The Joint Commission announces survey changes

The Joint Commission announces survey changes

The Joint Commission announced two changes to its survey process affecting facilities management departments. First, surveyors are now responsible for obtaining the facilities director/manager job description from the human resources representative to ensure it meets minimum standards for the position and also will verify documentation showing that this individual has specific competencies. Another survey change affects documentation review. The Joint Commission shared that, effective immediately, health care organizations submitting required data and documentation to surveyors and/or reviewers via USB storage devices also must provide a device, such as a laptop, to the surveyor and/or reviewer that can be used to access the required data.

DNV updates documentation review process

DNV Healthcare USA Inc.’s Healthcare Standards Application and Interpretation Team has updated the accreditation process for the National Integrated Accreditation for Healthcare Organizations program with changes to the survey team arrival procedures. Team leaders must present a list of requested documents within three hours of the surveyor’s arrival. This emphasizes the importance of hospitals having all necessary physical environment documentation readily accessible. Failure to produce these documents within the specified time frame may result in a nonconformance citation, impacting the hospital’s accreditation status.

CMS provides shared space guidance for CAHs

The Centers for Medicare & Medicaid Services (CMS) released guidance on compliance and expectations related to space sharing arrangements, including time-sharing and leased space agreements between critical access hospitals (CAHs) and other health care entities. In QSO-25-08-CAH, CMS states, “Current access to care challenges in rural communities call for flexibility in health care partnerships, while simultaneously protecting the safety and quality of care for patients. In this guidance, CMS seeks to provide clarity on how a CAH may leverage space sharing arrangements with other health care entities to increase access to additional care and services within the community, while maintaining independent compliance with all applicable participation requirements.”

NFPA public input periods open on four standards

The public input period for four National Fire Protection Association (NFPA) standards is open until June 4, 2025. The standards open for input include the 2028 editions of NFPA 13, Standard for the Installation of Sprinkler Systems; NFPA 20, Standard for the Installation of Stationary Pumps for Fire Protection; NFPA 80, Standard for Fire Doors and Other Opening Protectives; and NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. To submit a public input using the online submission system, visit NFPA.org and navigate to the standard’s webpage. Select the “submit public input online” button to begin the process. Users will be asked to log in or create a free online account with NFPA before using this system.