Is your health care facility ready for a Joint Commission audit?

The Puerto Rico Department of Health issued a moratorium on Rules No. 8807 and No. 8808 for Ambulatory Surgery Centers and Hospitals this past February 13th. The temporary measure gives some breathing room to health care providers who must update their infrastructure and comply with the latest applicable building codes.

When the moratorium ends, are you ready for an audit?

Health care facilities and hospitals are subject to audits that ensure license conditions and building standards are met. Chapter IV of both rules gives authority to accrediting agency SARAFS to designate facility inspectors who can audit unannounced. SARAFS ensures that federal reimbursement programs comply with Centers for Medicare and Medicaid Services (CMS) requirements, and evaluates based on the 2012 NFPA 101 Life Safety Code standards. These standards offer the minimum building design and construction elements to protect occupants in case of fire, smoke, and toxic fumes not only for new structures, but also existing spaces.

Any deficiencies found by a SARAFS designated inspector are to be addressed immediately or in a corrections plan, otherwise a facility risks losing its operating license. Fixing deficiencies can be costly. If they haven’t been budgeted, they may not be immediately attainable. One way to assess your readiness is by performing a building assessment beforehand and having and long term execution plan.

At CMA, we have experience performing life safety studies and code compliant assessments for multiple facilities. We can guide you through this process. For more information, visit us at

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