Joint Commission & AAAHC Inspection: Is Your Facility Compliance-Ready?

Regulatory inspections can be stressful, but with the right preparation, your facility can stay ahead of compliance requirements and avoid unnecessary disruptions. The Joint Commission (TJC) and the Accreditation Association for Ambulatory Health Care (AAAHC) set strict standards for medical equipment maintenance, and falling short can mean fines, operational delays, or even loss of accreditation.

So, how do you make sure your facility is always audit-ready? Start with these six key steps.

1. Keep Your Service Records Organized

When inspectors walk in, documentation is one of the first things they’ll ask for. Make sure your maintenance logs, calibration reports, and repair histories are updated, easily accessible, and well-organized. A missing record or incomplete log could raise red flags.

2. Stay on Top of Preventive Maintenance (PMs)

Regular preventive maintenance (PMs) isn’t just about avoiding breakdowns—it’s also a core part of compliance. Every piece of equipment should be serviced according to manufacturer recommendations, with clear records to prove it. Keeping up with PMs reduces the risk of unexpected failures and shows inspectors that your facility prioritizes safety.

3. Test Emergency Equipment Regularly

Defibrillators, anesthesia machines, backup power systems—any equipment used in an emergency must be in top working condition at all times. Inspectors will check that these devices are properly maintained and ready to use when needed. Perform routine functionality tests and keep detailed maintenance records to avoid compliance issues.

4. Train Your Staff to Be Compliance-Ready

Your team plays a huge role in passing inspections. Make sure staff members are trained on:

• Proper equipment use and maintenance

• Documentation and record-keeping protocols

• Regulatory safety procedures

Well-trained staff won’t just help you pass inspections—they’ll also improve efficiency and patient safety.

5. Don’t Overlook Your Medical Gas System

Medical gas systems come with strict safety and maintenance regulations, and non-compliance can lead to serious risks. Ensure that:

• Inspections are up to date

• Preventive maintenance is documented

• Air exchange and trace gas testing are completed on schedule

A well-maintained system keeps your facility safe and avoids compliance issues.

6. Run a Mock Audit Before the Real One

The best way to avoid surprises? Simulate an inspection. A mock audit helps identify gaps in compliance, giving your team time to fix any issues before an actual review. This proactive approach ensures you're fully prepared when inspectors arrive.

Bottom Line: Compliance Is About Preparation

Scrambling at the last minute for an inspection is a recipe for stress and risk. The key to passing with confidence is ongoing maintenance, clear documentation, and a well-trained team. By following these steps, your facility can make inspections smoother while maintaining uninterrupted patient care.

Need Help Ensuring Compliance?

We can help you get audit-ready with expert compliance assessments and equipment maintenance solutions. Contact us today to learn more.