10 common deficiencies in aging healthcare facilities

VOA's Douglas King pinpoints the top issues that arise during healthcare facilities assessments, including missing fire/smoke dampers, out-of-place fire alarms, and poorly constructed doorways. 

September 29, 2014 |
Stantec Blog

Image courtesy VOA

Many aging healthcare facilities are between a rock and hard place these days. With increasing demand for and regulation of healthcare on the horizon, more and more facilities don’t conform to all of the standards. The importance of these standards, such as the NFPA 101: Life Safety Code, can’t be denied; they’re meant to protect the sick and vulnerable, our loved-ones included, during their hospital stays.

Many older hospitals in the United States, some originally constructed with funding from the 1946 Hill-Burton Act, now face uphill challenges in terms of regulatory compliance. The last major wave of hospital construction occurred in the '80s. New hospital construction stalled during the recession, but the demand for healthcare is now surging.

Despite this, slim profit margins continue to make it difficult to justify funding a newly built facility. Healthcare facilities administrators are often challenged to choose between allocating resources to upgrade life safety systems or to complete facility upgrades that will enhance the financial viability of the institution.

Regulators and inspectors are keen to ensure that facilities do not overlook essential life/safety upgrades when renovating. The federal government earmarks hospitals contemplating major expansion projects for survey by the CMS (Center for Medicare and Medicaid Services). A team of CMS surveyors spend a week or more on site looking for deficiencies and producing a mandate for repair of existing deficiencies and violations (known as “K-tags”). Then, the client must address these K-tags in addition to managing the hospital’s planned renovation.

This needn’t be a surprise. Institutions planning a major healthcare renovation should prepare for a whole scale review and update of the facility. Before it signs off on these capital decisions, the institution needs an accurate assessment of its exposure for potential repairs to code violations, often including legacy deficiencies dating back to the original construction. A facilities assessment is essential to getting the full picture of the situation.



Getting a jump on things is best. A proactive assessment during master planning allows the institution to address deficiencies at its own pace, within a comprehensive strategy for renovation or replacement of buildings. Often, however, these assessments come only after CMS agents have visited. Then, its the regulators who impose the timeline.



Getting bad news isn’t much fun, especially when it’s a surprise.  Time after time, we see these ten deficiencies emerge during healthcare facilities assessments.

1. Fire and fire/smoke dampers  that are missing or incorrectly installed. Above ceiling conditions may render repair work very expensive

2. Lined duct work present within a facility

3. Sealing or penetration in fire, smoke or fire/smoke rated walls

4. Incorrectly built fire, smoke or fire/smoke rated walls

5. Electrical distribution systems with the wrong equipment connected to a particular branch

6. Rated stairwell exits that do not lead directly to the exterior

7. “Hazardous rooms” (per NFPA 101-20o0) that are not correctly fire rated or constructed correctly—commonly, storage rooms

8. Exit pathways that are not correctly signed or consistent with the facility’s life safety drawings

9. Doors located in rated wall construction that are not constructed correctly

10. Fire alarm devices that are not placed correctly



CMS inspections involve intensive assessment, analysis and correction of facilities. We’ve observed that facilities which take a proactive approach, developing and maintaining an ongoing plan of correction, usually have far fewer issues to resolve than those who decide to gamble and “wait and see” if they become subject to inspection.

There are two ways to take care of the deficiencies. One is to simply go in and physically make the repairs. But that can be costly, especially when a renovation is underway. The second is to achieve an equivalency using a FSES (a fire safety equivalency system) process.

The FSES equivalency algorithm mathematically confirms that a facility is safe in its current state, even if portions are not built to code. The presence of sprinklers and fire alarms, for example, can offset walls that are not rated to code. The federal government allows the FSES approach within certain boundaries, but it cannot cover all conditions. It’s not a cure-all, but it can give owners time to execute more targeted corrections.

We suggest performing assessments, preparing a plan of correction as well as developing what we call a “master life safety plan”–floor plans that capture the portions of the building that conform to code: fire-rated walls, sprinkler-equipped areas, etc.

There’s no magic trick involved here. By proactively applying a methodical approach for correcting deficiencies in the built environment, these aging institutions can better navigate daunting situations while continuing to deliver healthcare services to their communities in the process.

About the Author

Douglas J. King, AIA, NCARB, CSI, ACHA, is a Principal with VOA. He is an instrumental leader in VOA’s Healthcare practice, with a particular emphasis on VOA Federal Healthcare. As a code and regulatory expert, King has served on several committees for the Illinois Department of Public Health, and is part of the AIA sub-committee for preparing national standards. Doug also supports the education and mentorship of young architects, serving on advisory committees for two architecture schools that offer Masters concentrations in Healthcare Design. More posts by King.


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