Violations that Can Put Health Facilities on Medicare’s Termination

Posted June 07, 2018 by Koorsen Fire & Security

Common Life Safety Violations that Can Put Health Care Facilities on Medicare’s Termination Track

Going forward, health care facilities everywhere can expect more scrutiny from the accrediting organizations (AOs) that audit their facilities for compliance with the Centers for Medicare & Medicaid Services' (CMS) conditions of participation. This is due to a recent report in which the CMS continues to voice concerns that AOs are missing too many condition-level violations -- those that represent a severe or critical health or safety breach and can potentially put a facility on a 90-day termination track toward losing its ability to be reimbursed for care provided to Medicare patients.

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The report was published on July 28, 2017, and covers the performance of AOs, including the Healthcare Facilities Accreditation Program (HFAP) and The Joint Commission (TJC), during the federal fiscal year 2015 (October 1, 2014 to September 30, 2015). Results are provided for a number of different types of health care facilities and identify the violations most often missed by AOs.

Are You Ready for Your Next CMS Audit?

If you own or manage a health care facility that serves Medicare patients, you can expect that AOs will be much more rigorous in their audits now. While the CMS report did not cover every type of health care facility, CMS requirements apply to all types of health care facilities, including:

  • Ambulatory surgery centers and dialysis centers
  • Doctor’s offices and health care clinics
  • Hospitals and outpatient facilities
  • Psychiatric hospitals
  • Hospice and home care providers
  • Inpatient and outpatient rehabilitation centers
  • Nursing homes and assisted living facilities

In this article, we share the most common compliance issues identified in the CMS report for hospitals. However, many of the same general types of deficiencies were found in other types of health care facilities as well. So, understanding what the CMS found can help you take a closer look at your facility in order to become better prepared for your next annual audit.

The Most Common Violations

Most of the deficiencies cited in the CMS report pertained to violations of various National Fire Protection Association (NFPA) codes governing the physical environment (PE) and the National Fire Protection Association (NFPA) 101 Life Safety Code (LSC). The following list provides a summary of the main deficiencies, listed in order of their prevalence, that AOs missed -- and which you can expect they will pay greater attention to in future audits:

Means of Egress (tied with sprinkler violations as being the most prevalent)

  • Lights at multiple exits that did not meet the foot-candle requirements
  • Laundry chutes and shelving unit doors that protruded into the means of egress beyond their allowable limits
  • Lack of non-slip egress to a public way


  • Non-compliant tamper alarms on sprinkler systems
  • Poor maintenance of sprinkler heads
  • Poor documentation of maintenance of facility sprinkler systems

Fire and Smoke Barriers

  • Inadequate construction
  • Improperly sealed penetrations
  • Smoke doors that do not seal properly

Hazardous Areas

  • Lack of self-closing doors in hazardous areas
  • Hazardous areas without sprinkler systems
  • Hazardous areas without proper fire-rated construction
  • Lack of proper separation for hazardous areas


  • Hold-open devices on doors not properly tested in conjunction with smoke detectors
  • Doors without positive latching or that have roller latches, which are prohibited
  • Inspections that were done improperly or not at all
  • Doors incorrectly rated for their position in a fire and smoke barrier
  • Lack of proper signage on doors with a delayed-egress lock


  • Fire alarm systems not properly tested and maintained
  • Missing documentation of fire alarm testing
  • Failure to test hold-open devices on doors
  • Problems with transfer switches and life safety panels

Fire Alarms

  • Employees that did not know the location of the facility's manual fire alarm pull stations
  • Facilities that ignored potential issues with a fire alarm system when they were identified
  • Irregularities in the testing and maintenance of fire alarms


  • HVAC systems that failed to shut down when smoke detectors were activated
  • Systems not installed or maintained as required by the manufacturer's recommendations

Fire Extinguishers (these were the least prevalent of the violations found)

Koorsen Can Help You Avoid CMS Violations

The deficiencies cited in the CMS report highlight problems covered by many different regulations contained in several NFPA Codes that together, make compliance difficult to achieve at best. Koorsen is one of the few fire and security companies in the United States that can provide total protection from one source for healthcare facilities of all types.

Koorsen Fire & Security has the deep expertise you need to help navigate the myriad of requirements health care facilities must meet and can provide all the proper documentation you need to ensure your facility stays compliant with the CMS regulations. Contact Koorsen today to become better prepared for your next audit.

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Topics: Healthcare Industry

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Disclaimer: The information in this article is for informational purposes only. It is believed to be reliable, but Koorsen Fire & Security assumes no responsibility or liability for any errors or omissions in the content of this article. It does not constitute professional advice. The user of this article or the product(s) is responsible for verifying the information's accuracy from all available sources, including the product manufacturer. The authority having jurisdiction should be contacted for code interpretations.