The 3-Part Healthcare Compliance Blueprint for a Risk-Free Facility Part -1) OSHA & Joint Commission Compliance Checks

For healthcare facilities, Joint Commission accreditation is a gold standard that ensures patient safety, quality care, and regulatory adherence. Before starting James Construction, I was the directing manager of a Painting Company called Star Painting that has worked with multiple facility managers at one of the largest hospitals in the country preparing for several JCO inspections over the years.

Failing to meet The Joint Commission (TJC) standards can lead to penalties, loss of accreditation, and serious legal consequences. To help your facility stay compliant, I compiled a detailed Joint Commission compliance checklist covering essential areas that surveyors review during audits that we used to successfully pass each and every inspection with no shutdowns. This is part 1 of 3 of a compliance blog post series that delves into the ever evolving subject of healthcare construction compliance. Feel free to print out the checklist to make sure your facility comes out on-top of every JCO inspection.

A checklist can help you prepare for an upcoming JCO Inspection

Joint Commission Compliance Checklist

Use this checklist to prepare for audits and ensure ongoing compliance with The Joint Commission’s standards.

Facility Name: _________________________

Date of Audit: _________________________

Auditor(s): _________________________

1. Environment of Care (EC)

✅ Facility is free from physical hazards (e.g., floors, walls, ceilings in good condition)

✅ Emergency exits are clearly marked and unobstructed

✅ Fire extinguishers, alarms, and sprinkler systems are fully operational and regularly ✅. inspected hazardous materials are properly stored, labeled, and disposed of

✅. Medical equipment is maintained and tested according to manufacturer guidelines

✅. Security systems, including access controls and surveillance cameras, are in place

✅. HVAC, electrical, and plumbing systems are in working condition

Notes/Findings: ___________________________________________________

2. Healthcare Compliance Emergency Preparedness (HCEM)

✅. Emergency Operations Plan (EOP) is documented and accessible to staff

✅. Fire, disaster, and active shooter drills are conducted and documented regularly

✅. Backup power generators are tested and functional

✅. Staff is trained on evacuation procedures and patient transport plans

✅. Communication system is in place for emergency notifications

Notes/Findings: ___________________________________________________

3. Life Safety (LS)

✅ Fire doors function properly and self-close as required

✅. Fire safety systems (smoke detectors, alarms, extinguishers) pass inspection

✅ Sprinkler systems are in working order and regularly tested

✅ Hallways, exits, and stairwells are clear of obstructions

✅ Oxygen and other medical gases are properly stored and labeled

Notes/Findings: ___________________________________________________

4. Infection Prevention & Control (IC)

✅ Hand hygiene stations (soap, sanitizer) are available and accessible

✅ PPE (masks, gloves, gowns) is stocked and properly stored

✅ Cleaning and disinfection protocols for high-touch areas are followed

✅ Isolation rooms maintain negative pressure as required

✅ Sterilization procedures for medical instruments meet CDC and Joint Commission guidelines

Notes/Findings: ___________________________________________________

5. Medication Management (MM)

✔  Medications are stored in a secured and temperature-controlled environment

✔  Expired medications are discarded properly and documented

✔  Controlled substances are logged and tracked per policy

✔  Medication administration follows barcode scanning and verification protocols

✔  Emergency medication kits are properly stocked and accessible

Notes/Findings: ___________________________________________________

6. Patient Safety & Rights (PS)

✔  Two-patient identifier system is used before treatment or medication administration

✔  Fall prevention protocols (bed rails, non-slip flooring) are in place

✔  Informed consent documentation is completed and stored correctly

✔  HIPAA compliance measures protect patient confidentiality

✔  Restraint policies are properly documented and followed

Notes/Findings: ___________________________________________________

7. Leadership & Staff Credentialing  (HR & LD)

✔  Staff licensing and certifications are up-to-date and documented

✔  New employee onboarding includes compliance training

✔  Annual training on workplace safety, infection control, and emergency preparedness is completed

✔  Leadership oversight ensures compliance issues are addressed promptly

Notes/Findings: ___________________________________________________

Having visible up-to-date staff documentation is crucial for inspections

8. Information Management & Technology (IM)

✔  Electronic Health Records (EHR) are secure and HIPAA-compliant

✔  Cybersecurity measures (firewalls, encryption, multi-factor authentication) are in place

✔  Backup and disaster recovery plans for patient data are documented

✔  Patient data access is restricted to authorized personnel only

Notes/Findings: ___________________________________________________

9. Performance Improvement (PI)

✔ Quality improvement plans are in place and updated regularly

✔ Incident reports are reviewed, analyzed, and corrective actions are implemented

✔ Patient feedback is collected and used for process improvement

✔ Documentation is clear, complete, and follows Joint Commission standards

Notes/Findings: ___________________________________________________

Ensuring JCO compliance is not just about meeting regulatory requirements—it’s about safeguarding quality, enhancing operational efficiency, and maintaining industry credibility. By staying proactive with regular inspections, training, and adherence to best practices, your organization can avoid costly penalties and operational disruptions. Don’t wait for compliance issues to arise—take action today! Implement robust inspection protocols, stay updated on evolving standards, and partner with experts to navigate the complexities of JCO compliance with confidence.

Ready to optimize your compliance strategy? Contact James Construction today to learn how we can help streamline your inspection process and ensure your organization remains compliant and audit-ready!