Life Safety Code Surveyors

A question came up recently: “Is the Life Safety Specialist a requirement during a survey, or is the specialist used due to the complexity of the Life Safety Code and various areas of survey?”

No, the Life Safety Code Specialist surveyor for the Joint Commission is not a mandate or a requirement by the Centers for Medicare & Medicaid Services (CMS), or any other arm of the government. Over the years, The Joint Commission had some detractors in the US Congress, mainly because the Social Security Act of 1965 provided deeming authority to The Joint Commission to determine if a hospital was suitable to receive reimbursement funds for the Medicare and Medicaid government programs. This means that The Joint Commission received their deeming authority directly from Congress and they did not have to request the authority from CMS (or HCFA as it was known prior to 2000). This upset many members of Congress and over the years, they made it tough on Joint Commission.

Fast forward to 2004, and the Government Accountability Office (GAO) published a scathing report that clearly showed the Joint Commission failed miserably in the assessment of hospitals for compliance with the Life Safety Code. To their credit, the Joint Commission agreed (partly because they could feel the heat from Congress, but mostly because the report was true), and decided to hire Life Safety Code specialists and make them surveyors and put them on the survey team. The new LSC surveyors began surveying in January, 2005, for hospitals with 200 beds or more, and it was a huge success. Hospitals actually liked being inspected by knowledgeable surveyors and in 2008, the LSC surveyor program was expanded to survey all hospitals, including Critical Access hospitals.

As an aside, in 2009 Joint Commission finally felt the might and power of Congress and voluntarily decided to seek their deeming authority from CMS, which means Joint Commission has to apply for deeming authority to CMS every three years, just like HFAP and DNV, and they no longer receive their authority from Congress.