Preparing business occupancies for accreditation surveys

Are a hospital’s business occupancies ready for survey? With a push from the Centers for Medicare & Medicaid Services (CMS), one accreditation organization has moved forward with plans to increase compliance through surveys. Since July 1, 2021, The Joint Commission (TJC) has a total of 29 elements of performance that will be used to survey business occupancies. While other accreditation organizations have not defined how their own processes will work, they may follow one similar to TJC’s as CMS continues to zero in on life safety compliance on non-hospital occupancies. The key to a successful survey will be providing critical building information.

Much of the required information that is included in health care or ambulatory health care occupancy life safety drawings is not relevant to business occupancies. Providing drawings for a business occupancy may seem like a daunting task, but there is no reason to be intimidated. Getting started can be as simple as gathering all available information and starting on paper. Not all business occupancies will require life safety drawings, especially if it is a standalone business occupancy. However, having drawings that include the relevant information is a good best practice.

A facilities manager must be able to provide key details about the space, such as the construction date and type; freestanding or adjoining spaces, including exits that lead from one space to another; design occupant loads; and whether the building is an existing or new business occupancy. Additional information such as fire sprinkler systems, fire alarm systems and hazardous areas are also important to note if present.

Another key point is inspection, testing and maintenance (ITM) for life safety features. The National Fire Protection Association requirements for fire alarm and sprinkler testing apply to all occupancies, as do many of the electrical testing requirements such as egress lighting and exit signs and generators, if equipped. The ITM documentation process begins with an inventory and ends with correctly filed documentation. It’s important to remember that deficiencies must be addressed with a risk assessment, and an interim or alternate life safety measure may be required as a result.

Members of the American Society for Health Care Engineering can visit the link in this column to access a tool that will help in conducting a self-assessment and determining current level of compliance.