Getting Your House in Order for Life Safety Surveyors

Written by: John L. Crowder, Jr. PG, CHFM, CFPS

Accreditation and licensure surveys conducted by the Centers for Medicare & Medicaid Services (CMS) agencies are becoming more difficult nowadays due to the increase of personnel specifically trained in Life Safety Code requirements. Most — but not all — surveyors are there to assist you and want to see you succeed. To facilitate success, make sure you’re not caught off guard with an unknown deficiency during your survey.

For that reason, it is imperative that facility personnel take the time to perform tours of the physical environment on a predetermined basis in order to assess compliance. Develop a physical environment checklist tailored to your ambulatory surgery center (ASC) facility for personnel to follow and compare to the current state of the surgical environment. This is the first step in promoting a successful survey and ensuring a safe environment for all — patients, staff, and visitors.

Items to Check

Since Nov. 1, 2016, CMS has been surveying facilities for strict compliance with the 2012 edition(s) of the Life Safety and Health Care Facilities Code standards. With that in mind, there are specific items that facilities should include in their physical environment checklist to help maintain compliance.

Below are various components that key facility personnel should perform when conducting routine inspections. If anything is found to be amiss, be sure to address it as quickly as possible.

  • Ensure that all exit pathways and egress routes are free of obstructions.
  • Ensure that all doors and general finishes are not damaged.
  • Record temperature and humidity levels in all sterile locations, operating rooms, and other sensitive areas.
  • Confirm that all required pressure relationships are met for specific rooms and locations.
  • Confirm that all fire extinguishers are not obstructed from use or view.
  • Verify that all fire-rated and self-closing doors operate properly and latch; doors should not be propped open for ease of access.
  • Confirm that all manual fire alarm pull stations are unobstructed and clearly visible.
  • Ensure medical gas cylinders are properly restrained and connected appropriately.
  • Confirm that emergency power supplies are inspected in accordance with the National Fire Protection Association (NFPA) 110 or NFPA 111 standards.
  • Ensure that all sprinkler heads are clean and free of debris.
  • Ensure that all medical gas zone valves are clear of obstructions and properly labeled.
  • Ensure that the facility is clean and promoting a safe and sanitary environment.
  • Confirm areas are free of items that may promote slips, trips, and falls.
  • Confirm lighting in the facility is adequate.
  • Confirm that all stored items, including medical waste, are properly stored (i.e., off ground level).
  • Perform eyewash station checks in accordance with standards as defined by the American National Standards Institute (ANSI).
  • Evaluate all fire extinguishers in accordance with NFPA 10 (2010) standards.
  • Perform a generator test for 30 minutes at 30 percent load of the nameplate rating.
  • Conduct required fire sprinkler tests.
  • Conduct required fire alarm tests.
  • Perform line isolation monitor testing, if applicable.
  • Perform exit sign tests (30 seconds).
  • Perform egress light tests (30 seconds).
  • Perform fire drills by physically activating the system.
  • Confirm all doors required to positively latch are in good working condition.
  • Verify that stored items are not located within 18 inches of the ceiling level.
  • Confirm that all exterior items are free of defects (i.e., parking areas and lighting).
  • Conduct required fire sprinkler tests.
  • Conduct required fire alarm tests.
  • Review emergency preparedness policy and procedures.
  • Conduct required fire sprinkler tests.
  • Conduct required fire alarm tests.
  • Conduct an emergency mock drill.
  • Conduct required fire sprinkler tests.
  • Conduct required fire alarm tests.
  • Perform a 90-minute generator load bank test, if required.*
  • Conduct the annual diesel fuel analysis.
  • Obtain Fire Door Assembly Inspection reports.
  • Conduct medical gas testing in accordance with NFPA 99 (2012).
  • Consider having a test and balance performed of the heating, ventilation, and air conditioning (HVAC) system.
  • Conduct a tabletop emergency mock drill exercise.
  • Review all policy and procedures, including hazard vulnerability analysis (HVA).
  • Perform exit sign tests (90 minutes).
  • Perform egress light tests (90 minutes).
  • Assess building systems for risk assessment category.
  • Perform receptacle testing in patient care areas.
  • Perform circuitry testing.

*Only required if the monthly tests do not meet the minimum requirements for the last 12 months.

How to Conduct Yourself During Survey

Despite ensuring compliance for your facility in advance, undergoing a survey can be nerve-racking. This is especially true given that Life Safety Code surveyors speak a different language, making discussions tricky to navigate. Give yourself an advantage by learning what to say and what not to say during a survey.

Below are some pointers to keep in mind when talking with Life Safety personnel.

  • Be polite and respectful.
  • Be kind.
  • Don’t be a know-it-all.
  • Do not say, “We have been doing this for years and have never been cited.”
  • You are NOT “grandfathered.”
  • If you are unsure, ask questions.
  • If you think an item is incorrect, ask for the specific code requirement or standard.
  • Confirm in a positive manner that you and your team want to promote a safe and sanitary environment for all patients, staff, and visitors to the facility.

Welcome Surveyors with Confidence

Feel the security that proactive preparation gives you by following the tips in this post. Knowing that your facility is compliant and that you can properly conduct yourself in a survey, should allow you to welcome surveyors with confidence.

LEARN MORE: Join John Crowder Jr. for a 60-minute educational webinar that will help you ensure survey readiness, Friday February 28, at 11 a.m. PST / 2 p.m. EST. Register today.

NEED ADDITIONAL LIFE SAFETY SUPPORT? Progressive Surgical Solutions wants to be your go-to solution for life safety code compliance and survey readiness. Schedule a physical environment mock survey today!