As a new year begins, healthcare facilities across the country continue preparing for the seemingly constant regulatory inspections by CMS, The Joint Commission, DNV, state health departments, and others. While many organizations focus on proper documentation, improving policies, and staff training, one critical area is frequently overlooked for various reasons. That critical component of every facility’s life safety infrastructure is firestopping.
Unfortunately, firestopping deficiencies continue to be among the most cited deficiencies year after year. Understanding why these issues occur and how to address them can help facilities begin the year in a better-prepared, survey-ready position.
Why Firestopping Matters in Healthcare Inspections
Firestopping plays a vital role in maintaining fire-and smoke-rated assemblies which protect patients who are frequently unable to self-evacuate. In hospitals, long-term care facilities, and outpatient centers, smoke migration often poses a greater threat than actual flames do.
Inspectors don’t only look for visible damage; they assess whether fire and smoke barriers can perform as designed during an emergency. Even one small, unsealed penetration can compromise an entire compartment, increasing risk to patients, staff, and visitors.
Common Firestopping Deficiencies Cited by Inspectors
- Unsealed or Improperly Sealed Penetrations
One of the most frequent findings involves open or incorrectly sealed penetrations in fire- or smoke-rated walls and floors. These often occur around:
- Electrical conduct and cabling
- Medical gas lines
- Plumbing and mechanical systems
In many cases, penetrations are sealed with non-rated materials such as foam, caulk, or putty that do not meet fire-resistance requirements.
- Missing or Incomplete Firestopping Systems
Inspectors commonly find firestopping that:
- Does not match the tested system design
- Lacks required components
- Has been partially removed during renovations or repairs
Without a tested and listed system in place, the integrity of the rated barrier is compromised, even if materials appear “filled.” Filling penetrations with non-rated materials do very little to prevent the passage of smoke and fire.
- Firestopping Damage from Renovations and Upgrades
Healthcare facilities are constantly evolving. IT upgrades, equipment replacements, and department renovations frequently disturb fire-rated assemblies. When penetrations are added or modified without proper restoration, firestopping gaps accumulate over time.
These changes occur nearly every day in most hospitals across the country. The deficiencies are often hidden above ceilings or behind walls, making them easy to miss until an inspection occurs.
- Inaccessible or Concealed Deficiencies
Above-ceiling spaces are a common problem area. Inspectors routinely identify:
- Unprotected cable bundles
- Sleeves without firestopping
- Open joints or abandoned penetrations
Because these areas are out of sight, deficiencies may go unaddressed for years.
- Lack of Documentation and Labeling
Even when firestopping is installed correctly, facilities may be cited if they cannot demonstrate:
- What system was used
- Whether it is tested and approved
- When and where it was installed
Missing labels, system details, or inspection records can lead to compliance concerns during surveys.
Why These Deficiencies Continue Showing Up Every Year
Ongoing Facility Changes
Healthcare facilities, most notably inpatient hospitals, are among the most frequently modified structures. Each new cable, pipe, or device introduces an opportunity for a fire barrier breach, often without life safety leaders being notified.
Firestopping Is Often Treated as a Construction Detail
Firestopping is sometimes viewed as a finishing task rather than a life safety system. When it isn’t prioritized, it becomes inconsistent, undocumented, or improperly installed.
Limited Staff Awareness
Many people who work above ceilings such as IT, low-voltage contractors, and maintenance technicians, may not fully understand the importance of restoring fire-rated assemblies after their work is complete. Ongoing training is paramount in the overall compliance of a facility.
Reactive Instead of Proactive Approaches
Facilities often address firestopping only after a deficiency is cited during an official survey. Without routine inspections, problems compound and become more widespread. The primary function of a CMMS system is to prevent problems from occurring – hence, a ‘Preventive Maintenance Work-Order' or ‘PM’ is created. Waiting until a problem forms prior to correcting it, known as a ‘Corrective Work-Order', is a secondary function. If a facility leader’s approach is to wait until a deficiency is cited before correcting it, they probably shouldn’t be in the position they are in. Every facilities leader’s number one priority should be the preservation of human life, or Life Safety. Anyone who says otherwise doesn’t fully understand their role.
Starting the Year Survey-Ready
The beginning of a new year is an ideal time to shift from a reactive mindset to a proactive life safety strategy. Addressing firestopping early and often can:
- Reduce the risk of non-compliant outcomes during inspections
- Improve patient, staff, and first responder safety
- Support long-term compliance goals
By understanding common deficiencies and why they persist, healthcare facilities can take meaningful steps toward being inspection-ready year-round and not being surprised by deficiencies when surveyors arrive.
Begin the Year with Confidence
Firestopping deficiencies don’t have to be a recurring inspection finding. A proactive assessment strategy will identify gaps early, help prioritize repairs, and ensure your facility is prepared long before surveyors arrive.
National Firestopping Solutions offers healthcare facilities complimentary firestopping surveys to help assess existing conditions, identify compliance risks, and support your life safety goals.
Whether you’re preparing for an upcoming Joint Commission survey or simply want to begin the new year with greater confidence, our experienced team is here to help.
Contact us today to schedule your free firestopping survey and take the first step toward year-round survey readiness.