10 deficiencies AAAASF cites most and how to correct them — No. 1: The Life Safety Code standard

The American Association for Accreditation of Ambulatory Surgery Facilities compiled its 10 most commonly cited deficiencies and provided solutions on how to address them.

AAAASF Interim COO Thomas Terranova spoke with Becker's ASC Review about the organization's most cited deficiency, the Life Safety Code, section 9999.5.90, of the Medicare survey.

Here's what you should know about the standard and how to prepare for your survey:

Thomas Terranova: The most commonly cited deficiency to successful accreditation is the Life Safety Code portion — section 9999.5.90 — of the Medicare Survey.

This is a large and diverse section covering all life safety code and health care facility code requirements. The most common deficiencies, however, are generally related to policies and procedures facilities already have in place that simply need to be enforced or documented.

Within this standard, the most common findings include:

  • Lack of self-closing door mechanisms
  • Self-closing doors being propped open
  • Storage placed in the path of egress
  • Lack of 1-hour fire wall separation
  • Unsealed fire penetrations
  • Lack of evidence of fire drills
  • Door swings against direction of egress

Being fully prepared in advance of the survey is critical to ensure that your facility successfully meets the Life Safety Code standards.

First, make sure that there is a person available that has access to locked rooms and/or to the roof. Remember that surveyors will need access to your entire ASC and need to test backup power and alarm systems. They will also need to review city approved construction plans for the building showing construction type and location as well as fire rating of all fire walls, doors and windows, total square footage of the ASC, date of the construction of the building, date the facility was first occupied as an ASC, electrical plans, type and location of the emergency power transfer switches and type of electrical system.

You need to be prepared to provide the ASC’s emergency evacuation plan as well as records of all quarterly staff attended fire drills. This is a great example of not only having a policy, but ensuring all staff are familiar with and follow the established policy. This is critical to success in many survey areas.

The surveyor will review the ASC’s maintenance and testing records within the last 12 months for the medical gas and anesthesia equipment, fire alarm, fire sprinklers, generator or UPS battery system and emergency lights. If an on-site laboratory is located within the facility, be prepared to show all lab maintenance records.

Collecting the documentation in advance of the survey and evaluating the systems you already have in place will facilitate successful completion of the Life Safety Code portion of the survey.

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