Time Allowed for Repairs

Q: What are the time frames for repairing life safety deficiencies found during routine inspections? How much time would be allowed to repair emergency exit signs, or failed smoke detectors?

A: Well… if you’re talking about resolving a deficiency that was cited on a survey report, you have 60-days from the time you receive the report. This is actually a mandate from CMS under CFR 488.28(d). But CMS (and the accreditation organizations, or AO) understand if additional time is required, due to the need of obtaining approval from your governing body, or engaging in competitive bidding, as examples.

If you need more time and the deficiency is a LSC deficiency, then you have the option of requesting a Time-Limited Waiver, a Standard Waiver, or a FSES Equivalency. Each AO has their own instructions and procedures for you to follow when requesting one of these.

But if you conduct your own assessment and find certain items deficient, then you are not obligated to resolve the deficiency within the 60-day window. Most AOs will expect you to resolve the deficiency in a reasonable amount of time.

If all you need to do is install four new ‘Exit’ signs, then a month or so is reasonable. But a year would not be considered reasonable.  A failed smoke detector should not take more than a month or so, unless it is such a special item that delivery time is excessive.

Other than the 60-day window after a survey, I’ve never seen a set time-limit for life safety repairs. All of the AHJs I’ve worked with are willing to work with you. If you need extra time due to extenuating circumstances, they will be understanding.

Whatever is reasonable… Most AHJs will work with you on this, as long as the time-frame is reasonable.