In the world of healthcare facilities management, few topics carry as much weight as Life Safety compliance and Joint Commission readiness. Across the country, hospitals are preparing for January 1, 2026, the day on which Joint Commission’s Accreditation 360 and the new Physical Environment (PE) structure debut. Yet, despite evolving standards and new guidelines, the same issues appear again and again, no matter the year.
Tom Grice, Vice President of Regulatory & Facilities, Cref, sees these issues first-hand during mock surveys and regulatory readiness assessments. As one of the nation’s most experienced healthcare compliance leaders, Tom identifies the recurring Life Safety deficiencies that challenge hospitals nationwide—and how to fix them.
“We conduct six to eight full mock surveys every month,” Tom says. “In a 750,000-square-foot hospital, we typically find 500 deficiencies—and the patterns are consistent. It’s the same issues, over and over again.”
These patterns form the foundation of Cref’s Top Life Safety Findings list, a guide for hospitals seeking initiative-taking regulatory readiness and sustained Joint Commission compliance.
How the List Was Built
Cref’s list comes from thousands of field hours spent inside hospitals, completing full-scale Life Safety and Environment of Care evaluations. Each deficiency is cross-referenced with Joint Commission’s published Top 10 Life Safety findings, creating a real-world validation loop. The data shows that compliance failures often come from operational habits, not lack of knowledge.
“The biggest risks hospitals face aren’t new or exotic,” says Grice. “They’re the repetitive, operational oversights that slowly erode compliance readiness.”
The Top Life Safety Findings — and How to Solve Them
1. Fire Drills (Especially OR Fire Drills)
Issue: Repetitive drill schedules or missing annual OR drills.
Solution: Conduct unpatterned fire drills each quarter and a dedicated annual OR fire drill with documented critique and attendance. Include anesthesia, nursing, and surgical staff.
2. Blocked Med-Gas Shutoffs and Electrical Panels
Issue: Often, WOWs and storage overflow block emergency access points.
Solution: Reinforce the ‘why’—these areas must remain clear for emergency response. Maintain 8-foot corridor clearance and <4½-inch wall projections. If possible, add alcoves in plans to alleviate risk.
3. Cluttered Corridors and Equipment Storage
Issue: Space limitations lead to hallways being used as storage zones.
Solution: Design decentralized nurse hubs and micro-storage areas. Incorporate corridor management into leadership rounding.
4. Air Pressure, Temperature, and Humidity Out of Range
Issue: Aging infrastructure or insufficient monitoring leads to control issues.
Solution: Use real-time digital monitoring and document corrective actions. Balance clinical preferences with humidity requirements.
5. Damaged or Stained Ceiling Tiles
Issue: Damaged tiles can compromise smoke barriers and infection control.
Solution: Treat as an infection risk. Replace tiles immediately, inspect above ceilings, and repair penetrations.
6. Improper Pressure Relationships in Soiled Rooms
Issue: Positive pressure in soiled spaces leads to contamination.
Solution: Verify negative airflow and test with manometers. Maintain filters and document daily readings.
7. Kitchen Safety: Untethered Gas Equipment and Unsanitary Tools
Issue: Lack of awareness of safety standards and cleaning requirements.
Solution: Secure gas lines and clean can openers daily. Provide EVS and dietary staff training on Life Safety compliance and fire suppression requirements.
8. Improper Medical Gas Storage
Issue: Co-mingled cylinders or overstocking.
Solution: Separate oxidizing and flammable gases; limit storage to ≤12 E-cylinders per compartment. Provide ventilation and signage per NFPA 99.
9. Missing ICRA or ILSM for Maintenance Work
Issue: Too frequently, ICRA/ILSM’s are applied only to construction projects.
Solution: Apply infection control risk assessments to all dust-generating work. Train maintenance and contractors on compliance documentation and educate them on the “why” behind these activities.
10. Weak Cross-Department Collaboration
Issue: Facilities, infection control, and clinical teams (as an example, other departments can and often are part of the “silo network”) can work in silos.
Solution: Hardwire collaboration into processes the hospital utilizes via Safety Committees, joint rounding, staff education, morning huddles, etc. Explain the “why” behind compliance.
Root Causes: Why Findings Keep Repeating
Tom and the Cref team have identified three consistent drivers behind recurring Life Safety issues:
- Convenience over compliance: Staff make quick decisions that sacrifice safety.
- Communication breakdowns: Clinical and facilities teams can make assumptions that the other department has it covered, when in fact neither does.
- Loss of institutional knowledge: Retirements and turnover create training gaps.
“Hospitals have incredible people,” Tom says, “but systems often work against them. We need to make the right thing the easy thing.”
Solving for Life Safety: From Reaction to Prevention
Tom Grice and Cref advocate for a constant state of readiness, not a pre-survey scramble. Their three-step model:
- Educate and Explain the ‘Why:’ Incorporate brief refreshers during huddles and onboarding.
- Redesign and Re-engineer: Fix processes that make compliance difficult.
- Sustain Readiness: Conduct regularly scheduled internal mock surveys aligned with Accreditation 360’s PE chapter.
This proactive approach transforms compliance into a living, daily habit across the organization. “You can’t prepare for survey once every three years,” Tom adds. “You have to live in a constant state of readiness.”
Watch the Full Discussion with Tom Grice on the Healthcare Facilities Network: Accreditation 360 and Top Life Safety Findings Explained
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