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Tips for Succeeding During a Life Safety Building Tour

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oint Commission surveys can be a challenging experience for any

facility manager. “Sitting down with the Life Safety Code®* surveyor to review the documents is one thing, but then the building tour has always been my biggest

concern,” says Mark Kaldahl, facility support director at Carilion Franklin Memorial Hospital (CFMH). CFMH is a 37-bed, 66,605 square foot hos- pital located in Rocky Mount, Virginia. “Having gone through several surveys

over the years, the most recent one being

in June 2015, I’ve learned facility man- agers can lessen the stress of the building tour by putting these simple practices in

Carefully touring your own building, perhaps as part of a mock survey or mock tracer, can help organizations prepare for a life safety building tour.

place,” Kaldahl says.

Kaldahl recommends the following strategies to help prepare:

  1. Be sure your life safety drawings are up to date. Before the life safety surveyor begins the building tour, she or he is going to want to review the

    life safety drawings. Drawings that are incomplete or missing information are going to send up a red flag before the building tour ever begins.

  2. Be sure the person(s) responsible for the environment of care has a good knowledge of the “Environment

    of Care,” “Emergency Manage- ment,” and “Life Safety” standards. “During my recent survey the life safety surveyor told me you’d be surprised at how many facilities we go into where the person responsible for the environment of care doesn’t even have a copy of what those standards are,” says Kaldahl. It isn’t surprising that facilities don’t do well during the survey when those responsible for maintaining the building don’t even know what the life safety engineer


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    * Life Safety Code® is a registered trademark of the National Fire Protection Association, Quincy, MA.

    is looking for. But it doesn’t have to be that way. To stay proficient with environment of care management, Kaldahl advises facilities personnel to take advantage of the resources and training opportunities available to them from organizations such as The Joint Commission, Joint Commission Resources, and the American Society of Healthcare Engineers.

  3. Conduct your own building tour. The “Environment of Care” stan- dards require environmental rounds be conducted in all patient care areas every 6 months and all other non-patient care areas annually to minimize or eliminate risks in the environment. Environmental rounds are designed to identify and correct environmental issues on a regular basis so as to keep the facility in a constant state of readiness should

    an outside agency stop by to inspect the facility (for example, Fire Mar- shal, the US Centers for Medicare & Medicaid Services, Property Insurance Carrier, or The Joint Commission).

    The key to obtaining positive results from these rounds is the thoroughness of those doing the rounds. “Those

    making the rounds must be dedicated to improving the environment,” says Kaldahl. More often than not, rounds become ineffective because they fail to document those opportunities for improvement for fear of making that

    area leader look bad in front of his/her peers. “But the more thorough these environmental rounds are, the better prepared the facility will be when The Joint Commission walks through the front door,” says Kaldahl.

  4. Encourage staff reporting. Hospitals must have a process in place where staff can report building deficien-

    cies and problems to the facilities/ maintenance staff. Maintenance staff don’t typically go into every area of the hospital on a regular basis unless they are asked to do so (for example, surgery, patient rooms, ICU) but nursing and environmental services staff are in them every day. Encour- age staff to report building problems through the work order system rather than just stopping one of the mainte- nance staff in the hall. Placing a work order in the system allows for a record to be made of the request and allows

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    Tips for Succeeding During a Life Safety Building Tour

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    the request to be scheduled to get completed. Stopping and telling one of the maintenance workers in the hall may work at times, but more often than not they are forgotten and never get addressed.

  5. Maintain structures for safety.

“In every hospital I’ve worked, we’ve had a program in place to maintain the integrity of everything above the ceiling tiles,” says Kaldahl. These pro- grams included regular checks by the maintenance staff looking for penetra- tions, having above ceiling permits for contractors, and having agreements in place for cabling projects that ensure

ensure this didn’t happen, it did,” says Kaldahl. “I learned then, if you want to ensure the building stays in compliance, someone needs to be checking it to make sure that it is.” The old saying “you need to inspect what you expect” proved to me to be true.


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“It’s important to remember that whoever is doing these inspections needs

to know what to look for.”


—Mark Kaldahl, facility support director Carilion Franklin Memorial Hospital

building,” says Kaldahl. In the large facility in which I worked, I divided the building into 12 areas. Then working with the Maintenance staff, we inspected one area per month, repairing all the deficiencies we found as we went along. We checked above ceilings, checked fire doors to ensure they closed and latched, and examined fire extinguishers to ensure they had been checked, just to name a few things on our list of things to review. By the end of the year we had gone through the entire building one time.

The first cycle was very time consum- ing, but when we started over again the second year, the inspections were much quicker and very few repairs needed to be made.

The secret to these inspections is being

contractors maintain the integrity

of the hospital’s fire walls during the

thorough. “It’s important to remember

that whoever is doing these inspections

project. “How is it then that with all these programs in place surveyors still find deficiencies above the ceilings during the building tour?” asks Kaldahl. The answer is simple: Lack of accountability.


Conduct inspections

“Two surveys ago I was working at a much larger facility that encompassed about 800,000 feet. It was during the last survey I participated in there that I learned the secret to surviving the life safety building tour,” says Kaldahl.

During that building tour, the life safety engineer started down a long corridor on the ground floor of the hospital. By the time he inspected several smoke compartments, he told me to put the ladder away and that he was finished looking above the ceilings. His comment to me was there are so many deficiencies above the ceiling that I don’t need to look anywhere else (For example, pen- etrations in firewalls, ceiling grids, and lights supported by sprinkler pipes, and open junction boxes). Needless to say we received several findings on our survey from his inspection. “Although we had several programs/processes in place to

With CFMH being a 66,605 feet2 facility, it wasn’t very time consuming for me to do a thorough above ceiling inspection prior to our June 2015 visit by The Joint Commission. “For me it took about 18 hours,” says Kaldahl.

During the inspection I filled all the fire wall penetrations I came across, installed covers on open electrical boxes, removed wires holding up lights and ceiling grids which were attached to sprinkler pipes, re-routed flexible conduit that had

been wrapped around sprinkler pipes, and moved wires that were draped over sprinkler pipes with cable tie wraps. All of these things would have been found by the surveyor when s/he did the above ceiling inspection. “Much to my satisfac- tion, when the Life Safety Surveyor did his above ceiling inspection during our survey in June, he did not find any defi- ciencies in his above ceiling inspection,” says Kaldahl.

Some would say this would be easy to accomplish in a small facility like CFMH. But how do you stay on top of things in a much larger facility?“ The answer is easy–divide the building into small areas, where over the course of

a year you can get through the entire

needs to know what to look for,” says Kaldahl. Anything short of that will result in deficiencies being found during the Life Safety Building Tour. This is where having a good knowledge of the Life Safety Standards comes into play.

Many of the Life Safety elements of performance point out things surveyors examine when doing an above ceiling inspection (For example, LS.02.01.10 EP 9, LS.02.01.30 EP 18, LS.02.01.35

EP 4). These can be used as a guide when doing above ceiling inspections.

“With all the work that was done here at CFMH preparing for our survey, I’m happy to report we didn’t receive any direct/indirect findings related to the Environment of Care,” says Kaldahl. So it can be done. Surveys don’t have to be painful. But it does take a team of dedicated individuals working together to make it happen. What’s more, some- one in the facility must be accountable to make sure it all happens. But in the end it’s all worth it when you hear The

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Joint Commission survey team leader say “There were no direct/indirect findings to report related to the Environment of Care.” That’s what makes it all worth- while,” says Kaldahl. EC


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