Office-based Surgery - Life Safety Chapter

How does the Life Safety chapter apply to Joint Commission–accredited office-based surgery practices?

Any examples are for illustrative purposes only.  

The Life Safety (LS) chapter of the Accreditation Manual has not been applicable for non-deemed status Joint Commission accredited office-based surgery practices since January 1, 2015.  The criteria limits office-based surgery practices to a business occupancy, which is an occupancy having three or fewer patients at the same time who are undergoing treatment or anesthesia that renders them incapable of taking action for self-preservation under emergency conditions without the assistance of others. 

The LS chapter applies to office-based surgery organizations classified as an ambulatory health care occupancy, which is an occupancy having at least four patients at the same time who are either rendered incapable of self-preservation in an emergency or are undergoing general anesthesia.  Note: CMS considers the Life Safety code applicable to ambulatory health care occupancies with at least one person who is either rendered incapable of self-preservation or undergoing general anesthesia; therefore, TJC will survey the LS standards if there is only one person meeting this criteria. 

Reference LS.01.01.01 
Last updated on July 01, 2020
Manual: Ambulatory
Chapter: Life Safety LS

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