Joint Commission Survey Prep

JCAHO Elevator Compliance Prep Kit for Hospitals

An interactive checklist for hospital facility directors preparing for Joint Commission surveys. Work through every category that surveyors evaluate, understand what findings look like, and fix issues before survey day. Each item includes what the surveyor looks for, what a deficiency looks like, and exactly how to correct it.

Why Elevator Compliance Is Not Optional

Elevator findings rank among the top 5 most common Life Safety Code citations issued during Joint Commission surveys. The consequences extend far beyond a written deficiency. Loss of Joint Commission accreditation triggers loss of deemed status with CMS, which means your hospital loses eligibility for Medicare and Medicaid reimbursement. For most hospitals, that is an existential financial threat. A single unresolved elevator finding -- particularly fire recall failure or missing documentation -- can escalate to a Requirement for Improvement (RFI) or, in severe cases, Immediate Jeopardy. Preparing elevators for survey is not a facilities department checkbox. It is an institutional risk management priority.

Checklist Progress

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Documentation

Surveyors begin with paperwork. Missing or expired documents generate immediate findings.

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Current inspection certificates posted in each car

Maintenance logs accessible and up to date

Emergency response plan documented and current

Staff training records on file

Surveyor Questions Your Staff Should Be Able to Answer

›Where are the elevator maintenance logs kept?

›When was the last routine maintenance visit?

›Who do you call if a passenger is trapped?

›Where is the emergency response plan for elevators?

Life Safety Code / NFPA 101 Chapter 18

Life Safety Code findings carry the highest severity. Fire recall failures can trigger Immediate Jeopardy.

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Fire recall Phase I operational (automatic)

Fire recall Phase II operational (manual firefighter operation)

Smoke detectors in machine room and hoistway functional

Shunt trip operational (sprinklered machine rooms)

Emergency power (generator) tested under load

Surveyor Questions Your Staff Should Be Able to Answer

›Which floor do the elevators recall to during a fire alarm?

›How do you initiate Phase I fire recall manually?

›Where is the Phase II firefighter key kept?

›What happens to the elevators when the generator kicks in?

›When was the last fire recall test performed?

Equipment Condition

Physical condition of the elevator is inspected visually and operationally during the walkthrough.

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Door operators functioning properly

Car leveling within 1/2 inch of landing

Emergency lighting working in each car

Emergency communication device functional

Machine room ventilation adequate

Surveyor Questions Your Staff Should Be Able to Answer

›How often does the elevator technician perform routine maintenance?

›Have any elevators been out of service recently? Why?

›When was the last time the emergency car phones were tested?

›Is there a thermometer in the machine room?

ADA Compliance (Standards Section 407)

ADA elevator requirements under Section 407 of the ADA Standards for Accessible Design are evaluated as part of the overall Environment of Care review.

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Hall call buttons mounted at correct height (42 inches max)

Car controls within reach range (48 inches max for side reach)

Audible and visible signals at each floor

Door timing provides adequate time to enter (minimum 5 seconds for 60-inch door)

Car interior dimensions meet minimum requirements

Tactile floor designations on both door jambs

Surveyor Questions Your Staff Should Be Able to Answer

›Which elevator is designated for gurney transport?

›How do you assist a visually impaired visitor with the elevator?

›Are all elevators accessible to wheelchair users without assistance?

Signage

Missing or incorrect signage generates quick findings that are easily preventable.

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Floor designations visible and accurate

Capacity posted in each car

Emergency instructions posted

Certificate of operation displayed

Surveyor Questions Your Staff Should Be Able to Answer

›Can you point to the emergency instructions in this elevator?

›What is the rated capacity of this elevator?

›Where is the Certificate of Operation posted?

Staff Knowledge

Surveyors interview staff at random. Every person who may respond to an elevator emergency must know the basics.

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Staff can describe the elevator emergency response plan

Staff know where the machine room is located

Staff can operate Phase II firefighter service

Surveyor Questions Your Staff Should Be Able to Answer

›If you are notified that a passenger is trapped in an elevator, what are the first three things you do?

›Where is the elevator machine room?

›Do you have a key to the machine room? Who else has one?

›Can you show me how to put this elevator on Phase II firefighter service?

›When was your last elevator emergency training?

›What phone number do you call for elevator emergencies?

›If the fire alarm activates, what do the elevators do automatically?

Need a Qualified Elevator Inspector Before Survey Day?

Find QEI-certified elevator inspection companies in your state that specialize in hospital and healthcare facility compliance. Pre-survey inspections can identify and resolve findings before the Joint Commission arrives.

Find Elevator Inspectors Near You