Compliance News: Continuous TJC Compliance - An Uphill Battle

By Dean Samet, CHSP





Continuous compliance with The Joint Commission standards helps accredited organizations maintain safe and functional environments for patients, visitors and staff and maintain/improve safe, quality patient care.

What are the possible ramifications of not being continuously prepared and ready for survey, and what difficulties lay therein?

1. Loss of accreditation resulting in loss of deemed status
2. Loss of Medicare reimbursements due to loss of accreditation
3. Potential reduction in staff, services, quality of patient care, and a less safe environment due to loss of Medicare reimbursements
4. Cessation of services or possible closure of hospital due to loss of Medicare reimbursements

What are some of the matters or issues that could lead to loss of accreditation?

Being cited for an Immediate Threat to Health or Safety (ITHS).

• Inoperable fire alarm or pump without fire watch or interim life safety measures (ILSM) 
• Emergency generator down for an extended period without backup
• Lack of master alarms for medical gas systems
• Failure to maintain or significantly compromised fire alarm system; sprinkler system; emergency power system; medical gas master panel; exits.

Being found out of compliance with a standard’s elements of performance (EPs) designated under Situational Decision Rules (SDRs) and/or with Accreditation with Follow-Up Survey Rule AFS 13.

• Failure to implement corrective action(s) in response to identified Life Safety Code deficiencies
• Lack of a written interim life safety measure (ILSM) policy
• Failure to make sufficient progress toward the corrective actions described in a previously accepted Statement of Conditions™ (SOC) Plan for Improvement (PFI)

The hardest part of continuous compliance can be summarized as having to do more and more with less and less. All too often facility managers are being asked and forced to work with limited or reduced resources, e.g., budgets, staff, equipment, materials, supplies, etc. At the same time, TJC, CMS, and local and state authorities having jurisdiction (AHJs) are seemingly in an ongoing race to change and all too often add further requirements to their current regulations, codes, and standards.

You must know the rules (standards and scoring) or possibly lose the game (accreditation). Over the past several years there has been a turnover of personnel who in the past were responsible for maintaining compliance with the myriad of codes and standards. Their replacements have a steep learning curve that may best be accomplished via on-the-job (OTJ) training; reading and familiarizing themselves with the various codes and standards, especially the appropriate chapters of TJC’s accreditation manual; attending educational seminars, webinars, audio conferences; subscribing to reputable newsletters; joining organizations such as the American Society for Healthcare Engineering (ASHE); joining their state hospital engineering society; and inviting experienced consultants in who have the necessary expertise to provide on-site mentoring.

Finally, a few tips on being prepared for your next survey and continuous compliance despite any dwindling resources:

• Obtain the most current TJC accreditation manual and review the chapters for which you are responsible
• Highlight Direct Impact Requirement EPs
• Highlight Situational Decision Rule EPs
• Ensure policies and procedures are in place
• Ensure management plans are in place
• Ensure P&Ps and management plans are implemented and enforced
• Ensure minutes of meetings, risk assessments, records, logs, manifests, and performance indicators are up-to-date and accurate
• Ensure applicable staff training is provided
• Conduct your own mock surveys, tours, and tracers periodically