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What You Need to Know to Ensure Life Safety and

Emergency Preparedness Compliance

Kenneth Daily, LNHA,

President, Elder Care

Systems Group

Robbie Say, Safety & Health

Consultant , Ohio

Department of Heath

Facility Maintenance

• Maintaining a facility (or more than one) is not easy... But often you will be appreciated and thanked by all.

• Today maintenance is as much more than fixing ‘everything’ to inspection, testing and maintenance (ITM) of features and aspects of fire protection and safety

• ITM demands a lot of time and attention

• Remember - CMS requirements are for reimbursement but the NFPA requirements are for the health and safety of healthcare population

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CMS

Disaster

Rule

Life

Safety

Code

2012

Healthcare

Code

2012

NFPACodes adopted effective July 5, 2016

101 Chapter 19 – Existing

101 Chapter 18 -New Facilities

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Compliance?

• Know the requirements such as NFPA 101, 99, etc.

• Know your Building & Equipment

• Be aware of the work your vendors are contracted to perform (and due dates for required inspections)

• Know your Staff Training is Complete (Orientation &

• In-Service)

• Educate the “why” to staff, family members and residents

• Maintain documentation and records

Ohio Deficiency Trend

Year Citations

per Facility

Change

2016 4.7 +6%

2017 4.0 -15%

2018 4.9 +23%

2019 5.5 +10%

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Top 15 States - LSC DeficienciesRank State Ave Deficiency # Surveys Region

1 Montana 10.8 52 VIII

2 Nevada 9.0 59 IX

3 Kansas 8.7 283 VII

4 Illinois 8.1 581 V

5 Virginia 6.7 123 III

6 Indiana 6.5 380 V

7 Pennsylvania 6.3 511 III

8 Nebraska 5.9 116 VII

9 Iowa 5.7 275 VII

10 Ohio 5.5 660 V

11 Washington 5.3 157 X

12 California 5.3 859 IX

13 Missouri 5.1 350 VII

14 Colorado 5.0 165 VIII

15 Michigan 4.8 344 V

Ohio Leading Deficiencies

K Tag Deficiency

K0353 Sprinkler System - Maintenance and Testing

K0920 Electrical Equipment - Power Cords and Extends

K0222 Egress Doors

K0345 Fire Alarm System - Testing and Maintenance

K0712 Fire Drills

K0761 Maintenance, Inspection and Testing - Doors

K0914 Electrical Systems - Maintenance and Testing

K0321 Hazardous Areas - Enclosure

K0363 Corridor - Doors

K0372 Subdivision of Building Spaces - Smoke Barrie

K0918 Electrical Systems - Essential Electric System

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Deficiencies That are Trending

• Fire protection represent 35% of deficiencies

• Doors are now the leading deficiency - K211, K222, K263 and K761 - 15% of deficiencies cited

• NFPA 99 Health Care Facilities Code is now account for 23% of deficiencies

• K 913 (K 511) - GFCI

• K915 Generator Branches

• K521 HVAC

Survey Preparation

• LSC Note book – everything in one place

• Current survey cycle only• Archive older records• Review past surveys and ensure that

prior deficiencies are corrected• Evacuation plans – correct, posted and

staff familiar• Audit vendor record keeping• Remind them that we must follow 2012

code • Complete any recommended repairs or

updates • Ladders available surveyor use?• Flashlights ready surveyors use?

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Facility Layout

• The location of all rated walls and barriers in all zones. Indicate the fire rating and purpose of each barrier;

• Identify the location of all hazardous rooms;

• Identify the level of exit discharge for each building;

• Identify the location of all smoke compartment barriers;

• List the furthest travel distance to the closest smoke compartment barrier door for each smoke compartment;

• Pull stations

• Fire Extinguishers

Survey Documentation

• Facility Layout

• ODH Self Inspection Form

• Occupancy Permit

• State Fire Marshal Report

• NFPA 99 Risk Assessment (K901)

• Policies - Fire Watch, smoking, space heater, Fire Safety (K346, K354, K781, K741, K711)

• In-services (K923, K712) - O2 safety, fire/disaster, State Fire Marshal

• Fire Drills (K712)• Monthly (one/month, per shift, per

quarter)

• Fire Door Inspection (K761)

• Annual

• Exit signs (K291)

• Monthly

• Certificates for boilers and elevators

• Medical gas end user certificate

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Survey Documentation

• Fire Pump (K345)• Weekly, Monthly, Annual

• Generator (K918)• Weekly• Monthly • Load Bank (if necessary) • 36-month load exercise • Diesel fuel testing

• Annual• Back up fuel source (letter)

• Emergency Battery Lighting (K291)

• Monthly 30 sec. test

• Annual 90 min. test

• Hood Suppression (K324)• Monthly inspection• Semi-annual ITM

• Non-hospital grade receptacles (K914)

• Annual

• Fire Hydrant (K353)

• Annual

• HVAC (K511, K521)

• Manufacturer recommendations

Survey Documentation

• Sprinkler System (K353)• Pressure gauges readings

recorded weekly/dry• Pressure gauges readings

monthly/wet• Quarterly inspection• Annual inspection • Annual head inspection • 3yr. Pressure test (dry)• 5yr. internal inspection• Back-flow annual testing• Anti-freeze

• Fire Alarm (K345)• Monthly

• Fire Alarm Inspection (K345)• Semi-annual and annual

inspection/ testing• Batteries every 4 yrs.

• Smoke detectors (K345)• At 1 year and every 2 years

thereafter

• Fire/Smoke Dampers (K521)• Test and lube every 4yrs.

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Inspection, Testing and Maintenance (ITM) and Record Keeping

• A majority of the citations of the TOP 10 deficiencies are a result of inspection, testing or maintenance issues, with many involving just record keeping

• If deficient issues are discovered by Contractor’s testing or inspection report, you must fix it immediately

• A minimum of 2 staff members must know where all ITM records are located and have access

NFPA 25, 2011 Edition Standard for the Inspection, Testing, and Maintenance of Water-based Fire Protection Systems

LSC 9.7.5 Maintenance and Testing

• All automatic sprinkler systems and standpipe systems required by this code inspected, tested, and maintained in accordance with NFPA 25

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Sprinkler System K351

• Sprinklers must be installed throughout a facility in accordance with NFPA 13

• Complete sprinkler system required for all new construction and existing facilities

• Complete sprinkler system required for all nursing homes, regardless of construction type by Aug. 13, 2013

• S&C Memo 09-04

• Waivers and FSESs for lack of sprinklers in certain areas will are not permitted

Sprinklers Required

• Common areas that require sprinkler coverage• Closets

• No size requirements to qualify a space as a closet

• Combustible overhangs that extend more than 48” including gutter from building

• Room behind dryers

• Elevator machine rooms

• Elevator shaft (top and bottom

• Electrical rooms• Walk-in coolers/freezers

• Linen/Trash Chutes

• Attics

• Car ports

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NFPA 72, 2010 Edition - National Fire Alarm and Signaling Code

• • LSC 9.6.1.5

• • To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code

VisualInspection

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Visual Inspection

• Start at control panel

• Check for the obvious

• All equipment is in proper place, and properly mounted and oriented

• All notification appliances must be operated annually and proper operation must be verified

• Periodically verify system is “normal” and not in ‘trouble’, ’fault’, ‘supervisory’

• No obvious wire breaks, corrosion, or other damage to connections

• All documented (each device)

Testing

• NFPA 72 Section 14.4

• Before beginning testing, notify:• Building occupants–

place signs on exit doors, send emails, signs in lobby, bulletin boards

• Fire department• Monitoring company

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Testing

• Smoke detectors • Tested in place to ensure smoke entry into the sensing

• chamber and an alarm response

• Use smoke or listed and labeled product acceptable to the manufacturer or in accordance with published instructions

• Magnet testing NOT acceptable

• Smoke detector functionality test • Conducted annually (minimum)

• Aerosol smoke acceptable

• This is NOT a sensitivity test

• Visual notification appliances • Test performed in accordance with manufacturer’s instructions

Smoke Detectors• Smoke detector functional testing

and servicing done with annual fire alarm system service.

• Smoke detector sensitivity testing must be done within the first year after installation and every alternate year thereafter

• Duct smoke detectors tested

• Same number of detectors not tested

• Detectors not replaced/recalibrated

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Sensitivity Test Report

CMS Survey and Certification MemoJuly 28, 2017

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Life Safety CodeNFPA 101 (2012 edition)

Codes effective July 5, 2016

NFPA 101 Life Safety Code

NFPA 80 Fire Doors

Fire Drills K712• Simulation of emergency fire conditions.

• Fire drills include a fire alarm signal • Conducted monthly per shift for 4 drills on each shift

per year.• One drill per shift per quarter.• Different locations in the facility• Differing time of drills on each shift• Differing days of the week including weekends.• All departments are involved.• Documented observations of staff response.• Equipment functioning, doors released, alarms

sounding, staff monitor exits, etc. • Residents are not evacuated during the drill.• Transmission to fire station

• Where drills are conducted between 9:00 PM and 6:00

AM, a coded announcement may be used instead of

audible alarms.

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Fire Safety Plan K 711

• Use of alarms

• Pull stations

• Smoke detection

• Transmission of signal

• Alarm connected

• Response to alarm

• Defend in Place

• RACE

• Responsibilities of staff

• Isolation of fire

• Compartmentalization

• Close doors and windows

• Use of sprinklers

• Extinguishment of fire

• Sprinklers

• Fire extinguishers (PASS)

• Evacuation of area

• Immediate removal direct

threat (R)

• Evacuation of compartment

• Recuse through horizontal exit

• Move to area of refuse• Evacuation floor/ building• Horizontal/vertical• Transportation

• Individual responsible to call

emergency services (911)

Smoking Requirements K 741 • Smoking shall be prohibited in any room or compartment where

flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking

• In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required

• Smoking by patients classified as not responsible shall be prohibited

• The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision.

• Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. (6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. 18.7.4, 19.7.4

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Common Smoking Citations

• Smoking by residents on O2 (actually there have been 2 IJs in past year)

• Use of unacceptable ashtrays such as coffee cans, pop cans, various cups, the ground, etc.

• Smoking in unauthorized areas

• Individuals assessed as unsafe not being supervised

• Ashtrays emptied into trashcans or trash in the ashcan

NFPA 99 Health Care Facilities Code

• Standard becomes a Code

• The code is intended for professionals involved in the design, construction, maintenance, and inspection of health care facilities, in addition to the design, manufacture, and testing of appliances and equipment used in patient care rooms of the health care facilities

• Unique because the code is based on Risk Assessment as determined by the facility

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Chapter 6 Electrical Systems

• Requirements for existing facilities specifically referenced in chapter

• Addresses hazards related to electrical power distribution systems

• Covers performance, maintenance and testing

• Receptacle testing

• Circuit Breaker testing

• Generator

K 915 Life Support/ Branches

• Facilities with residents requiring life support must have a generator and is considered a Type I Essential Electrical System (EES)

• The EES must be broken into braches to allow for

• Life Safety Branch: Egress lighting, exit signs, alarm systems, communications systems, task lighting at the genset, elevators, automatically operated doors

• Critical Branch: Critical care areas, patient care areas, nurse call, telephone equipment, medical task lighting

• Equipment Branch: Suction systems, sump pumps, compressed air systems, kitchen range hood, HVAC, etc.

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Generator - NFPA 110 (2010) Standard for Emergency Power and Standby Systems

• 8.1.1 Routine maintenance and operational testing program based on the following:

• Manufacturer’s recommendations

• Instruction manuals

• Minimum requirements of this chapter

• Authority having jurisdiction

CMS Actions

• On September 2016 CMS released FINAL disaster rule, Emergency Preparedness Standards for Medicare and Medicaid Participating Providers and Suppliers

• Develop comprehensive disaster management program: Mitigation, Preparedness, Response and Recovery

CMS EMERGENCY

RULE

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What Are we Preparing For?

• Possible hazards for Long Term Care facilities

• Natural hazards• Manmade/technological

hazards

• Fire

• Power failure

• Severe weather

• Computer network crash

• Leaking roof

• Missing resident

• Community incident

Key Issues Facing LTC’s

• Plans fails to address four core areas

• Outdated plans with no annual review protocol

• Failure to complete the required trainings and exercises

• Facilities do not adequately address the availability of emergency

supplies or emergency power in their emergency plans.

• Low awareness level of communications and incident command

• Little involvement with local emergency management resources

• Lack details for “Shelter in Place”

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Appendix Z

• Because the individual regulations for each specific provider and supplier share a majority of standard provisions, we have developed this Appendix Z to provide consistent interpretive guidance and survey procedures located in a single document

• There are 43 surveyor guidelines of which 26 apply to SNFs and 25 ICF/IID.

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E Tags (Leading Tags in Red)

• E-0001 Establishment of the Emergency Program (EP)

• E- 0004 Develop and Maintain EP Program

• E -0006 Plan Based on All Hazards Risk Assessment

• E-0007 EP Program Patient Population

• E- 0009 Process for EP Collaboration

• E -0013 Development of EP Policies and Procedures

• E-0015 Subsistence needs for staff and patients

• E- 0018 Procedures for Tracking of Staff and Patients

• E- 0022 Policies and Procedures for Sheltering

• E -0024 Policies and Procedures for Volunteers

• E- 0025 Arrangement with other Facilities

• E -0026 Roles under a Waiver Declared by Secretary

E - Tags (Leading Tags in Red)

• E- 0029 Development of Communication Plan

• E- 0030 Names and Contact Information

• E -0031 Emergency Officials Contact Information

• E- 0032 Primary/ Alternate Means for Communication

• E- 0033 Methods for Sharing Information

• E- 0034 Sharing Information on Occupancy/ Needs

• E- 0035 LTC and ICF/IID Notifications

• E- 0036 Emergency Prep Training and Testing

• E- 0037Emergency Prep Training Program

• E- 0039Emergency Prep. Testing Requirements

• E- 0041 LTC Emergency Power

• E- 0042Integrated Health Systems

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Kenneth Daily, LNHALife Safety and Emergency Preparedness Specialist

kenn@qissurvey.com

• Survey compliance

• Facility management

• Disaster preparedness planning

• Mock surveys and audits

• FSES

• Policy and procedure development

• Professional development and training

Bureau of Survey & Certification

Supervisor:

Rick Hoover

(614) 752-6855

Ricky.Hoover@odh.ohio.gov

Safety & Health Consultant:

Robbie Say

Robbie.say@odh.ohio.gov