Life Safety Code Surveys

Scott Furgason, CFPS, CFI, CFPE

As a life safety surveyor for the Accreditation Association for Ambulatory Health Care (AAAHC), Scott has conducted hundreds of accreditation surveys for healthcare organizations throughout the United States.

With expertise in policy development, risk assessments, personnel management, fire inspections, fire plan review, and fire prevention, Scott is a knowledgeable asset for his clients. He currently performs survey readiness services across the United States for healthcare organizations, with a particular emphasis on ambulatory surgery centers.

Q: What is the most common deficiency that you cite during a Life Safety Code survey?

A: Improper inspection, maintenance, and testing of the building features that protect occupants from smoke and fire seem to be the area I tend to cite the most. The focus in ambulatory surgery centers (ASCs) has changed from evacuation of patients to shelter-in-place. Staff is trained to move patients and themselves to safety behind barrier walls that are designed to limit the transfer of fire and smoke.

The following features are often neglected:

  1. Fire and smoke dampers – Many times, ASC staff have no idea if the facility even has fire and smoke dampers. Since the dampers are usually located above the ceiling tiles, they are often forgotten. Dampers are required to be inspected and tested one (1) year after inspection and every four (4) years after that. I have found that ASCs that are maintained by hospital maintenance staff often only conduct the testing every six (6) years, as required for a hospital, instead of every four (4) as required for ASCs. I am often asked who inspects and tests fire dampers. I usually suggest that the original HVAC contractor be contacted first for guidance. If they can’t help, I suggest that they contact other ASCs or the hospital to find out who they need to conduct the work.
  2. Barrier walls – Once above the ceiling tiles, barrier walls are often forgotten. Regardless of the type of barrier wall, the wall needs to be inspected and maintained to ensure that it is compliant with the standard. There shouldn’t be any open holes. Penetrations should be properly sealed. Walls should be properly constructed for their type. I often suggest that at least annually ASCs should have someone, with knowledge of the standards, inspect the barrier walls for deficiencies. Deficiencies should be repaired by trained individuals.
  3. Rated fire doors – Rated fire door assemblies are required by NFPA 80 edition 2010 to be annually tested and inspected. Usually, the doors are not inspected, or the inspection does not meet the standard. Besides deficiencies related to door inspections, the next prevalent deficiency is fire doors being propped open.