Always keep in mind that JCAHO is the mastermind of a private for-profit business that strong-armed themselves into accrediting hospitals and charging said hospitals for inspections.
Pay the money and you pass. Find me a Las Vegas hospital that doesn't. They have the worst nursing ratio's and staffing in the country and they're all JCAHO approved because to close em' down would kill people.
JCAHO "accreditors" are also pathetic registered nurses who take their 3-4 weeks "how to be" classes and then are turned loose on the general public.
JCAHO has also created "spin-off" businesses called Mock JCAHO Audits who will, additionally, charge hospitals a fee for pretending they are being audited.
A JCAHO auditor is a registered nurse with a new job and artificial power and authority.
They are paid by you to certify you as certified. If you don't pass, well, they'll come back and charge you again until you do pass.
The Mafia has been doing this for some time now.
I got hold of one of their handbooks while I was working to "certify" a residential care facility for the elderly. Something to the effect of "...always leave an air of uncertainty during your preliminary exit interview, stating "We have found a number of decrepancies," but only disclose 2 or 3 of the issues to the staff. This will encourage the facility to take even more strigent measures to pass your inspection."
JCAHO. Uh huh.