Life Safety Audits: Preparation Is Key

Life Safety audits can be stressful events for administrators and maintenance directors.  The key to making these surveys less stressful and achieve successful results is to prepare.  LS surveys can identify areas where safety can be improved for both residents and employees, and in some instances good performance in Life Safety can impact the financial stability of a facility. We asked Barry Derossett, BSN, RN, LNHA, for some thoughts on the importance of LS.


Facilities always strive to be deficiency-free. What Life Safety tip do you recommend they begin immediately?

About 1 in 5 facilities are found to be deficiency-free each year. It requires that the administrator and maintenance director are both acutely aware and organized with respect to regulatory required testing and maintenance.  The administrator and maintenance director should meet regularly to review the documentation to ensure the facility is in compliance. A best practice approach is for the two to conduct a walking round of the entire facility, together, once a month or at least once per quarter.  Although many administrators and maintenance directors do walking rounds, they are routinely done independent of each other.  By conducting these tours together, it will help eliminate any miscommunication or missed communication for critical issues.


What are some issues that cause facilities to not be in compliance?

1.  Entrapment Assessments - All facility beds are required to have an entrapment assessment completed annually.  There are 7 zones that must be assessed with measurements to determine if the bed is safe or if it poses an entrapment risk.

2. Annual Receptacle Testing - Receptacles are to be tested annually in patient areas.  Each receptacle should be identified by the maintenance director and tested annually.  The exception is hospital grade receptacles.


What mistakes do you see facilities often make?

A very common mistake that facilities encounter, often inadvertently, is the follow-up testing for equipment after it has been replaced or repaired.  An example would be testing a smoke detector and it fails to pass testing/inspection.  Most of the time the failed detector is replaced but the facility or vendor fails to do a test on the new detector to ensure it is now functioning properly.  It is possible that the newly installed detector could be defective and malfunction.  This has been observed several times with respect to receptacle testing.


When it comes to Life Safety, preparation can uncover issues, code violations and infractions which can save you time and money. It can also be the difference when faced with an emergent situation.

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