From the August 2017 issue of HealthCare Business News magazine

Codes can be very confusing and frustrating. You can take a simple code and find that it references other codes which also reference other codes and on and on. You will also find some accreditation standards referencing codes that date back years, and even decades, and good luck finding copies of them.

Architects and engineers are not always 100 percent versed in the proper interpretation of codes. Many have never seen your specific accreditation standards, and even the contractors who perform required inspection and testing activities for you have never read those specific standards, and therefore, do not have a true picture of what it takes for you to meet the requirement of your position. They, for example, have no idea that certain inspections now have time frames that they must be completed within. This needs to be shared and enforced with your contractors/vendors. They don’t know what they don’t know. I would even go as far as to suggest having your key contractors available when your code consultant is on site in order to obtain more in-depth knowledge of the codes that impact your health care facility and clinics.


Trying to have your surveyor fired or re-assigned is not always the correct and most efficient path to follow. Once you come to grips with the fact that deficiencies are going to be found, and you have a professional plan with the right support team in place to properly defend your compliance, your grievance process will be less traumatic, and could be less costly. Your organization is not perfect. Even brand-new facilities don’t open for occupancy 100 percent code compliant. It just does not happen. Within a year, additional deficiencies will be found, either those that pertain to the building or to documentation. They will be found.


About the author: Robert Harris has been in the health care field for 47 years. He has held various leadership roles throughout his career, and has experienced both union and nonunion environments. He has had more than 65 articles published since the early ‘80s, and only writes about subject matter he has actually experienced. His experience has included working with state surveyors in five states, either on building proejcts or validation surveys, and he has gone through 15 accreditation surveys with both Joint Commission and HFAP.

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