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Prevention · Fire & Life Safety Inspections
Fire Inspection Process for Hospitals:
The Office of the State Fire Marshal (OSFM) does joint inspections with the Department of Health (DOH) using the 2000 edition of NFPA 101, Life Safety Code and The Center for Medicare/Medicaid Services (CMS) interpretations and standards.
Frequently Asked Questions (FAQs):
Q. How will I know when a fire inspection is due?
A. Fire inspections are unannounced and done in conjunction with the DOH relicensing surveys
Q. What happens after the inspection?
A. The DSFM will email the DOH survey team leader a report detailing the findings. If there are no deficiencies the DOH team leader will attach the OSFM report to the health report and mail both to the hospital within 10 working days of the exit date. The hospital is then considered compliant for licensing with the LSC.
Q. What happens if the DSFM finds violations?
A. If there are deficiencies found the hospital will complete a plan of correction (POC) on the form 2567 for the DOH health report AND must put a correction date that the they expect to have the deficiencies corrected (must be within 90 days). The hospital representative confirming the LSC deficiency correction date will also provide his/her printed name, contact information, and signature. This is sent to the DOH team leader.
Q. How will the DSFM know the corrections have been made?
A. The DSFM will contact the hospital representative on or shortly after the correction date provided to schedule a re-inspection.
Q. How will DOH know the hospital is compliant?
A. The DSFM will send a report to the DOH team leader stating that the facility is compliant and “approved”.
Q. What if corrections have
not been made?
A. If the DSFM cannot confirm that all corrections have been made after the re-inspection, another report will be sent to DOH stating the facility is “disapproved”. Actions taken after DOH receives a “disapproved” report will be addressed accordingly between DOH and the SFMO.
Q. What if I disagree with a citation that the DSFM wrote up?
A. You can initiate an Administrative Appeal per WAC
212-12-030.
Q. What code does the Fire
Marshal use for inspections?
A. The SFMO uses the 2000 Life Safety Code. See Center for Medicaid/Medicare Services link below.
For additional information please contact:
Chief Deputy State Fire Marshal Brandon LeMay
Email: Brandon.Lemay@wsp.wa.gov
Telephone:
(360) 596-3906
Mailing Address:
210 11th Avenue Southwest
Olympia, WA 98504-2600
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