codes will be adopted with some revisions and exceptions. Lastly, additional changes to reporting and inspection procedures are coming to the hospitals located in Illinois as Governor Pat Quinn recently signed legislation establishing a new fee to generate the necessary revenue to implement these changes. The new rules will require more frequent and thorough inspections which will further accentuate the need for better preparedness from existing facilities. For full details on all of the changes impacting TJC accreditation, visit

In summary, regular Life Safety Code assessments by qualified Life Safety experts are becoming more critical in a constantly changing regulatory environment. Many of the discovered items are simple to address before they become an issue or before they are cited in your facility’s TJC report. Life safety experts, such as Primera Engineers, can assist in facility assessments to determine compliance with these key areas of evaluation. Life Safety Code deficiencies discovered during preliminary assessment can either be resolved immediately or addressed by one of three TJC recognized processes. Qualified life safety professionals can guide healthcare organizations through the entire evaluation, inspection and accreditation process. Awareness and continuous preparation are truly the keys to success in this highly competitive arena.

State of Illinois CMS State Operations Manual, Rev. 9, 09-27-13
Susan B. McLaughlin, Standard Issues, Health Forum, a subsidiary of AHA
TJC website,
Crain’s Chicago Business, July 8, 2014: New state hospital fee to pay for quality reporting system, more inspections;

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