Have you received a deficiency because of a vendor-related issue?


Does this sound familiar?

A conversation between a surveyor and the Administrator/Director of Facilities.

Surveyor: Here is the list of my concerns

Admin./DOF: But our vendor did this last month, here is the invoice.

Surveyor: I see but they didn’t…… (fill in the blank )

Admin./DOF: “They’re killing’ me”, we paid them a lot of money.

During my years as an AHCA surveyor and continuing as a consultant, the most frustrating deficiencies that I would write would be due to vendor-related issues.  As irritating as it was to me, I know that it was exponentially more so for the Administrators and Facilities Directors.  Vendor related issues probably accounted for 30%-50% of the deficiencies.

The frustrations were due to different sources.  First, facilities pay and trust for a professional, knowledgeable, and complete service.  Secondly, there was a part of me that would lament the fact that it was the Administrator or Director of Facilities who were being punished for work that was entrusted to a vendor.  The other side of that coin is that those responsible should ensure contracted work is performed correctly.  This is true.  At the same time, someone can’t be an expert in everything, much less keep up with code changes which you don’t find out until the surveyor tells you and gives you your citation.  Amazingly the contractors themselves can’t or don’t keep up with code changes until they are called out to correct a deficiency that was written.

Here is a very short list of common issues:

  • Incomplete or incorrect documentation of inspection/testing/maintenance
  • Items/devices missed form inspection inspection/testing/maintenance
  • Vendor canceled or rescheduled out of dates of compliance
  • IT/Electrician vendor ran wiring and made swiss cheese out of your fire/smoke barriers
  • Penetrations in fire/smoke barriers after your annual inspection were completed
  • Deficiencies were noted on the report but not communicated to Administrator/ Director of Facilities
  • Vendor installed alcohol hand rub above outlets
  • Improper cylinder storage by Med gas supplier
  • Vendor painted over fire/smoke door labels, sprinkler heads or did not replace wall signage after painting
  • Vendors not maintaining ICRA barriers

Now, how can you limit some of these issues?  One of the most effective ways is to have a plan and procedure for work done in your facility.  Here is a common example:

  • Have a written explanation of the work to be performed. Signed by all parties involved.
  • Pre facility walk-thru with the vendor through the areas of concern.
  • Discuss your expectations and their acknowledgment of the responsibilities of work to be performed (which should be in the written explanation of #1) . Include protection of fire/smoke barriers, sprinkler heads, smoke detectors/devices, ICRA barriers etc.
  • Periodically check the ICRA barrier for compliance (if required)
  • Post facility walk-thru. Is the work complete to satisfaction as stated?  Were penetrations sealed?  Do parts need to be ordered?
  • Face to face discussion before they leave the facility of any deficiencies, concerns, or other issues.
  • Review the report

My favorite policy is from a hospital.  In their contract which spells out every step and must be signed off includes a penalty for not complying.  For instance, if a contractor leaves an unsealed penetration in a rated barrier it is 10% off the invoice.  If the contractor does it again on another job….30% off.  After the third time, they are not allowed back in the facility for 3 years.

Granted, they have vendors knocking down the door for business in a large hospital, but the concept behind it is what I appreciate.  What can your facility put in place to hold those responsible…responsible?

If you would like to discuss further please feel free to contact me.