Would your ambulatory surgery center (ASC) or healthcare facility pass a life safety survey if surveyors walked in today? If your facility is accredited or participates in the Center for Medicare Services program, it must comply with the 2012 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code and its referenced standards. A mock survey will help prepare your facility and staff for an actual life safety survey.
What is a Mock Survey?
A qualified fire and life safety code expert conducts a mock survey to assess your facility from the perspective of an accreditation surveyor.
The mock surveyor will:
- Conduct a facility tour, inspecting all facility spaces for compliance with NFPA 101 Life Safety Code
- Review inspection, testing, and maintenance records to ensure they meet code and standard requirements
- Assess policies and procedures for alignment with life safety requirements
Beyond checking for compliance, a mock survey provides education for staff, boosting confidence and reducing the stress often associated with accreditation surveys.
Why are Healthcare Facilities Subject to Stringent Fire and Life Safety Codes?
Patients in healthcare facilities are uniquely vulnerable, so fire and life safety codes place the facilities under intensive scrutiny. Many patients can be under anesthesia, have impaired mobility, or rely on life-support equipment, making evacuation in emergencies difficult or impossible without staff assistance. This vulnerable population is why ASCs and healthcare facilities must comply with one of the most restrictive fire and life safety codes.
Challenges in Life Safety Code Compliance?
Complexity of Regulations
Navigating the Life Safety Code can be very complex, particularly for healthcare leaders without formal fire and life safety training, whose responsibilities often include life safety compliance in ambulatory surgery centers and other smaller facilities. Additionally, facilities professionals must keep up with changes in requirements and code editions.
Frequent Facility Changes
Healthcare facilities are dynamic, ever-changing environments where modifications, relocations, and operational changes occur frequently, making it challenging to maintain compliance. Add to the mix staff turnover, which can result in the loss of critical institutional knowledge about a facility’s fire and life safety history.
Inconsistent Survey Results
Different surveyors may interpret codes differently based on their varied backgrounds and areas of expertise, making compliance even more difficult to achieve.
All these factors create challenges for healthcare facilities striving to meet regulatory requirements while maintaining patient care operations.
The Consequences of Non-Compliance
When an accreditation surveyor identifies non-compliance with fire and life safety codes during a Life Safety survey, it can have serious consequences for healthcare facilities. Deficiencies often require considerable time and financial resources to correct. Suppose an accreditation surveyor or authority having jurisdiction (AHJ) identifies those deficiencies during an official survey or inspection; the facility must correct the non-compliance issues within CMS’s timeline for the official plan of correction. This can lead to rushed projects and emergency vendor contracting to meet deadlines. An immediate jeopardy deficiency can put both patient care and accreditation status at risk.
Non-compliance could also damage the organization’s reputation and, in severe cases, result in the facility losing its ability to participate in Medicaid and Medicare programs, which could disrupt other contracts and payor agreements.
Common Life Safety Code Deficiencies
Many healthcare facilities struggle with similar life safety code deficiencies that surveyors and AHJs find during accreditation and code compliance surveys. Below are some of the most frequently identified deficiencies.
Fire and Smoke Barrier Penetrations
Openings in fire-rated walls compromise fire and smoke containment, allowing them to spread more easily.
Medical Gas System Failures
One example is medical gas zone valves improperly located, which can delay emergency shutoff in critical situations. Other deficiencies may be in medical gas storage rooms, such as improper ventilation or separation, creating additional hazards.
Emergency Power System (generators and UPS systems) Failures
Failures in design, configuration, or installation are problematic and can affect their reliability during power outages.
Inspection Testing, and Maintenance (ITM) Deficiencies
Lapses in required fire alarms, fire sprinklers, and emergency lighting systems lead to non-compliance and potentially reduced effectiveness during emergencies.
Non-Compliant Emergency Policies, Response Plans, and Drills
Policies, plans, and drills sometimes do not adhere to code requirements, or staff inconsistently follow them, which weakens facility preparedness.
Fire Door Issues
Fire doors are another common issue, as they often have missing labels, non-compliant gaps, or hardware, preventing them from functioning properly during a fire.
Hazardous Area Violations
These areas, such as storage rooms, soiled linen rooms, and mechanical spaces, often have deficiencies related to fire-rated separations or inadequate fire protection.
Identifying these issues early in a mock survey allows healthcare facilities to address them proactively, which is vital to maintaining compliance and ensuring the safety of patients, staff, and visitors.
Mock Surveys: The Solution to Compliance Challenges
A mock survey is the most effective way to reduce and eliminate life safety survey deficiencies.
THREE BENEFITS OF MOCK SURVEYS
Identify Deficiencies Before an Official Survey
One of the most significant benefits of a mock survey is identifying deficiencies before an actual life safety survey. This allows facilities to address issues on their own timeline rather than being constrained by a mandated plan of correction. When deficiencies are found during an official survey, a plan of correction must be submitted and approved within CMS-required timelines. This can result in rushed repairs, potentially leading to higher costs due to expedited work and vendor availability constraints, which may drive up pricing.
Train and Educate Staff
Mock surveys also serve as a valuable training opportunity for facility staff. The individual conducting the mock survey can explain code requirements and discuss potential mitigation strategies in detail. This is especially beneficial for newer or less experienced staff members as the training enhances employees’ code knowledge, making mock surveys an investment in both compliance and professional development.
Reduce Survey Anxiety
Familiarizing staff with the survey process builds confidence, reducing stress and improving overall readiness. This leads to a more prepared and composed team when the real survey occurs.
How Telgian Engineering & Consulting (TEC) Can Help
The TEC team has extensive experience conducting mock surveys for ASCs and hospitals. Our Life Safety Code experts are ready to assist all types of healthcare facilities in preparing them for accreditation with organizations such as The Joint Commission, Accreditation Association for Ambulatory Health Care (AAAHC), Det Norske Veritas DNV, American Association for Accreditation of Ambulatory Surgical Facilities (Quad A), Accreditation Commission for Health Care (ACHC), and others.
Additional Services
In addition to mock surveys, TEC offers Life Safety Code compliance coaching and due diligence assessments to identify gaps in code compliance. For new construction and remodel projects, Telgian can provide code compliance design input for ASCs and healthcare facilities, including plan compliance reviews and new facility commissioning. We can also offer Plan of Correction assistance to help facilities address deficiencies identified during actual surveys.
Be Prepared – Schedule a Mock Survey Today!
A mock survey will prepare your facility, educate your staff, and reduce the stressful uncertainty of the life safety survey process. Contact TEC today to learn how we can get your ASC or healthcare facility survey ready!
About the Author
Dale Lyman, CFPS, is a Senior Fire Protection Consultant at Telgian Engineering & Consulting (TEC). He provides fire protection consulting services, as well as fire and building code compliance and fire/life safety system evaluations. A recognized fire protection and life safety expert, Mr. Lyman authored the Ambulatory Surgery Center Safety Guidebook (Elsevier Publishing, 2017) and ASC Life Safety Survey Prep Guide (Kindle Direct Publishing, 2023).
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