Prepare to deal with the cost of safety code violations

Prepare to deal with the cost of safety code violations

August 22, 2017
Risk Management
From the August 2017 issue of HealthCare Business News magazine

By Robert Harris

Life Safety Code surveys of health care organizations almost always end up costing the organization money.

CEOs and CFOs pretty much dislike seeing any surveyor enter the building to perform a life safety survey. Depending on the bed count and overall square footage, these surveys can last anywhere from one day to between three and five days. The mood of the survey as it progresses from hour to hour, or day to day, also depends on other variables, including:

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  • How many deficiencies are found in the first two to three hours.
  • The critical nature of the deficiencies found.
  • The knowledge level of the individual from the facility walking with the surveyor and the ability to respond to questions correctly and promptly.
  • The attitude of the individual from the facility (argumentative, makes excuses, makes too many jokes, etc.).
  • The attitude of the surveyor or survey team, which is sometimes dependant on the points noted above.


It does not matter how prepared a facility is for an unannounced survey. The end result could include findings related to both the building tour and the document review session. It's just inevitable! You will be shoveling out money to correct deficiencies found during the tour, and sometimes also related to findings from the document review session. Frustration really builds when you finish an accreditation survey with little life safety findings, and three weeks later, the state conducts a validation survey and presents you with page after page of deficiencies.

One of the most interesting characteristics of a survey is how the state, the accreditation team, you and your senior leaders all interpret a code deficiency that is cited. You could take five state surveyors, five accreditation surveyors and put them in a room with an NFPA expert who is teaching the 2012 LSC. After the morning session the instructor could send those 10 surveyors out separately to look at the same code deficiency, and then send them for a break. Once back in class the instructor would go around the room and ask for an interpretation from each, and you would be amazed at the differences of opinion, even though that morning they had been instructed on how to interpret and enforce the code related to the deficiency. You will also note that the more experienced surveyor will interpret the findings differently than an individual who only has a few years of survey experience. Out in the field you will find two types of surveyors. One will be willing to help you with the proper way to make the correction. The other will simply state, “I’m paid to find the deficiencies, your job is to correct them," and walks away. You will make the corrections based on how you interpret the deficiency and code reference, only to find that when the surveyor returns he says the corrections are incorrect and will cite you again.

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