Joint Commission Compliance Checklist and Audit Prep Toolkit

INTRODUCTION: WHY JOINT COMMISSION COMPLIANCE IS GETTING HARDER

Regulatory expectations for healthcare security have grown dramatically in recent years.
Increases in workplace violence, patient safety incidents, identity threats, and cyber-physical risks have placed physical security squarely in the spotlight.

Joint Commission surveyors now expect fully documented, easily retrievable, and consistently executed evidence across:

• The Environment of Care
• Life Safety
• Emergency Management
• Human Resources
• Workplace Violence Prevention
• Access Management
•  Infant/Child Security
• Video & Alarm Response Protocols
• Incident Reporting
• Visitor Management

Paper logs, siloed systems, manual reporting, and fragmented vendor environments make compliance more difficult—and less defensible.

This toolkit helps executives rapidly assess preparedness and identify modernization priorities.
It reflects the reality of today’s healthcare environment and the growing expectation for digital auditability.

AT-A-GLANCE: WHAT SURVEYORS EXPECT

Surveyors focus on both process and proof.
This checklist summarizes the most common areas where security leaders struggle.

Surveyors Expect:
• Clear, updated policies for security, violence prevention, and access control
• Documented roles and responsibilities for security personnel
• Demonstrated implementation of security workflows
• Immediate retrieval of access logs, alarm logs, video clips, and visitor data
• Consistent access governance for staff, contractors, agency, and vendors
• Rapid incident reconstruction (with video correlation)
• Proof of infant/pediatric security controls
• Evidence of monitoring and maintaining security technologies
• Demonstrated cybersecurity protections for physical security systems
• Comprehensive risk assessments and workplace violence metrics

Graphic Placeholder:
“Top 10 Compliance Fail Points” bar chart.

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PAGE 4 — FULL COMPLIANCE CHECKLIST, SECTION BY SECTION

(Use as a working tool for internal audits.)

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1. Environment of Care (EC)

Required Evidence:
☐ Access points defined, secured, and monitored
☐ Visitor access controlled and logged
☐ Video surveillance coverage documented
☐ Alarm systems tested & documented
☐ Areas of high risk identified (ED, NICU, pharmacy, OR)
☐ Incident response policies updated & consistent
☐ Periodic security risk assessments on file

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2. Life Safety (LS)

Required Evidence:
☐ Access controls are not impeding egress
☐ Doors, frames, locks functioning & documented
☐ Delayed egress, controlled access doors properly configured
☐ Fire/life safety systems integrated with access control where required
☐ Monthly/annual testing logs accessible

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3. Emergency Management (EM)

Required Evidence:
☐ Security role defined for Code Silver, Code Pink, Code Amber, active threat
☐ Lockdown workflows documented and tested
☐ Integrated security systems support emergency response
☐ After-action reporting workflows defined
☐ Security participation in EM drills documented

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4. Human Resources (HR)

Required Evidence:
☐ Background checks and identity verification policies
☐ Role-based access privileges
☐ Immediate deactivation workflows
☐ Contractor/agency labor access controls
☐ Staff training records for security/emergency procedures

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PAGE 5 — CHECKLIST CONTINUED

5. Workplace Violence Prevention (NEW REQUIREMENTS)

Required Evidence:
☐ Annual violence risk assessment
☐ Incident logs for assault, aggression, threats
☐ Violence prevention policies updated
☐ Staff reporting pathways
☐ Post-incident review workflows
☐ Metrics dashboard (frequency, type, location, severity)

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6. Infant / Pediatric Security

Required Evidence:
☐ Controlled access for NICU / L&D / Pediatrics
☐ Infant protection devices integrated with access/video
☐ Automated alarm response workflows
☐ Locked units fully documented
☐ Video retention for infant zone events
☐ Visitor restrictions and tracking in place

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7. Video Surveillance & Alarm Management

Required Evidence:
☐ Camera coverage map available
☐ Video linked to access & alarm events
☐ Retention policy documented & enforced
☐ Alarm response procedures proven during survey
☐ Video retrieval must be immediate
☐ Evidence that cameras/alarms are maintained & tested

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8. Visitor Management

Required Evidence:
☐ Visitor identity verification
☐ Badging and color-coded access
☐ Time-bounded and unit-bounded access
☐ Vendor/contractor workflows clearly defined
☐ Visitor logs retrievable for last 12–24 months

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PAGE 6 — COMMON GAPS THAT TRIGGER NONCOMPLIANCE

Based on internal audits and industry surveys, the most frequent weaknesses include:

1. Siloed Systems

Logs and video stored in multiple locations create delays.

2. Manual Documentation

Paper logs and ad-hoc reporting cannot survive survey scrutiny.

3. No Real-Time Incident Correlation

Surveyors increasingly ask, “Show me what happened here.”
Most hospitals need 20–40 minutes to reconstruct an event.

4. Undefined Response Workflows

Especially Code Pink/Amber, ED violence, and controlled-access pharmacy events.

5. Inconsistent Credential Governance

Delayed revocation is a direct compliance and safety risk.

6. Missing Audit Trails

Surveyors expect complete, tamper-proof audit logs.

7. No Violence Prevention Metrics

The new standards require quantifiable trend data.

Graphic Placeholder:
“Top Compliance Gaps” infographic.

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PAGE 7 — HOW TO PREP FOR A JOINT COMMISSION SECURITY SURVEY

Step 1 — Prepare Core Documentation

☐ Security management plan (SMP)
☐ Violence prevention plan
☐ Access control policies
☐ Visitor management policies
☐ Surveillance policies
☐ Vendor/contractor programs

Step 2 — Preload Evidence in a Digital Binder

☐ Last 12–36 months of logs
☐ Risk assessments
☐ Door testing documentation
☐ Camera/alarm maintenance records
☐ Incident reports with video

Step 3 — Practice Live Demonstrations

Surveyors may ask:
“Show me the video from this door at 9:15.”
“Show me the visitor log for Room 3C yesterday.”
“Show me the alarm history for this pharmacy door.”

BluSKY makes this easy. Legacy systems do not.

Step 4 — Prepare Your Team

Security officers should know:
• How to retrieve logs instantly
• How to pull linked video
• How to respond to scenario questions

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PAGE 8 — BUILDING A DIGITALLY AUDITABLE SECURITY PROGRAM

Joint Commission surveys increasingly emphasize:
• Immediate access to data
• Cross-system correlation
• Reliable reporting
• Incident documentation
• Workplace violence prevention metrics
• Audit trails for identity & access

A digitally auditable program requires:

1. Unified Event Architecture

One place for access, video, alarms, visitors, and analytics.

2. Cloud-Based Accessibility

Surveyors may ask for data from months or years past — instantly retrievable.

3. AI-Driven Summaries & Trend Data

Essential for workplace violence requirements.

4. Automated Reports

Daily, weekly, monthly logs without manual effort.

5. Identity Governance Integration

Ensuring only authorized users have access, and terminations deactivate immediately.

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PAGE 9 — HOW BLUSKY + BLUBØX AI SIMPLIFY COMPLIANCE

BluSKY addresses nearly every pain point in Joint Commission compliance and audit readiness.

Integrated Compliance Tools Built for Healthcare
• Unified logs for access, alarms, video, and visitors
• One-click video retrieval
• Automated audit-ready reporting
• Real-time dashboards for risk & violence trends
• Automated lockdown & infant protection workflows
• Full audit trails for every action by staff or contractors

AI-Driven Compliance Intelligence

BluB0X AI automatically:
• Summarizes incidents
• Creates searchable narratives
• Identifies patterns in violence, tailgating, zone breaches
• Flags anomalies in workflows
• Supports risk assessments

Rapid Survey Response

What normally takes 10–40 minutes in legacy systems can be retrieved in seconds.

Graphic Placeholder:
BluSKY Compliance Workflow Diagram.

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PAGE 10 — AUDIT PREP FOR MULTI-HOSPITAL SYSTEMS

Large healthcare networks face additional complexity:
• Multiple credentialing systems
• Inconsistent visitor workflows
• Different access hardware
• Legacy systems scattered across campuses
• Staff mobility between facilities
• Decentralized incident reporting

BluSKY centralizes compliance across the entire health system:
• Standardized access/visitor policies
• Single audit repository
• Cross-campus dashboards
• Unified credential governance
• Systemwide violence prevention metrics

This standardization dramatically reduces survey surprises.

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PAGE 11 — RAPID SELF-ASSESSMENT SCORECARD

(Your design team can turn this into a 1-page worksheet.)

Score each category from 1 (Not Ready) to 5 (Fully Ready).

Category Score 1–5 Notes
Access Logs 
Alarm Logs 
Visitor Management Records 
Video Retrieval Speed 
Workplace Violence Metrics 
Infant/Pediatric Security Evidence 
Identity Governance 
Incident Reporting 
Audit Trails 
Cross-System Correlation 
Cyber-Physical Hardening 

Interpretation:
• 40–50: Strong readiness
• 25–40: Moderate risk
• Below 25: High risk — modernization recommended

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PAGE 12 — CALL TO ACTION

Make Your Next Survey the Easiest One Yet

BluSKY gives healthcare leaders a unified, cloud-based, AI-powered security platform designed to meet modern Joint Commission requirements with confidence.

Ready to see how BluSKY simplifies compliance across your entire health system?
👉 Schedule a Healthcare Security Compliance Demo