Joint Commission surveys are unannounced — the official policy. In practice, most facilities receive 4–6 weeks advance notice through the unannounced survey window that follows the previous triennial accreditation. But the facilities that are genuinely ready for a survey are those that maintain continuous readiness, not those that sprint through a 90-day preparation cycle.
That said, if your facility does not currently have robust continuous readiness practices, a structured 90-day preparation effort can meaningfully improve your survey outcome. This guide provides a practical framework for that effort, with specific attention to the Environment of Care and Life Safety domains where facility directors have primary responsibility.
The 90-Day Plan: Overview
Days 1–30: Assessment and Documentation
- Complete a comprehensive internal Environment of Care mock survey
- Audit all EC management plan documentation for currency and completeness
- Identify and begin addressing physical plant deficiencies
Days 31–60: Remediation and Training
- Address all identified physical deficiencies within resource constraints
- Conduct departmental Environment of Care training
- Update all EC management plans and policies to reflect current operations
Days 61–90: Validation and Readiness
- Conduct final mock survey
- Verify all documentation is retrievable and current
- Brief leadership on likely surveyor areas of focus
Days 1–30: Assessment Phase
Internal Life Safety Walk — Use the Joint Commission’s published surveyor worksheets and standards interpretation guidance to conduct a walk of every occupied building and floor. Document every finding, no matter how minor. Common findings to specifically look for:
- Propped or non-latching smoke barrier doors
- Corridor obstructions (equipment stored between uses, supply carts, linen)
- Exit sign illumination issues
- Fire extinguisher inspection tags out of date
- Sprinkler heads painted, obstructed, or missing
- Penetrations in fire-rated walls and smoke barriers
- Electrical panel clearances
- Hazardous area doors that are improperly rated or not self-closing
Documentation Audit — Pull all documentation that surveyors typically request and verify it is complete and current:
Fire safety documentation: Fire drill records (4 per year per shift, minimum), fire extinguisher inspection records, sprinkler inspection records, fire alarm inspection records, kitchen hood suppression inspection records.
Life safety system documentation: Generator test records (monthly brief run, annual 2-hour load test), transfer switch test records, battery-backed lighting test records, fire pump test records.
Utility system documentation: PM completion records for all life safety equipment, water management program records, elevator inspection certificates, boiler inspection certificates.
EC Management Plan documentation: Current EC management plan (all seven topics), EC Committee meeting minutes for the past 12 months, annual EC management plan review documentation, Proactive Risk Assessment documentation.
Deficiency Tracking — Enter all identified deficiencies into a tracking system (spreadsheet or CMMS) with assigned owner, target completion date, and resource requirements.
Days 31–60: Remediation Phase
Physical deficiency remediation — Address all identified physical deficiencies systematically. Priority order:
- Immediate life safety risks (non-latching smoke doors, corridor egress obstructions, inoperable fire alarm devices)
- Regulatory compliance gaps (expired inspection certificates, missing documentation)
- Recurring problems (equipment regularly stored in corridors, doors regularly propped)
Root cause, not just correction — Fixing a propped door by removing the prop is not a lasting solution. The door is propped because someone has an operational reason for propping it. Identifying and addressing the underlying reason (the door slams loudly, the latch requires excessive force, there is no way to communicate across the secured door) prevents recurrence.
Staff training — Conduct brief (15–30 minute) Environment of Care training in each department. Key topics: fire response procedure (RACE), fire drill expectations, corridor equipment policy, how to report safety concerns. Focus on what surveyors will ask frontline staff, because they will ask.
Documentation completion — Address all documentation gaps identified in the assessment phase. Update EC management plans to reflect current operations and current regulatory requirements. Ensure all signatures on EC management plans are current.
Days 61–90: Validation Phase
Final mock survey — Conduct a second internal mock survey using a different team or external consultant if possible. The second survey validates that remediation was effective and identifies any new deficiencies that have developed.
Documentation retrieval test — Simulate the surveyor documentation request process. Ask a staff member unfamiliar with the filing system to retrieve specific documents as quickly as possible. If retrieval takes more than 5 minutes per document, your organization system needs improvement.
Leadership briefing — Brief facility leadership on the areas of focus expected in the survey based on recent Joint Commission published findings, current National Patient Safety Goals, and known areas of institutional vulnerability. Pre-brief the surveyor response process: who accompanies the surveyor, who answers questions about EC, how documentation requests are handled.
Hot button areas (2022 focus) — Based on Joint Commission Perspectives publications and surveyor feedback patterns in 2021–2022, areas of elevated survey focus include:
- Water management program documentation and implementation
- Workplace violence prevention program
- Ligature risk in behavioral health settings
- Fire door integrity (especially smoke barrier door latching)
- Interim Life Safety Measure documentation for active construction projects
During the Survey: Facility Director Responsibilities
When the survey is underway, facility directors and plant operations managers should:
- Accompany the surveyor in all mechanical, physical plant, and utility areas
- Answer surveyor questions directly and factually. Do not volunteer additional information beyond what is asked. Do not speculate about standards interpretation.
- If you don’t know the answer to a question, say so and offer to find the information. Never guess.
- Have a runner available to retrieve documents quickly
- Document what the surveyor observed and commented on for the exit conference
Frequently Asked Questions
Can we ask Joint Commission what areas they will focus on during our survey? You can ask; they are unlikely to provide a specific answer. However, The Joint Commission publishes annual data on the most frequently cited standards, and their newsletter (Perspectives) provides ongoing guidance on standards interpretation. This published information is the best available predictor of survey focus areas.
What happens if a significant deficiency is found during the survey that we did not identify? Acknowledge the finding directly and provide an accurate assessment of corrective action timeline. If you can correct it during the survey (a propped door can be unpropped in minutes), do so. If correction requires capital or extended time, provide a realistic timeline. Surveyors distinguish between facilities that are trying hard to maintain compliance and those that are chronically non-compliant.
How do we handle a surveyor who seems to be generating findings in an area where we believe we are compliant? Remain professional and engaged. Ask the surveyor to clarify the standard element they are citing and what specifically they are finding deficient. If you have documentation or physical evidence that addresses their concern, provide it calmly. The appropriate time for formal disagreement is the Informal Dispute Resolution process after the survey, not during the survey itself.
Should we schedule any construction projects to be complete before a survey? If ILSM-triggering construction can be completed before the survey period without creating operational problems, doing so reduces the number of complex compliance issues the surveyor needs to assess. However, construction that would be completed hastily (and thus potentially with quality issues) is worse than construction properly underway with well-documented ILSM measures. Never allow survey preparation to compromise construction quality.
