The top 10 CMS Life Safety Code citations

For nursing home administrators and maintenance directors, annual life safety audits can be a dreaded occurrence—especially when you consider that only one in five facilities are found to be deficiency-free each year. So we’ve taken a look at recent Centers for Medicare & Medicaid Services (CMS) data to determine the top 10 violations and help facilities managers be better prepared for the surveyor’s visit. After all, the results of the audits are published for all consumers and residents’ families to see so it is a good idea to commit to audit-preparation as a standard maintenance best practice and stay on top of these common infractions.

The top four violations remain fairly consistent, presenting a clear opportunity to prevent major citations and to protect the reputation of the long-term care facility.

The top 10 citations

1. Sprinkler system maintenance (prevalence: 21% of all facilities cited)

The testing and maintenance of the fire alarm system has to be conducted at the proper frequency in accordance with National Fire Protection Agency (NFPA) 25. Most often, sprinkler violations are due to improper testing and maintenance. Testing problems generally stem from a lack of documentation, lack of qualified individuals doing the calibration of the equipment, or incorrect frequency of inspections. Maintenance citations are most often issued for missing parts, lack of replacement parts or tools, uncalibrated gauges and placement of storage near the sprinkler heads.

2. Electrical wiring and equipment (prevalence: 20% of all facilities cited)

All electrical wiring has to be in accordance with the NFPA 70 and the National Electrical Code. Violations are overwhelmingly due to the unacceptable use of power strips or extension cords, missing junction boxes, light switches, or electrical outlet cover plates, and unlocked electrical service panels in areas that are accessible to residents.

3. Hazardous areas (prevalence: 15% of all facilities cited)

Hazardous areas are often cited for incorrect door requirements, for messiness and disorderliness and for doors being propped open by bins and doorstops when they should remain closed. In addition, because hazardous areas can be defined by what’s in the room (soiled linen, trash or repair areas are all defined as hazardous) if the room’s use has changed it may now be defined as hazardous and yet not meet the requirements resulting in citations.

4. Corridor doors (prevalence: 14% of all facilities cited)

Doors that protect corridor openings are required to prevent smoke. Violations commonly occur with the improper use of automatic and self-closing doors, door obstructions and with door gaps that occur when doors age.

5. Generator inspections and tests (prevalence: 11% of all facilities cited)

This violation has been cited more frequently in recent years. All generators must be inspected weekly and exercised under load for 30 minutes per month (some regions are more onerous). Oftentimes inspections are not completed, the inspection is at the incorrect frequency, or the inspection is completed but not documented.

6. Access to exits (prevalence: 11% of all facilities cited)

Exits have to remain clear of obstructions and accessible at all times. Many facilities are cited when exits lead into a fenced off area, storage is placed in the way of the exit, or doors are camouflaged to prevent the elopement of residents with dementia.

7. Smoke barriers (prevalence: 11% of all facilities cited)

Smoke barrier walls must have a half-hour Fire Resistance Rating (FRR), or 1 hour FRR for new construction. For existing buildings citations are often pertaining to places where contractors renovate and add wiring or install new phone lines that create penetrations in the walls.

8. Fire drills (prevalence: 10% of all facilities cited)

Fire drills are required to be conducted randomly at a minimum of once per shift every quarter. Facilities are mainly cited for not making fire drills random—they tend to fall into predictable patterns.

9. Fire alarm system testing and maintenance (prevalence: 8% of all facilities cited)

CMS requires that fire alarm systems be tested as per the NFPA frequencies. Missed tests or missing documentation of testing are the major reasons for citations. Also, the testing of off-premises transmission equipment to the fire department is often neglected.

10. Sprinkler installation (prevalence: 8% of all facilities cited)

Fire sprinklers are required to be installed throughout the facility. Citations commonly occur for areas that are easy to miss, like closets, storage areas, or attics. Many facilities are cited for improper spacing and coverage during installation as well as obstructions such as ductwork, light fixtures, or storage—modifications completed as the building ages.

Reminders, self-audits and documentation

So, how can facility managers address these issues? Close examination reveals a few common themes that can be used to prevent future citations.

Compliance reminders generated by web-based facilities management software are an effective way to prevent many of the top citations. This includes not just a reminder but also notes on the required inspection points and readings. By pushing tasks automatically to mobile devices staff are able to complete the required documentation in real time—eliminating the risk of missed documentation. Visual dashboards showing what’s overdue are also a helpful communication tool for facilities managers and administrators.

In addition to providing reminders and documentation for scheduled maintenance and inspections, mobile devices can be used as a part of a mock survey program. Monthly and/or quarterly surveys completed with a multi-disciplinary team ensure 24×7 survey readiness. These checks should include historical problem areas such as blocked egress paths, storage too close to sprinkler heads and changes in the use of rooms, unapproved use of power strips and door stops. Creating simple mobile-enabled check lists with the ability to complete the task on a mobile device ensures ongoing success.

Many facilities management applications can also create standard QA inspections, randomly selecting locations for spot checks. Each week, a set of locations is chosen randomly and managers use mobile devices to complete the survey. Graphing the results can help facilities managers and corporate management see where potential problems are concentrated.

And of course it doesn’t stop at the work the facilities management team is responsible for. It is important to also create reminders and documentation for compliance related work that is outsourced and to create follow up inspections any time there are outside contractors working in the community (e.g. checking for penetrations to smoke barriers in drop ceilings)

With these safeguards in place, long-term care facilities will be much better prepared to keep their residents and staff safe. Inspections and audits will be completed in less time and having little to no issues with the environment and facilities audits will lessen the scrutiny faced by other departments. A clean citation reputation is a valuable asset.

Josh Malbogat is Director of Senior Living for TheWorxHub by Dude Solutions, Cary, N.C.


Topics: Articles , Executive Leadership , Medicare/Medicaid , Regulatory Compliance