You got a joint commission what?

A Joint Commission survey can be overwhelming. It’s unannounced, the codes are in constant flux making it hard to know what to expect, Requirements for Improvement (RFIs) are common, and most importantly your accreditation is placed at risk. It’s important to know what to expect and what deficiencies to look out for. This way you can resolve any issues and save yourself from many unwanted citations in the future. It’s also important to know what steps to take after your Joint Commission survey if you happen to receive RFIs. This can not only help things run more smoothly, but lessen the risk of losing accreditation.

Prevention Tips for the Top Cited Life Safety Deficiencies

Some of the most common cited deficiencies revolve around life safety issues. These deficiencies include means of egress, fire and smoke barrier penetrations, fire door issues, and proper documentation of fire safety testing.

Means of egress: This usually revolves around corridor clutter and blocked hallways. The best way to resolve this issue is to have clear communication with staff about the importance of keeping hallways clear. Evacuation drills are a good way to demonstrate the risk this could potentially pose during emergencies. George Mills, director of the Department of Engineering at the Joint Commission also suggests, “Making regular rounds to develop relationships with these equipment users is critical to lasting success.”

Fire and smoke barrier penetrations: In terms of firestopping deficiencies, some of the most common citations stem from mixing materials and systems and the use of unapproved and unrated materials. Using an experienced contractor who is familiar with UL codes can help you resolve these issues. Because this has become such a huge issue, The Joint Commission and ASHE have been working with the fire-stop industry and others to use symposiums to educate facility staff about barrier management. If you are interested in attending a symposium to learn more about maintaining your fire barriers you can find the schedule and locations on the FCIA website. A great way to stay on top of your fire and smoke barrier deficiencies is to set up a firestop maintenance program to ensure that your facility is looked at on a regular basis. Also above-ceiling access permits can help you stay aware of areas where work is being done to check for penetrations.

Fire door issues: Some of the most common fire door deficiencies include broken, defective, or missing hardware items, painted or missing labels, and poor clearance dimensions around the perimeter of the door in the closed position. Some of these issues are easy to resolve in-house, but using an Intertek Certified Door Inspector can help you fix larger issues and ensures your doors are properly fixed. Fire door compliance is a lot more complicated than it seems, NFPA code requires that your door inspectors are experienced and have detailed knowledge of NFPA and other codes. Your door inspectors should be able to identify these deficiencies quickly and accurately, repair them up to code standards, and coordinate recertification for missing labels. Read more about the top fire door deficiencies and how to prevent them here.

Life safety inspection documentation: This issue is commonly cited when facilities are unable to provide documentation related to testing. With every inspection that goes on it’s important that all the findings are efficiently documented to code standards. This is your proof that everything is functioning as it is intended to. The Joint Commission expects these documents to be clear, detailed, concise, and most importantly – that you have them!

What Happens After My Survey?

After your survey is complete, your summary report will let you know which Plans for Improvements require an Evidence of Standards Compliance (ESC) submission. With any deficiencies listed, it’s important that you coordinate repairs immediately and get any issues that came up in your survey resolved. Your Evidence of Standards submission is a report you need to send to the Joint Commission no more than 45 and/or 60 days after the survey that addresses the corrective action you took for each element identified in RFIs. To find out more about the post survey process read here.


Accreditation and complying with the Joint Commission standards is a public commitment to continuous improvement and delivering high quality care in a safe environment. It’s important to know how to properly prepare and know what to do after your survey is complete. For more information on how to keep your healthcare facility compliant read our other articles here or visit our website for more info.
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