Audits & Review of The Joint Commission’s Requirements for the “Physical Environment”
SMS, Inc. specializes in reviewing the program documentation required for compliance with The Joint Commission's requirements for the Physical Environment. Newly reorganized in 2009, these standards include the chapters for the Environment of Care (EC), Life Safety (LS), and Emergency Management (EM). SMS, Inc.'s highly experienced technical staff systematically evaluate all components of these program areas, including Management Plans, Policies, and Procedures. Our technical experts will interview your key personnel and mentor them in the ways of successful program management. Where indicated, our technical staff will teach and train your staff using survey-proven methods to best present the organization's programs to the surveyor. Upon completion of an audit and review, the consultant will provide a comprehensive report of the status of your programs, including a scorecard of compliance you can use for corrective action. In addition to this snapshot of compliance, the consultant will make specific recommendations of how the organization might improve programs and accreditation scores. We recommend that the audit take place at least 6 months before the survey to allow sufficient time to fine tune programs and prepare for the survey.
Life Safety Code® Evaluation
SMS, Inc. staff has served on numerous NFPA® committees over the past 20 years including NFPA Life Safety Code 101®. We have conducted complete Life Safety Code evaluations in hundreds of hospitals across the country, some of them as large as three million square feet. We have taught NFPA and The Joint Commission-Life Safety Code requirements and interpretations to both engineers and Joint Commission surveyors for over 20 years. We pride ourselves on our thoroughness and accuracy, as well as our ability to provide practical solutions to complex problems. SMS, Inc. licensed engineering staff can complete Plan Reviews and assist the facility in the preparation for construction.
Production of the Statement of Conditions™ (SOC™) & Electronic Statement of Conditions™ (eSOC™) Documents
No other firm in the country provides a better qualified or more experienced staff relative to preparation of The Joint Commission’s SOC/eSOC process. Many of our clients express they simply do not have the time to complete an SOC/eSOC themselves, whereas others say they lack the expertise to do the job thoroughly and accurately. Regardless of whether your problem is time, expertise, or both, SMS, Inc. can assist you with the timely completion of your facility’s SOC/eSOC. Furthermore, SMS, Inc. has AutoCAD capabilities for the integration of LSC information into the architectural drawings of the facility.
Equivalencies
SMS, Inc.’s staff has complete knowledge of both Fire Safety Evaluation Survey (FSES) and the traditional equivalency processes. Whether your equivalency needs are related to The Joint Commission, Centers for Medicare and Medicaid Services (CMS) or a state agency, we know the systems and the process to give you the best opportunity to obtain the most cost effective equivalency. Life Safety Code and NFPA 101 are registered trademarks of the National Fire Protection Association, Quincy, MA.
EC-Online™
EC-Online™ is the healthcare industry’s foremost web-based, subscription service devoted to Environment of Care code and standards issues. EC-Online™ was created to help facility’s management professionals address the myriad of regulatory, code and standards issues which challenge them daily. The components of EC-Online include: The Library (a collection of resource materials), Managing the Healthcare Environment™, (Newsletter) “Ask the EC Expert™” (where free-form questions are addressed individually), Frequently Asked Questions (FAQ’s) and Message Board.
Program Development & Management
Once we have conducted a thorough assessment of an organization's programs for the Physical Environment, we can help develop new plans, or improve existing plans that do not meet all of the criteria in the standards. Our expert staff can tailor these programs to meet your facility’s specific needs. SMS, Inc. has staff members intimately familiar with The Joint Commission and Federal requirements for Emergency Management, including expertise in the development of The Joint Commission’s Hazard Vulnerability Analysis (HVA), Hospital Incident Command System (HICS) and The Department of Homeland Security’s National Incident Management System (NIMS).
Building Maintenance Programs
SMS, Inc. has the expertise to assist the healthcare facility in developing those areas necessary to comply with The Joint Commission’s BMP requirements. These services may include the original facility survey, including, but not limited to: data collection, sampling, and documentation of compliance percentages. Once compliance levels are established, SMS, Inc. will develop protocol sheets, item locations, quantities and tracking tools, and establish inspection frequencies and compliance thresholds. As with Life Safety Code® concerns, SMS, Inc. can identify these program elements in AutoCAD® drawings and assist the facility in the management of these drawings.
Pre-Construction Risk Assessment
SMS, Inc. is experienced assisting facilities in the development of their procedures and processes for The Joint Commission’s requirements in healthcare PCRA. These services include Infection Control Risk Assessment, Utility Service disruptions, Interim Life Safety activities, environmental monitoring, indoor air quality, and a host of other items associated with the management of healthcare construction. Additionally, SMS, inc. is practiced in the training and education of facility staff, contractors and other vendors in this compliance.
Interim Facility Management & Program Support
For facilities with serious problems relative to Environment of Care-Life Safety-Emergency Management standards, or who require temporary or full-time assistance, SMS, Inc. can provide part or full-time contract management services for Safety and/or Engineering programs. Our experienced staff can manage your program areas – we have a solid list of satisfied customers for whom we have provided these extended services.
Accreditation Program Development
Upon completion of our mock survey, we are available to provide extensive assistance from highly qualified individuals to help facilities develop programs that will meet the intent of The Joint Commission standards. This service can range anywhere from a few days of policy development to full responsibility for development and implementation of specific program components.
Accreditation Appeals
SMS, Inc. staff are expert in the Joint Commission appeal process, and are qualified to advise your facility of its rights and options under the standards. Our staff have been on both sides of the table during the appeal process. It is for this reason that our staff is better equipped to represent your facility during an appeal than any other firm. Life Safety Code and NFPA 101 are registered trademarks of the National Fire Protection Association, Quincy, MA.
