Volume 2025 | No. 2
SURVEYOR
PHYSICAL ENVIRONMENT AND LIFE SAFETY
13.01.05 Signage Frequency of the citation: 29%
14.02.01 (CAH) 13.02.01 14.02.02 (CAH) 13.02.02
Fire alarm system – Installation and maintenanc e
Overview of the requirement: Exits are marked by illuminated signs and doors that could be confused with exit doors are marked NO EXIT. Comment on deficiencies: Surveyors observe exit/no exit signs and review documentation of monthly inspections to ensure illumination of exit signage. Examples of ACHC Surveyor findings: ■ Exit and stairwell signage were missing or incorrect, including absent “NO EXIT” signs on courtyard doors, missing terminus identification in enclosed stairwells, and a misdirecting exit sign in the medical waste corridor. ■ Exit signs were not illuminated in some areas, and there was no documentation of the required monthly exit sign inspections.
Fire alarm system - Testing
Frequency of the citation: 14.02.01 78%; 13.02.01 65% | 14.02.02 67%; 13.02.02 39%
Overview of the requirement: Fire alarm systems are installed, maintained, and tested per NFPA 101 Life Safety Code (2012 edition) and NFPA 72 National Fire Alarm Code (2010 edition). Basic and secondary components are included in testing and documentation is retained for at least three years. Comment on deficiencies: Compliance is assessed through observation and document review. For these related standards, ACHC Surveyors noted issues with: ■ Detector location and installation.
Compliance tips for:
■ Notification and annunciation devices. ■ System performance and reliability. ■ Testing, inspection, and documentation. ■ Inventory accuracy and test frequency.
All exits must be marked with illuminated signs unless the exterior exit is clearly identifiable. Doors that do not lead to exits but could be confused for exits require signage with NO EXIT. “NO” must be 2-inches tall and “EXIT” must be 1-inch tall. Enclosed stairways serving three or more stories (new construction) and five or more stories (existing construction) also require signage. ■ Audit monthly exit sign inspection logs. ■ For signs with directional arrows, ensure that the path indicated leads to an exit access. ■ Pair your exit sign inspections with other routine tasks, like checking for stained ceiling tiles or inspecting fire extinguishers, to maximize efficiency and minimize disruption.
Nerd Newbies (understand the requirement)
Examples of ACHC Surveyor findings: ■ Smoke detectors closer than 36-inches from the air supply or return grille were observed in the linen storage room, kitchen food prep area, surgery suite corridor, and mother-baby unit near the nurses’ station. ■ No smoke detector was installed within five feet of the two MRI overhead rolling fire doors. ■ The fire alarm system was observed to be in a "trouble alarm" condition at the main fire panel. The facility director detailed that the audible voice alert component of the system was garbled/ distorted during fire alarm announcements. The root cause of the problem had not been determined, and this had been ongoing for the past three to four months. ■ At the first floor environmental services storage area, a smoke detector was observed hanging from its wiring. ■ The on-call staff sleeping room was not provided with a fire alarm annunciation device. ■ Required fire alarm pull stations were not installed at the lobby exit/dining room exit/community development office exit. ■ Stored equipment blocked access to the fire alarm pull station in the medical gas room.
Nerd Apprentices (audit for excellence)
Nerd Trailblazers (prepare the path for others)
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