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Environmental Health & Safety

The Joint Commission Response Procedure

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The Joint Commission Response Procedures

  1.    PURPOSE
  2. This procedure provides guidance to EH&S office staff to coordinate notifications of appropriate internal staff who will need to respond to an unannounced Joint Commission inspection. It provides direction to respond to and prepare for the unannounced inspection.

    This policy also gathers all pertinent information for the audit that would need to be presented to The Joint Commission surveyors as supporting documentation to their management plans.

  4. EH&S Director, Support Staff, Environmental Compliance Unit Manager, Senior Sanitarian, Radiation Safety Officer, SMH Fire Safety Specialist, Occupational Safety Specialist, Emergency Preparedness Manager, OSU Technician responsible for ECC Surveys.

  6. N/A

    1. The Director of Environmental Health and Safety will be notified via the hospital Joint Commission paging notification system
    2. The Director of EH&S will notify the CFO/Senior Vice President for Administration and Finance
    3. The Director of EH&S will call the Main EH&S Office and notify the front office staff either by direct communication or by voice mail
    4. The front office staff receiving the message will make the following notification:
      1. Manager of Environmental Compliance Unit
        - If not available, the backup is the Senior Sanitarian
      2. Radiation Safety Officer
        - If not available, the backup is the Imaging QA Technician
      3. Hospital Fire Safety Specialist
        - If not available, the backup is the Fire Marshal
      4. Occupational Safety Unit Manager
        - If not available, the backup is the Certified Industrial Hygienist
      5. ECC Surveyor
        - If not available, the backup is Facilities Safety/Compliance Manager
      6. Assistant Director of Facilities Operations
        - If not available, the backup is the Director of Facilities
      7. Real Estate Services Manager
        - If not available, the backup is the Executive Director of Real Estate Services
      8. Director - UR Network and Communications
        - If not available, the backup is the Co-Deputy of the CIO or the Director, Enterprise Applications
      9. Project Director, DR/BCP
        - If not available, the backup is IT/IS Analyst Programmer
    5. After opening meeting, Director will notify front office staff to make the following notification of the EOC document review meeting.
      1. Manager of Environmental Compliance Unit
      2. Radiation Safety Officer
      3. Hospital Fire Safety Specialist
      4. Occupational Safety Unit Manager
      5. Emergency Preparedness Manager
      6. Administrative Assistant to the Director of Operations, Facilities, who will then notify the ECC System Tracer Attendees distribution list
      7. Administrative Assistant for the SMH Emergency Preparedness Subcommittee, who will then notify the Emergency Management System Tracer Attendees distribution list
    1. The Director of EH&S will gather JC waivers and report to the opening conference. The opening conference will take place in the ACF Board Room.
    2. The Director of EH&S, Radiation Safety Officer, Senior Sanitarian, and Occupational Safety Unit Manager will accommodate the Joint Commission Life Safety Surveyor during the hospital tour.
    3. The Hospital Fire Safety Specialist will gather the 12 month history of the following documents and bring them to the Hospital's Director's Office Conference Room:
      1. Fire detection system testing
      2. Monthly fire pump tests
      3. Fixed extinguishing system inspections
      4. Sprinkler main drain test
      5. Helipad foam system inspections
      6. Quarterly circuit tests
      7. Semi-annual sprinkler water flow tests
      8. Monthly valve inspections
      9. Semi-annual valve tamper tests
      10. On-site fire drill reports
      11. Off-site fire drills/disaster drill reports
      12. Interim Life Safety Assessments
      13. Life Safety Plan (Fire Marshal's office)
      14. Emergency Preparedness Book (Fire Marshal's office)
    4. The Hospital Fire Safety Coordinator will then tour the hospital and ensure the following
      1. Verify all fire alarmm control panels are green with no alarms
      2. No doors propped or wedged open
      3. No door latches taped over
      4. All doors and hardware in good repair, all positively latch (unassisted if equipped with a closer)
      5. Stairwells free of obstructions and debris
      6. Corridors free of storage, debris, combustible items or items blocking egress
      7. Electrical and telephone closets free of debris
      8. Ceiling tiles and grids in place and in good repair
      9. Fire extinguisher inspections are current and signs are visible
      10. Fire extinguishers, fire alarm stations, fire hose cabinets, medical gas valves not blocked by storage, properly labeled and inspected
      11. Verify no smoke detectors are covered
      12. Inspect construction sites to ensure fire load is low
      13. Verify extinguishers at construction sites are inspected and hot work activity is compliant with procedures
      14. All exit lights functioning and all exit signs unobstructed
      15. Ensure ILSM measures are posted at all required locations
      16. All fire breaches properly fire sealed and patched
      17. Oxygen and other gas bottles upright and properly secured in a stand or chained to prevent tipping - NOTE: Oxygen Storage - if there are more than 12 tanks present you are to contact the nurse manager IMMEDIATELY
      18. Report status to Fire Marshal
      19. Repeat sweeps once per day for the duration of The Joint Commission's visit
    5. The Manager of the Environmental Compliance Unit will:
      1. Retrieve and make available for the EOC Document Review session the Materials/ Waste Management Committee (MWMC) binder. This binder will contain at a minimum the last 12-month period of meeting minutes, quarterly reports and supporting documentation. The binder also contains the Hazardous Materials/Waste plan and the previous year's evaluation and supplemental goal accomplishments
      2. Be available and present during the EOC Document Review Session and notify other Committee members they should be available for specific questions in their area of expertise
    6. The Senior Sanitarian will:
      1. Participate in the Building Tour for the Dietary areas
      2. Be available and prepared to answer questions regarding pest control services and IPM methods routinely used in SMH
    7. The Radiation Safety Officer will gather the 12 month history of the following documents and bring them to the EOC Document Review Session:
      1. Laser Safety Report
      2. Radiation Safety Management Plan
      3. Quality Assurance Matrix
      4. Records of mis-administrations
    8. The Occupational Safety Unit Manager will have a 12 month history of the following ECC documents available for inspection:
      1. Employee Incident Reports
      2. Visitor & Patient/Public Areas Report
      3. Blood Exposure Report
      4. Identification of location of all other areas which fall under the Safety Management Plan
    9. The ECC Surveyor in charge of ECC Inspections will compile the last three years worth of ECC Inspection binders to be taken for the document review and aid the Occupational Safety Specialist with any needed up to date sample surveys, quizzes, or other needed documentation for the Safety Management Plan.
    10. The Environmental Compliance Manager will participate in the building tour for the Waste Processing areas
    11. The Emergency Preparedness Manager will bring the ExPlans, Controller-Evaluator Handbooks, EECs and After Action Reports for all drills and actual events from the last year
      1. They will ensure there is 3 years' worth of documentation available, if requested
      2. Participate in the EP Systems Tracer
    12. The Administrative Assistant to the Director of Operations, Facilities, will bring the following to the ACF Board Room:
      1. All Management Plans
      2. All Annual Management Plan Reviews
      3. Quarterly Reports
      4. Quarterly Additional Accomplishments Reports
      5. Meeting Minutes
    13. All EH&S staff will be available to answer questions or resolve open issues
    1. SMH Comprehensive Emergency Management Plan
      1. Disaster Drills
    2. Life Safety Plan
    3. Safety Management Plan
      1. Laser Safety Plan
      2. Radiation Safety Plan
    4. Hazardous Materials Plan
    Comprehensive Accreditation Manual for Hospitals
  12. Date

    Revision No.


    10/12/07 1 Added Information Technology ECC Rep to notify list
    3/30/10 2 Added additional backup contact information; updated information needed under Procedures
    9/10/10 3 Added additional contact information; updated terminology in References
    10/30/15 4 Updated contact information
    7/17/18 5 Triennial update
    1/8/19 6 Added information for EP Manager's responsibilities

Contact EH&S at (585) 275-3241 or e-mail EH&S Questions.

This page last updated 3/18/2019. Disclaimer.