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Be Proactive to Avoid Financial Setbacks

Whether you’re breaking ground on a new building or renovating part of an existing facility, it is imperative your architect and general contractor are not only focusing on codes required by your state’s Department of Health & Human Services, but also the codes required by the NFPA 101-2012 edition, which is also required by The Joint Commission and Centers for Medicare and Medicaid Services (CMS). Re-work due to conflicting codes may lead to intrusive construction after patients are moved in, not to mention the significant financial setback. Let’s work together to keep your project on track as you work towards eliminating issues related to complex codes.

Our Approach

We’ve developed a phased approach to help organizations keep their projects on track when it comes to following often complex codes and standards.

Phase One

Experts from JCR will meet with your organization, architects, and general contractor to review architectural drawings for their compliance with Joint Commission standards. This review is based on NFPA 101-2012 Life Safety Code and the most current version of the FGI Guidelines. After this phase, a list of concerns with the building design will be developed to help the project managers and architects prioritize the issues. If needed, a facilitated NFPA 99 risk assessment can also be performed during this phase.

Phase Two

When the building has achieved approximately 95% completion, our experts will complete an on-site assessment to field verify compliance to the architectural drawings and Joint Commission standards. During this on-site assessment, our experts will:

  • Compare the built environment to the drawings.
  • Evaluate the built environment to Joint Commission Environment of Care and Life Safety standards.
  • Evaluate the space above the ceiling before the ceiling tiles are installed to identify non-compliance with NFPA 101-2012.
  • Evaluate fire and smoke barriers including properly sealed penetrations, rated doors and windows.
  • Review egress routes.
  • Evaluate acceptance and certification documents for the fire protection and notification, emergency power, and medical gases systems.

You will receive verbal summary of consultative and educational information during the daily debriefings, followed by a written summary of the services, findings, and recommendations at the end of this phase.

Phase Three


After occupancy has been granted, another on-site visit will be performed to identify change of use or repurposed spaces and verify building compliance to Joint Commission standards. During this on-site assessment, our experts will:


  • Field verify drawings to the built environment.
  • Identify issues of non-compliance with final phase of the built environment.
  • Focus on compliance issues related to repurposing space, last minute change orders and unexpected construction modifications.
  • Review rated barriers, doors, locking mechanisms, and means of egress.
  • Review acceptance and commissioning documents supporting the utilities infrastructure.

At the end of the phase, our experts will suggest a process for data transfer from construction management to operations.

Related Resource: Planning, Design, and Construction of Health Care Facilities, 4th Ed.

Comprehensive guide for health care organizations looking to build new facilities—or update current structures.

*The use of Joint Commission Resources consultative technical or advisory services is not necessary to obtain a Joint Commission Accreditation award, nor does it influence the granting of such awards.