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The Joint Commission is coming: Here’s your cheat sheet to success

Michael Bernstein. Photo courtesy of Corporate Realty, Design & Management Institute.

Michael Bernstein. Photo courtesy of Corporate Realty, Design & Management Institute.

Michael S. Bernstein, Life Safety Code Surveyor for The Joint Commission, offered his tips for a successful inspection at the NYC: 5th Annual Hospital, Outpatient Facilities & Medical Office Buildings Summit. The event, held Sept. 17 at the New York-Presbyterian Hospital, was sponsored by Corporate Realty, Design & Management Institute and the Health Care Institute of IFMA.

Healthcare FMs, architects, designers and real estate executives attended 11 information sessions that ranged from the funding of medical center expansions to emergency surge planning to how to reduce ligature risks in your facility. The McMorrow Reports covered the conference and will be sharing highlights of some sessions.

Bernstein advises what to expect on day 1 on inspection.

  • Day One morning: Facility Orientation – New as of May 2017 – Usually before the 8 or 9 a.m. : Visit generators. Obtain nameplate info. Look for EPO. Visit fire pump room. Electric or diesel (Day tank at least 2/3 Full). Spare sprinkler heads and tools 100° F.
  • Day One morning: Document Review: Paper or electronic, 90 minutes is the goal! Same checklist the Life Safety Code Surveyors (LSCS)/Hospital use. Serves as hospitals prep tool for survey – mock review, checklist has standard, EP, Time frequency.
  • Policies and procedures for Interim Life Safety Measures (ILSMs): Written fire response plan (LIP) at Operator or Security. Evaluations of fire drills conducted for the past 12 months – complete fire drill matrix. Maintenance records for fire protection & suppression equipment. Maintenance records for emergency power systems. Maintenance records for piped medical gas and vacuum systems.

Tip for success:

  • Know the number and types of sprinklers so you can determine the number of spares needed.
  • Organize testing document binder in the same order as the checklist.
  • Close all open issues and place work orders right behind the report.
  • LSCS will use IOU if not readily available.
  • One fire drill per shift per quarter. It should be three months plus or minus 10 days. It has to be more than an hour apart. (Best Practice: Vary days)
  • Place central station and FDC checks on fire drill form – save time and money and eliminate missed annual and quarterly requirements.