This guide lists the findings Survey Ready Consulting sees most often across hospitals, surgery centers and nursing facilities, with the reason each one gets cited and the fix.
1. Fire door assemblies held open or missing annual inspection
NFPA 80 requires an annual inspection of every fire door assembly with documented results. Surveyors check for the inspection record and for doors that are propped, wedged, missing closers or not latching. Fix: inventory every rated door, inspect annually, repair deficiencies and remove anything used to hold a door open.
2. Corridor storage and obstructed means of egress
Corridors in health care occupancies must maintain their required clear width, and nothing may obstruct an exit, exit access or exit discharge. Carts, equipment and supplies parked in corridors are among the easiest findings to write. Fix: define storage locations, round daily and hold department leaders accountable.
3. Unsealed penetrations in fire and smoke barriers
Every cable, pipe and duct that passes through a rated barrier must be sealed with a listed firestop system. Above-ceiling work by IT, HVAC and low-voltage contractors is the most common source of new penetrations. Fix: barrier management program with above-ceiling permits and quarterly inspection.
4. Emergency generator testing not documented
NFPA 110 requires weekly inspections, monthly load tests of at least thirty minutes and an annual test, each documented. Missing weeks and monthly tests that did not reach the required load are routinely cited. Fix: a generator log that captures every required data point, reviewed monthly.
5. Medical gas and vacuum system testing out of date
NFPA 99 requires periodic inspection and testing of medical gas and vacuum systems, including alarms, outlets and source equipment, with qualified personnel. Fix: annual third-party verification and a record of corrective actions.
6. Fire drills not conducted or documented per shift and quarter
Health care occupancies must conduct fire drills quarterly on each shift, at varying times, with documentation of staff response. Fix: a drill calendar by shift, a standard drill record and a critique of each drill.
7. Damaged finishes that cannot be properly cleaned
Torn flooring, damaged wall surfaces, stained ceiling tiles and worn upholstery are cited under the physical environment and infection control standards because they cannot be cleaned and disinfected. Fix: include surface condition in rounds and keep a repair backlog.
8. Temperature, humidity and pressure relationships not monitored
Operating rooms, sterile processing and other critical spaces have ventilation requirements for temperature, humidity and pressure relationships. Surveyors ask for the logs and the response to out-of-range readings. Fix: continuous or daily monitoring with documented corrective action.
Frequently asked questions
CMS has adopted the 2012 editions of NFPA 101 Life Safety Code and NFPA 99 Health Care Facilities Code. Some states have adopted newer editions for licensing, and the stricter requirement applies.