Health Care Facilities Experts

Consultation Services on Accreditation, Survey Preparation and Regulatory Affairs

We are dedicated to providing health care facilities expert consultation in the area of accreditation, survey preparation and regulatory affairs. SMS, Inc. assists healthcare organizations as they prepare the programs of their Physical Environment for survey, regardless of the accreditation entity. SMS, Inc. works with organizations accredited by:

  • The Joint Commission® (TJC)
  • American Osteopathic Association (AOA)/Healthcare Facilities Accreditation Program (HFAP)
  • DNV/National Integrated Accreditation for Healthcare Organizations (NIAHOSM)
  • Centers for Medicare & Medicaid Services (CMS)

SMS, Inc. provides comprehensive Environment of Care®, Emergency Management and Life Safety Code® support services, including Statement of Conditions™, mock surveys, safety risk assessments, and publishes a variety of technical publications.

We also host EC-Online™ The health care industry’s foremost web-based code and standards research service – EC-Online addresses facility-generated questions posed in relation to TJC, AOA, CMS, NFPA®, OSHA and EPA standards and guidelines.  For an overview of EC-Online:

TJC® Update:

On December 26, 2013, The Joint Commission® (TJC) released a Prepublication Requirements and a revision to their Accreditation Programs Survey Activity Guide. The Prepublication Requirements for Diagnostic Imaging Services changes are for Ambulatory Care Centers, Hospitals and Critical Access Hospitals issued December 20, 2013 and effective July 1, 2014. There are 12 proposed new Environment of Care® (EC) elements of performance and one existing element of performance (EP) changes. The majority of the standards are requirements that Radiology/Imaging departments may already have in place or required by other governmental agencies. In addition to the EC chapter changes, there are new EP’s in Human Resources (HR), Medication Management (MM), Provisions of Care (PC) and Performance Improvement (PI). SMS, Inc. will develop publications in the near future to reflect these changes.

The Accreditation Programs Survey Activity Guide (SAG) has been revised and is now effective January 2014.  The SAG has identified additional documents required upon review during the Preliminary Planning Session and Surveyor Planning Sessions. These documents will be the last 12-months of data. This is the current list of documents required for the Physical Environment and Infection Control only (new documents are underlined): EC data including the Statement of Conditions (SOC) from the last survey, as applicable, EC Management Plans and annual evaluations, EC multidisciplinary team meeting minutes for the 12 months prior to survey, Emergency Operations Plan (EOP) and annual evaluation, Hazard Vulnerability Analysis, Emergency Management drill records and after action reports, written Fire Response Plan, Interim Life Safety Measure Policy, Fire Drill Evaluations, Infection Control Plan  (Annual Risk Assessment and Annual Review of the Program and Assessment-based, prioritized goals), and Infection Control surveillance data from the past 12 months. The Accreditation Survey Activity List or time frames with each section has not been changed.


The revision process for the Hospital Incident Command System (HICS) continues. EMSA has determined it is necessary to delay the release of the new HICS materials until March 2014.

The ten member HICS Final Review Group met on August 27-28, 2013 in order to assess and discuss revisions made in response to the over 2000 valuable comments and recommendations received during the national review process.  The Final Review Group reconvened on November 6 and November 13. The HICS Guidebook is in the process of being finalized, and the Incident Planning Guides and Incident Response Guides are nearly finished.  The HICS forms are being finalized and will be converted to a user-friendly fillable format. EMSA expects to receive the 75 Job Action Sheets for final review over the next several weeks.

This collaborative HICS revision and subsequent review process has been extensive and time consuming.  EMSA has learned many lessons from this process that will most certainly expedite future revisions and assist with determining realistic time frames in advance.

EMSA appreciates the national and international enthusiasm for HICS and is eager to release outstanding HICS materials in March 2014.

Are you ready for the 2012 Hazard Communication Standard changes?


What are the changes in OSHA’s Hazard Communication 2012?


OSHA’s Hazard Communication Standards hasn’t changed since 1994. These changes were brought about to improve safety and health of workers through more effective communications on chemical hazards. The changes in the standards are labeling, safety data sheets, hazard classification of chemicals. With these changes in the standard, all relevant documentation and training on chemicals will also need to be updated. This is a great opportunity to take a deeper look into your Hazard Communication Program for compliance and revise to the new standard.


What is GHS and how does that affect the Hazard Communication Standard (HCS)?


GHS stands for Globally Harmonized System.  The United Nations Conference on Environment and Development (UNCED) mandated, in June 1992, after little progress was made regarding international harmonization. Supported by the U.S., it called for the development of a globally harmonized chemical classification and labeling system. The globally harmonized hazard classification and compatible labeling system, including material safety data sheets and easily understandable symbols, should be available, if feasible, by the year 2000 was the mandate. It took another 12 years to change OSHA’s Hazard Communication Standard. The affect is changes to the standard through labeling, safety data sheets, and hazard classification of chemicals.


How do I get my hands around the HCS requirements?


The significance of this revised standard is the employee’s knowledge on the “Right To Know” law. Employees have been using the acronym MSDS since 1983. The culture of safety will be a challenge in documentation and training for the next couple of years. Understanding of the requirements and their trickle-effect of changes will be the challenge for these new requirements. SMS Inc. can assist with this challenge.


How can Safety Management Services, Inc. help my organization to become compliant with the Hazard Communication Standards-Globally Harmonized System (HCS-GHS)?


Safety Management Services, Inc. provides training to your staff on the new label elements and safety data sheet (SDS) format and will update all the policies, procedures and response plans of your organization related to HCS-GHS.

A typical consultation will:

  • Assist in reviewing and revising existing hospital policies and procedures related to training and management regarding hazardous chemicals.
  • Ensure the resulting policies and procedures will be compliant with HCS requirements as well as be integrated into current Joint Commission requirements.
  • Develop a HCS orientation program.
  • Conduct a facility review for compliance with Hazardous Material & Waste requirements under The Joint Commission and HCS.

Health Hazard Chart

Venformate Compliant Provider of services to healthcare organizations