We just ran a mock CMS survey — here’s what I wish we’d caught sooner
We brought in a third-party CMS/TJC mock survey team last month — 2.5 days, three consultants, they opened every door we didn't want them to open. I thought we were in decent shape. The report was humbling.
Here's what I wish we'd caught sooner.
The ones that surprised me
Door gaps. Five fire-rated door assemblies had measurable gaps at the top or sides exceeding the NFPA 80 ⅛-inch limit. Nobody measures those during routine walkthroughs — we just eyeball them. The surveyor had a gauge set.
Penetration seals that "looked fine." Three IT-closet penetrations where someone had pulled new cable through after the original firestop job. The cable was there. The re-seal... wasn't. I had zero documentation of who pulled that cable or when. This is exactly what the firestopping article warns about — if you can't prove the penetration was resealed, you assume it wasn't.
Spare sprinkler cabinet inventory list. We had the cabinet, we had the spare heads. We did NOT have the written inventory list per NFPA 13 §16.2.7. K-Tag K-0291 finding on the dot.
Generator monthly load test documentation. Our logs showed 30-minute runtimes. What they did NOT show was voltage, frequency, or fuel consumption during those runs — all required by NFPA 110. Deficiency.
Annunciator not exercised quarterly. We tested FACP monthly like clockwork. The remote annunciator in Security? "Whenever we think about it." Not per K-0353.
The ones we already "knew"
The consultant flagged seven items we were already tracking on our internal list. Good news: we're not blind. Bad news: we'd been tracking them for four months without fixing any of them. *Aware* isn't *remediated*.
What's different about how I prep now
- I walk the building with an NFPA 80 gauge set twice a year now. Physical tools, not just eyes.
- Anyone pulling cable through rated assemblies signs a log. No signed log = we assume unsealed until proven otherwise.
- Monthly condition-of-maintenance check of the spare sprinkler cabinet. Written list, dated, initials.
- Generator logs now include a printed load-test sheet with voltage / frequency / fuel. Five extra minutes per month. Would have saved us the finding.
- Annunciator exercise is a quarterly calendar recurrence with the security supervisor, not "someday."
The mock cost $8,200 and was worth every dollar. If you're in a CMS-surveyed facility and haven't done one in two or more years, find a consulting group and book it. Better to eat the critique from a consultant than from a surveyor.