How Hospital Security Departments Can Comply with Joint Commission and CMS Standards

Doing so can validate a hospital security department’s progress and professionalism.

For some hospital security directors, panic sets in when they learn that the Joint Commission, Centers for Medicare and Medicaid Services (CMS) or some other state or local accreditation agency is coming to visit. After all, not being in compliance with these agencies’ standards could jeopardize a facility’s federal funding and reimbursement.

However, directors that embrace CMS and Joint Commission guidelines often realize that these standards provide a template by which hospitals can design their security programs.  Directors should rest a bit easier if they have set up their programs with these guidelines in mind.

Additionally, following the Joint Commission and CMS standards can help a healthcare organization comply with National Fire Protection Association (NFPA) codes and the Health Insurance Portability and Accountability Act (HIPAA), as well as other regulations and local ordinances. In fact, when inspectors come to visit, if a protection program has been designed in accordance with these standards, it can be an opportunity to validate a hospital security department’s professionalism and progress.

Standards Cover a Wide Array of Issues

The Joint Commission requires hospitals to have a written security plan that is reviewed and updated annually, if not more frequently. Additionally, the standards cover access control and visitor management; written procedures to be followed when a security incident happens; hazard vulnerability analysis; security and law enforcement patient interaction; incident reporting, monitoring and investigations; and emergency management, just to name a few. There also are standards that apply to security but aren’t clearly indicated in the guidelines. These topics include lighting, the handling of toxic materials, medication storage, staff training and more.

According to healthcare security consultant and author Bryan Warren, who is a frequent contributor to Campus Safety magazine, the Joint Commission gives healthcare organizations a lot of leeway in how these standards are met.

“The Joint Commission does not give any indication as to how you are to implement any of these mitigation techniques, only that they need to be done,” he said in The Joint Commission and Healthcare Security: Knowns, Known Unknowns and Unknown Unknowns. “For example, how you identify visitors entering your facility (color coded self-expiring badges, electronic scans of photo identification, etc.) is up to you, so long as you have a process in place. Similarly, there is very little in the way of defining success of such standards.”

Determining which mitigation and security techniques are most appropriate for a particular healthcare campus can be challenging for novice hospital security directors, but even for veteran security professionals when the situations are complex. The correct solutions might need to be selected on a campus-by-campus or even department-by-department basis.

Help Is Available

A trusted systems integrator can provide valuable input on security solutions so that a hospital is fully compliant with standards from the Joint Commission, CMS, and state and local accreditation agencies, as well as NFPA, ADA and other codes.

STANLEY Security partners with healthcare facilities to develop customized security programs for their campuses. By developing functional standards across the facility, a cohesive security program can be put in place that not only ensures compliance, but also improves security and public safety.

There are many electronic security solutions available for all areas of healthcare campuses, and STANLEY Security frequently provides the following systems to its healthcare partners:

  • Access Control Systems
  • Video Surveillance Cameras and Video Monitoring
  • Intrusion Alarm Systems
  • Standards Development and Strategic Planning
  • Software Support, Consultation and Integration
  • Personal Safety and Security Response Mobile Apps
  • Patient Safety Solutions
  • Mass Notification and Emergency Communication
  • Lockdown Solutions
  • Custom System Integration
  • Fire Alarm Systems and Regular Tests and Inspections
  • 24 Hour UL and ULC Monitoring Services
  • System Consultation, Design and Installation
  • Preventive Maintenance and Service Plans

For more information on the solutions you can implement in your healthcare setting, or for educational resources on improving your security program, visit STANLEY Security at


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