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Joint Commission Regulatory Compliance Management

SSR takes a management approach to assuring effective and affordable regulatory compliance.  We will help you develop an overall compliance master plan and determine how individual processes, tools and activities can be integrated for proper execution and documentation.  Our Joint Commission Regulatory Compliance Management program includes six chief activities:

1. Continuous Compliance Cycle
An integral part of SSR’s overall compliance management, the Continuous Compliance Cycle ensures your organization’s transition from Survey Readiness to Continuous Readiness.  It is designed specifically to assist your organization in staying fully compliant and within the compliance “track record” with a score of 2 at all times in all areas of the environment of care. Quarterly on-site visits allow follow-up and close surveillance of progress toward full and continuous compliance.  A progressive, written report after each site visit provides the organization with not only a management tool, but documentation of the overall compliance program.

2. Statement of Conditions
With direct hospital experience on our side, we understand the standards and regulations medical facilities face as well as how those standards and regulations affect actual daily operations.  SSR provides an overall assessment of facility environment, Life Safety Assessment (LSA) and development of the Statement of Conditions (SOC) Parts 1 through 4.  CAD floor plans can be developed for your continued use. 

The completed SOC includes a detailed Plan for Improvement (PFI), developed in partnership with your staff.  We will work with the hospital facility management leadership to provide in-depth justification for funding the items identified on the PFI, and in a format that can be presented immediately to hospital leadership for approval.

SOCs completed by SSR maintain a 100% acceptance rate by the Joint Commission.

3. Joint Commission Equivalency Report
Utilization of the Equivalency Report may save your organization thousands of dollars in unnecessary construction or renovation costs.  Our consultants provide facility assessment and complete Joint Commission Equivalency Reports ready for submission to the Joint Commission.

We are exceedingly aware of the cost of Plan for Improvement (PFI) maintenance and how other processes/procedures that hospitals use can meet the standards. SSR can provide a facility assessment and complete the Joint Commission Equivalency Report in a “ready” format for submission to the Joint Commission. 

If we complete the Statement of Conditions, the cost of completing the Joint Commission Equivalency Report, submission and report acceptance tracking with the Joint Commission is minimal.

4. Building Maintenance Program
In the Statement of Conditions 3A, Part 6J and 3B, Part 6I, the Joint Commission describes a plan for healthcare facilities to develop an effective Building Maintenance Program (BMP).  A BMP is a tool designed to monitor and resolve maintenance-related Life Safety Code deficiencies in lieu of identifying specific locations and creating a Plan for Improvement (PFI). The BMP includes items typically cited during Joint Commission and CMS building tours, such as penetrations, burned out egress lights and exit signs, and doors that do not operate or close properly.

SSR has a proven way to make your BMP easy and operational. Providing a facility Life Safety Assessment (LSA) is the beginning. LSA components (SOC Part 6J) are entered into a database, and then placed on LSA plans.  Using a state-of the art system with a laptop PC, we provide education on how to identify deficiencies and manage data effectively.

What can a BMP do for you?

  • Validate and document your Life Safety initiative
  • Improve the operational reliability of fire safety components
  • Automate aggregation of data to support a 95% effectiveness rate
  • Provide an automated platform for generating Plan for Correction work orders to resolve Life Safety issues without declaring them on an SOC/PFI
  • Support your peace of mind during Joint Commission visits, announced and unannounced

5. Survey Preparation
SSR provides on-site coordination of all aspects of survey preparation and completion. Our services are custom designed to meet your needs, and may include:

  • Practice interviews
  • Evaluation of current policies and procedures
  • Review and critique of meeting minutes
  • Review and evaluation of mock root cause analysis
  • Environment of Care Risk Assessment
  • Review assistance with the preparation of presentation manuals

The SSR consultant can be on-site during the actual Joint Commission survey to provide moral or actual work support.  At the completion of each survey day, we provide information sessions for the staff and leadership team.

6. Periodic Performance Review
SSR lead organizations in performing the required mid-cycle Periodic Performance Review to include all required documentation, data aggregation, and a comprehensive building tour.  All EC standards and Elements of Performance will be individually assessed and scored according to Joint Commission guidelines.  An electronic report adhering to the Joint Commission PPR option #1 will be provided in the event the organization elects to submit the full PPR.

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