Healthcare compliance

“Drop Everything You’re Doing,” They Say. “The Joint Commission Is Here.” What Life Safety Surveyors Focus On

A practical guide to Joint Commission Life Safety surveys: the first hour, document review, what gets a closer look on the building tour, offsites, and ten pointers. By Stanislav Samek.

Relocatable Power Taps in Healthcare: Can You Mount a Power Strip to the Wall?

NEC 400.8/400.12 regulates the cord, not the strip; UL 1363 vs 1363A; why NFPA 99 §10.2.3.6 requires attaching the strip to the equipment inside the patient care vicinity; CMS K-920, TIA 12-5, and the Georgia 2012-vs-2024 crosswalk. By Miller Brown.

Field Observation #003: This Hatch Is Fire Rated… Will It Perform?

Sheff's Field Observations — a labeled fire-rated hatch that didn't self-close, and the five-checkpoint assembly review that catches it. Field find by Jarell Sheffield.

Field Observation #002: A Smoke Detector Is Present — But Is It Compliant?

Sheff's Field Observations — a smoke detector positioned too close to an HVAC vent, airflow effects on detection, and the one-ceiling-tile rule of thumb. Field find by Jarell Sheffield.

Field Observation #001: Is This Delayed Egress Stair Door Compliant?

Sheff's Field Observations — a construction-turnover lesson on delayed egress signage, occupant understanding, and complete-system review. Field find by Jarell Sheffield.

Soiled Utility vs. Soiled Holding: Same Room, or Two Different Rooms?

FGI separates them by fixtures, NFPA 101 and ASHRAE 170 do not separate them at all — plus the 64-gallon room threshold vs the receptacle threshold, and why 2012 and 2024 disagree

The Joint Commission Binder: Can You Find It in 60 Seconds?

The 2026 PE chapter and Survey Process Guide, binder architecture right-sized to your facility, the seven-element test every ITM record must pass, and free templates

LSRA & ILSM — Life Safety Risk Assessment & Interim Life Safety Measures

All 11 ILSMs explained, ASHE templates, TJC survey prep, and CMS K-tag guidance

CMS K-Tags for Fire Safety — Complete Reference

Every fire safety K-Tag explained — K-0029 through K-0072, NFPA 101/99 mapping, common survey deficiencies

Hazard Vulnerability Assessment (HVA)

Kaiser model scoring, CMS requirements, Georgia GEMA resources, and interactive HVA scoring tool

TJC Physical Environment (PE) Standards

PE chapter structure, key standards (PE.01–PE.03), SOC/PFI, annual and triennial assessments, common survey findings

Healthcare Occupancy (NFPA 101 Ch. 18/19)

Defend-in-place strategy, corridor and door requirements, suite arrangements, and hazardous areas

PCRA — Pre-Construction Risk Assessment

Four PCRA risk domains, ICRA relationship, barrier classes I–IV, ILSM triggers, and documentation

Smoke Compartments in Healthcare

22,500 sq ft maximum, 1-hour smoke barriers, door requirements, and defend-in-place support

CMS Survey Process for Fire Safety

Survey types, Life Safety Code survey focus areas, Immediate Jeopardy, and Plan of Correction

ASHE Fire Safety Compliance Toolkit

ASHE resources, ILSM templates, compliance calendar, Healthcare Fire Safety Week, and best practices