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Allegan General Hospital

Case Study: Allegan General Hospital

About Allegan General Hospital

Allegan General Hospital is a 25-bed, not-for-profit, acute care facility located in Allegan, Michigan. Built in the 1930s, the hospital is rich with history and has served thousands of patients in the last eight decades.

Allegan General Hospital

The Problem

In August of 2019, the Centers for Medicare & Medicaid Services (CMS) found Life Safety deficiencies within Allegan General Hospital that required immediate action. Compliance One was contacted by Allegan General Hospital’s director of facilities to manage the response to CMS, as well as the repair and reinspection process. Within days, the hospital and Compliance One submitted a Plan of Correction (POC), budget, and project timeline to CMS.

The Solution

Using a holistic approach, Compliance One identified 14 rated doors that were not in a rated fire barrier. Compliance One then sought and received approval from the Michigan Bureau of Fire Services (BFS) to remove the fire rating tag from those 14 doors, which removed some of the stringent and expensive requirements of those fire doors. 


To properly complete the repairs and door replacements, Compliance One partnered with IDN, a security hardware and door distributor, who employs specialized craftsmen needed for a project of this scope. Over the following months, IDN completed hundreds of small repairs - such as filling and adjusting gaps - and replaced complete doors and frames. 


By December 30, 2019, the project was complete and a new NFPA 80 Fire Door Inspection was completed, locating zero deficiencies.