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:


We attended the recent ASHE Conference in our hometown of Chicago and we enjoyed meeting new friends and reconnecting with old friends. During this conference we gained further knowledge about the new changes and some clarifications on information that has been written in publications. Some of the hot topics are explained below:

  • Timeframes clarified: Quarterly is plus or minus 10 days. The clarification is different than what was expected. For example: quarterly fire drills. The date you perform a fire drill for a particular shift will need to remain within that same month on the next quarter. In other words, if you perform the 1st shift drill in July, you will need to perform the next 1st shifts drill in October (+/- 10 days). However, when you perform 3rd month of the quarter drill or testing, you will not be able to pass into the next quarter. For example: Supervisory signal devices test was performed June 30th. The next quarter test will be due in the month of September but the plus 10 days cannot extend into the month of October (4th Quarter).
  • Power Taps: The clarification for the time being is if you have Relocatable Power Taps (RPT’s) or Special Purpose Relocatable Power Taps (SPRPT’s), extension cords, or UPSs being used as outlets, it is best to perform an inventory of all those devices throughout your facility. We are currently creating an inventory specific to this advice from TJC.
  • Electronic Statement of Conditions: The items listed on the eSOC needs to include only ‘Life Safety’ NFPA deficiencies. Not deficiencies, such as med gas valves
  • Equivalencies: When TJC arrives at your facility for survey, any equivalencies documented on your eSOC will be physically evaluated to the terms of the equivalency while on site. This information of acceptance or non-compliance will be stated in your “Onsite Report’ in the Equivalency/PFI Summary, along with the number of PFIs on your eSOC.
  • New: Opportunities for Improvement (OFI): Single observations at C category EPs will be included in a separate section of the accreditation onsite report. OFIs will not require Evidence of Standards Compliance (ESC) response as there is no follow-up required.
  • Compliance with PE Standards: It was discussed at ASHE, the top ten non-compliance areas within the standards that hospitals are receiving during survey. In 2014 and 2013, 80% of the top ten deficiencies reported were either in EC or LS chapters with 51% of those in the EC chapter. There is and will continue to be a focus on PE during survey.

If you have any questions or need to contact us for further information, please do not hesitate in contacting us.

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.

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