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Best Practices When a Deficiency is Identified


Deficiencies can have a significant impact on employees, your business, sensitive assets, and more. It’s important to stay ahead of potential ones while also not delaying the resolution of current or persistent ones. The goal is to identify a deficiency before a survey.

By identifying and repairing deficiencies ahead of surveys, business and building owners along with those using the building benefit by:

  • Safer working/living environment for employees/residents
  • Safer building for visitors, shoppers, clients, etc.
  • Business and job security
  • A possible reduction in insurance premiums

Identifying a Deficiency

Prior to a survey, it’s important to have a checklist to help you prepare for the inspection and locate any deficiencies that may arise during the survey. They may be found by onsite staff or experienced fire professionals.

If there have been previous issues with certain fire and life safety systems, be sure to spend extra time inspecting those and note any corrections that have previously occurred. If you find the system is deficient, note it and immediately begin to process the resolution steps.

If the fire inspector finds problems, he/she will spend more time checking additional equipment. It's better to make sure that any equipment the fire inspector checks has been properly inspected and maintained by an experienced fire and life safety professional.

What to Do After Identifying a Deficiency

When a building owner or fire professional discovers a building feature or deficiency that is not compliant with the National Fire Protection Association (NFPA) Life Safety Code, or in the health care industry, the Joint Commission standards, the preferred course of action is to immediately correct the issue. There are a few steps the owner can take to ensure the corrective measures are being put into place.

Improvement Plan Form

One step to take when you discover a deficiency is to complete an internal improvement plan form. An improvement plan is a process set in place for employees for when they identify deficiencies (either before or after). An improvement plan includes the following steps:

  1. Identifying what systems and specific parts need improved

  2. Rational to back up your improvements

  3. Outline to employees, tenants, etc. detailing information and the plan

  4. Training on locating deficiencies, related topics and for direct reports so they can provide future support in identifying deficiencies

  5. Schedule and spot checks

  6. Sign off to ensure work was completed

The improvement plan form is completed whenever a need is identified to ensure the quality and safety of your building, those inside, and any assets. Improvement plan forms can also be completed if it is directed by a city or state official who, upon survey, may fail the facility due to deficiencies. Internal employees, owners, experienced fire professionals, or an outside company who specializes in fire protection and life safety can complete improvement plan forms.

Now that all the hard work is done and the plan for improvement is complete, submitting a plan for improvement is simple. The submittal will go to the direct point of contact, decision makers for the building, or even a board of directors. Whomever oversees final decisions for fire and life safety will be the recipients and it changes industry by industry. Once the plan has been submitted, the approval process can take anywhere from a day to many months depending on how severe the deficiencies are that have been identified.

While a plan for improvement can be used for any industry, there are some specific routes the health care industry takes.

Equivalency Plan for Health Care

The health care industry is a whole different ball game in and of itself. It must follow the standards of the NFPA along with the Joint Commission standards. The Joint Commission conducts health care facility surveys and if your facility is found non-compliant, there could be serious ramifications.

In some instances, corrective actions for deficiencies may pose a hardship to the organization and not directly impact visitors, tenants, or when it comes to health care, even patients. When this is the case, the organization can submit a request for equivalency to the Joint Commission for review and consideration.

There are two types of equivalencies an accredited organization may submit: a traditional equivalency or a fire safety evaluation system equivalency. A traditional equivalency is based on verification by the local fire marshal responsible for fire safety of the building; a registered architect or Professional Engineer; or a certified fire protection and life safety professional. A fire safety evaluation system equivalency (FSES) process was developed by the NFPA. It objectively applies specific values to building features and allows deficiencies to be deducted from the building features numerical value. Once the calculations are completed, if the building score is zero or better, the building as evaluated would be considered compliant based on the FSES process and the identified deficiencies would not be considered a threat to occupants of the building.

The submittal process is quite lengthy and has strict standards. Once submission has occurred, if any documents are missing, the facility has two weeks to submit any missing paperwork to the Joint Commission. If this is not met, the equivalency will be rejected. Upon receiving the submission, the Joint Commission will begin its full analysis and present its findings. For more information on the equivalency process, reference this document.

 Identifying deficiencies are an important aspect of how a business or building operates. Ensuring all fire and life safety systems are in working order is essential. If there are simple deficiencies, fix them. If there are costly items requiring attention, discuss alternatives and compliance timeframes with your inspector. Most fire inspectors are willing to negotiate a longer time period since the inspector is most interested in gaining compliance and making your building safer without causing you financial difficulties. Not all compliance items cost a great deal of money or require great effort. Many can be operational issues and are easily corrected.

Tags: preferred protection, life safety, fire safety, deficiency, emergency safety