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WHCA / WiCAL 2017 DHS DQA 1 Life Safety Code Update April 7, 2017 WHCA / WiCAL 55 th Annual Conference David Soens, PE, RA Life Safety Fire Authority Add C 2 Overview • Introduction • Federal updates • LSC data – Top 10 • Systems approach • Correction 3 Resources Internet: DQA construction 4 Priorities #1 Federal surveyor Centers for Medicare & Medicaid Services #2 State plan reviewer Verification #3 State inspector Validation 5 QUALITY vs RISK Direct relationship Role of the Facility 6 Motivation Regulations exist to avoid negative outcomes or Regulations exist to ensure the right things happen
Transcript of WHCA / WiCAL 2017
WHCA / WiCAL 2017
DHS DQA
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Life Safety Code Update
April 7, 2017
WHCA / WiCAL 55th Annual Conference
David Soens, PE, RALife Safety Fire Authority
Add C
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Overview
• Introduction
• Federal updates
• LSC data – Top 10
• Systems approach
• Correction
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Resources
Internet: DQA construction4
Priorities
#1 Federal surveyorCenters for Medicare & Medicaid Services
#2 State plan reviewerVerification
#3 State inspectorValidation
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QUALITY vs RISK
Direct relationship
Role of the Facility
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Motivation
Regulations exist to avoid negative outcomes
or
Regulations exist to ensure the right things happen
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Ground Rules
Read code
Understand use
Code in effect remains
Nothing guarantees success
Code is not a design manual
10,000 rule
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Question
Is there one answer for every code question
(a) True
(b) I don’t know
(c) False
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Data
Fatalities / Year Healthcare (fire) 5
Airline Passengers 520
Motor Vehicle 41,800
Hospital Infections 100,000
Lung Cancer 124,000
Heart Disease 125,000
Source: ASHE Training Seminar
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Fire Data
Leading Causes of FireCooking 41%
Clothes dryer 14%
Heating equip. 9%
Smoking 7%
Electrical 6%
Intentional 4%
Trash 2%Source: NFPA Fire Analysis and Research
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Federal Policy
Life safety survey process• Entrance • Building observations• Document review• Exit
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Federal Prep
Accurate life safety plans
• Legible 11 x 17 or larger
• Building & department names
• Year constructed
• Construction type I, II, III …
• Sprinkler status : full, partial, or none
• Occupancy : health, ambulatory, clinic
• Smoke compartment : name & area
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Federal Prep
Organized testing records
• Dated documents
• Who completed the testing
• What did they do
• How where problems corrected
• Scope of the system
• Operational / procedures / equipment
• Historical archives
• Contacts14
Life Safety Plan
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Question
Is the LSC survey process changing …
a) Yes
b) It depends
c) No
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CMS
Active
Operations
Total Concept
Passive
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2012 Edition of NFPA 101
Life Safety Code (LSC)
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LSC Policy
Facility agrees to be certified and follow NFPA 101 ….
LSC rules apply to the resident regardless of their location
customary accessLSC 18.1.3.3
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2012 Life Safety Code
• New Health Care Facilities– Approved after July 5, 2016
LSC chapter 18
• Existing Health Care Facilities– Approved or built prior to July 5, 2016
LSC chapter 19
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Codes vs Standards
NFPA
NFPA
NFPA
NFPANFPA
NFPA
NFPA
NFPA
NFPA
NFPA
NFPANFPA
NFPA
101101
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Updated Standards
• NFPA 13 Sprinkler systems 2010
• NFPA 70 Electrical 2011
• NFPA 72 Fire Alarm 2010
• NFPA 80 Fire Doors 2010
• NFPA 90A Ventilation 2012
• NFPA 96 Cooking 2011
• NFPA 99 Health Care 2012
• NFPA 110 Emergency power 201022
Health Care
Subsection19.1 19.219.319.419.519.719.X
Chapter 19 Organization
DescriptionGeneralEgress
ProtectionSpecialUtilities
OperationsNFPA 99
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Health Care
SubsetK- 100 seriesK- 200 seriesK- 300 seriesK- 400 seriesK- 500 seriesK- 700 seriesK- 900 series
Organization
DescriptionGeneralEgress
ProtectionSpecialUtilities
OperationsNFPA 99
Subsection19.1 19.219.319.419.519.719.X
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LSC Surveyor Form
CMS-2786R 2016 version
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Wisconsin Top 10
1 sprinkler testing K-3532 hazardous areas K-3213 fire drills K-7124 corridor doors K-3635 fire alarm testing K-3456 utilities K-5117 generator testing K-9188 exit access K-2119 fire alarm installation K-34110 sprinkler installation K-351
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Corridor Doors K363
• Gap between leafs• 1/8 inch allowance
• Corridor doors
• Smoke barrier doors
• Hazardous room doors
• Fire wall doors
• Exceed 1/8 inch = “astragal”
• Avoid gaskets
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Corridor Doors K363
• Inactive leafs• Auto flush bolts
• Corridor doors
• Sleeping room
• Therapy room
• Occupied rooms
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Walls
• Common Deficiencies– Holes
– Cracks
– Concrete block removed
– Improper materials
– Reception Window
– None latching doors
– Door clearances
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Wall Lessons
• Lessons Learnedo Life Safety Plan
o Contract requirements
o Proactive maintenance• Suggestion: 1-wing per quarter
– Door latching manual testing
– Above ceiling visual inspection
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Hazard Classification
Hazard of contents shall be classified by the registered design professional
(RDP)
LSC 6.2.1.2
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Hazards
Degree of hazard greater than normal shall provide one of the following(1) Enclose area with 1-hour fire rating,(2) Protect the area with automatic extinguishment, or(3) Apply both (1) and (2) where the hazard is severe
LSC 8.7.1.1
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• Hazardous Areaso Boiler and fuel-fire heater rooms
o Laundries (greater than 100 sq feet)
o Repair, maintenance and paint shops
o Combustible storage (> 50 sq feet)
o Trash collection rooms (> 64 gallon)
o Soiled linen rooms (> 64 gallon)
Hazards K321
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Hazards K321
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• Common Deficiencies– Enclosure penetrations
– Door with no closing device
– Door won’t close and latch
– Combustible storage outside of a hazardous room enclosure
Hazards K321
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Hazard Lessons
• Seal all enclosure penetrations
• Ensure door closing is working
• Ensure door latches into frame
• Inventory combustible storage
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Sprinklers
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Sprinkler Credits
Full building sprinkler credits• Construction type
• Travel distance
• Delayed-egress door locking
• Hazardous room enclosure
• Corridor walls & doors
• Smoke dampers
• Window sizes
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Sprinkler Testing K353
• Weekly / monthly inspections
• Quarterly tests
• Annual tests
• Five year internal inspections
• Twenty year fast response testing
• Fifty year sprinkler test
2011 NFPA 25 Table 5.1.1.2
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Clean Agent Testing
• Semi-annual agent test
• Annual enclosure inspection
• Supervised by fire alarm system
• Existing elevator applications
• Limited coverage
2012 NFPA 2001
LSC 9.7.3
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Sprinklers K353
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• Common Deficiencies– Obstructions
– Missing quarterly tests
– Dirt buildup on sprinkler head
– Spare heads for each sprinkler type
– Lacking supervision by fire alarm system
Sprinklers K353
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Sprinkler Lessons
• Perform all tests – weekly, monthly, quarterly, and annual
• Remove lint or dust from sprinklers
• Replace broken or damaged sprinklers
• Supply sufficient number of spares– two per each type
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Fire Drill K712
Written plan for the protection of all residents and for their evacuation in
the event of an emergency
Drills are held at unexpected times under varying conditions
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(1) Use of alarms
(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire
LSC 19.7.2.2
Fire Drill K712
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Fire Drill Planning
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Fire Drill K712
• Common Deficiencies– Lack of staff participation
– Missing smoke compartment
– Pattern of drills
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Staff Participation Example
Fire Drills
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Fire Drill Lessons
• Maximize staff involvement
• Include smoke compartment
• Distribute drills within shift
• Train new staff promptly
• Staff are your best detectors
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Fire Alarm System Documentation
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Smoke entry test is requiredListed aerosol
2010 NFPA 72Table 14.4.2.2 Item 14 g
Magnets can not fulfill this testThis test is required for all systems
Functional Test K345
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One year after installationTwo year thereafter
Five year if within range
Factory range, measured, pass / fail
2010 NFPA 72 – 14.4.5.3
Sensitivity Test K345
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• Test all interface connectionso Main to remote panelo Kitchen hoodo Delayed egress doorso Elevatorso Fan shut-downo Smoke damperso Door hold-openso Fire pumps
Fire Alarm Testing K345
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Fire Alarm Lessons
• Perform quarterly off-premises transmission and document
• Maintain entire system
• Test all components
• One record in one location
Integrate facility systems
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Functional testing and inspection1 year after installation
4 year cycle thereafterHospitals permitted every 6 years
2010 NFPA 80 – 19.4 2010 NFPA 105 - 6.5
Damper Testing
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Access shall be verified and corrected
Fusible links shall be removed to ensure full closure
Document location, date, inspector name, and deficiencies discovered
Document how deficiencies were corrected
2010 NFPA 80 – 19.4 2010 NFPA 105 - 6.5
Damper Testing
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Damper Fusible Link
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Culture Change
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Culture Change
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Culture Change
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Private Room
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ComparisonInstitutional (facility) Culture Change (resident)
Locked exit doors No locks
Group feedings on facility schedule
Private dining experiences on resident’s schedule
Large group activities chosen by facility activity director
Variety of activities chosen by resident
Staff assigned to specific tasks Universal worker assigned to household
Double loaded corridors Households with up to 10-12
Shared rooms Private rooms
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Cooking Options
I. Central
II. Limited• No grease or smoke vapors
III. Decentralized• 30 or less• NFPA 96 full effect
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Central
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Suppression
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Limited Cooking
Residential equipment used for food warming shall not be required to be protected as a
hazard
Annex: Intended to permit small appliances used for reheating, such as microwave ovens, hot plates, toasters, and nourishment centers
LSC 18.3.2.5.2
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Limited Cooking
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Limited Cooking
No grease or smoke vapors68
Limited Cooking
Steam table
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Decentralized Cooking
Staff supervision70
Decentralized Cooking
Stainless & seamless
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Decentralized Cooking
Permitted open to the corridor
• Limited capacity of 30 beds
• Smoke barrier separated cooking area
• Type I grease hood– Minimum 500 CFM exhaust
– No corridor plenums IBC 1018.5
– Makeup air required IMC 508
– No flex duct
LSC 18.3.2.5.3
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• Fire suppression UL 300 or UL 300A
• Manual release of the extinguishing system per NFPA 96
• Interlock turns off all sources of fuel and electrical when fire suppression is activated
LSC 18.3.2.5.3 continued
Decentralized Cooking
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• Portable fire extinguishers are located in all kitchen areas
• Kill switch deactivates all equipment, restricted access and defaults on a 120 minute timeframe
• Prohibited solid fuel or deep-fat frying
LSC 18.3.2.5.3 continued
Decentralized Cooking
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• Inspection, testing, and cleaning of every cooking station per NFPA 96
• Smoke detection in the corridor inspected, tested, and maintained NFPA 72
• Sprinkler protected smoke compartment inspected, tested, and maintained NFPA 25
LSC 18.3.2.5.3
Decentralized Cooking
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Station Kill Switch
Concealed76
Semi-annual Inspection
Clean when dirty
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Cooking K324
• Common Deficiencies– Not connected to fire alarm
– Missing semi-annual inspection
– Not cleaning when dirty
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• Moderate volume operations• Semi-annual Inspections
• Suppression system links• Semi-annual replacement
• Clean when dirty• Hood to fan
2011 NFPA 96 – Chapter 11
Cooking K324
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Cooking Lessons
• Staff trained
• Connected to fire alarm system
• Semi-annual inspection
• Access to equipment
• Fuel shut-off locations
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Fireplaces
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Fireplace Option
Direct-vent gas fireplaces are permitted
• Glass seal front with mesh screen
• Installed and maintenance per NFPA 54
• Quick response sprinkler protection
• Controls are locked or restrict access
• Carbon monoxide local detectors
• No fireplaces inside of a sleeping room
LSC 18.5.2.382
Solid fuel–burning fireplaces are permitted
• Fire separation of 1-hour fire resistance
• Fireplace installed and maintenance NFPA 211
• Hearth a minimum of 4 in height
• Heat tempered glass enclosure
• Supervised carbon monoxide detection
• AHJ input for other precautions
LSC 18.5.2.3
Fireplace Option
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Question
Is staff supervision critical when a fire place is burning fuel ?
a) Yes
b) Don’t know
c) No
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Medical Equipment
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Medical Equipment
Wheeled equipment permitted in 8 foot corridors
• Maintain minimum 60 in. clear width• Fire plan and training relocate equipment• Permitted wheeled equipment
o Equipment in useo Medical emergency equipmento Patient lift and transport equipment
LSC 18.2.3.4 (4)
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Fixed Furniture
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Fixed Furniture
Fixed furniture permitted within 8 ft corridors
• furniture is attached to the floor or wall• maintains a minimum 72 in. clear width• located only on one side of the corridor• grouped in 50 ft2 areas or less • groupings separated by at least 10 ft• does not obstruct access to building / fire equipment• smoke detected corridors, or the furniture allows
direct supervision by facility staff at a staff station
LSC 18.2.3.4 (5)
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Equipment & Furniture
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Furnishings, Mattresses, and Decorations
Draperies, curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall meet the flame propagation performance criteria contained in NFPA 701
LSC 18.7.5.1
Furnishings
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Furnishings
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Exempt flame propagation criteria
• shower curtains
• draperies at sleeping room windows
• draperies and curtains
• Individual panel less than 48 ft2 and
• total area is less than 20 percent of the wall area
LSC 18.7.5.1
Furnishings
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Combustible decorations are permitted when treated with an approved fire-retardant coating that is listed and labeled for the intended application
Decorations shall not interfere with door operation
Decorations shall not be placed on fire-rated doors
LSC 18.7.5.6
Decorations
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Decorations on non-fire-rated door, wall, or ceiling areas
• 20 percent allowance • per room not sprinkler protected
• 30 percent allowance • per room sprinkler protected
• 50 percent allowance • per sleeping room not exceeding a four person capacity
within a sprinkler protected smoke compartment
LSC 18.7.5.6
Decorations
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Maintain Control
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NFPA 99
Essential Electrical
Medical Gas
Ventilation
Fire Protection
Hyperbaric
96
Chapter 4 Fundamentals
Risk assessment categories
New systems
Category 1 – major injury or death
Category 2 – minor injury
Category 3 – no injury yet discomfort
Category 4 – no impact
NFPA 99
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Emergency Power K918
• Common Deficiencies– Insufficient testing
– No task lighting
– No manual stop switch
– No block heater
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Emergency Power
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Diesel generators exercised monthly
30 minutes @ 30% of the nameplate
Diesel generators that can not load to 30%
Annual load bank for 1.5 hours
Level 1 EPSS 36 month full duration test
All EPSS fuel shall be tested annually
2010 NFPA 110
Section 8.3.8 and 8.4.2
Generators K918
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Spark-ignited generators
Exercised monthly
Loading with available load
2010 NFPA 110 - 8.4.2.4
Generators K918
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Power Lessons
• Inspect generators weekly
• Test generators monthly
• Always record a generator load
• Test battery lighting 30 seconds monthly / 90 minutes annually
• Save those records
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Fire Watch
• Evacuate building or fire watch
• Fire protection outage
o Fire Alarm : More than 4 in 24 hours
o Sprinkler : More than 10 in 24 hours
• Contact DHS and local fire authority
• Dedicated staff
• Continuous
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Fire Watch question
Question: How are staff going to alert the fire department when the fire alarm system is down ?
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Fire Watch Lessons
• Initiation at 4 or 10 hours
• Accurate contacts
• Fire alarm outage is different than a sprinkler outage
• Log rounds
• Continuous
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DQA Memo
DQA Memo 17-003
Fire Plan, Watch, and Fire Reporting
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Fire Watch Record
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Written records shall be signed and kept onsite
New and existing door assemblies
Testing shall be performed by individuals who can demonstrate knowledge and understanding
2010 NFPA 80 Chapter 5
LSC 7.2.1.15
Fire Door Inspections
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Floor space on both sides
Force necessary to open doors
Door hardware is functional
No damage to door, frame, or hardware
No field modifications to assembly
Powered doors open upon power failure
Signage is installed, intact, and legible
Delayed locking device operation and timing
Security features do not circumvent operation
Fire Door Inspections
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Door openings not in proper operating condition shall be repaired or replaced without delay
LSC 7.2.1.15
Door Repairs
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Plan of Correction
I’m going to fix
I can’t fix
I don’t need to fix
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Correction Option I
• I’m going to fix• POC 30 or less days
• Avoid 45 – 90 day window
• Temp Waiver 91 - 364 days
• Temp Waiver 365 +
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I’m going to Fix
• Temporary Waivers – Timetable with milestone dates
• site mobilization, installation, certification, inspection, final cleaning, occupancy
– Increased fire safety awareness • Interim Life Safety Measures
• Additional detection / extinguishes
• Fire Watch
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Safeguarding Construction
Temporary Separation Walls
Walls shall have at least a 1-hour fire rating
Opening at least a 45-minute fire rating
Non-sprinkler protected construction
2009 NFPA 241 - 8.6.2
Interim Life Safety
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Correction Option II
• I can’t fix– Waiver
• Not automatic
• Reviewed each year
• Two key criteria
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Waivers
• Process• Deficiency
• Plan of Correction
• State Recommendation
• Federal Decision
• Notification
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Waivers
• Financial Hardship • Estimated cost of the installation
• Extent and duration of the disruption of normal use of resident areas resulting from the construction work
• Estimated period over which cost would be recovered
• Remaining useful life of the building
• Availability of financing
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Waiver Factors
• No adverse impact to resident safety
• Financial burden statement
• Staffing levels, training, and drills
• Additional fire safety measures
• Letters are current
• Name and signature
SOM 2480118
Correction Option III
• I don’t need to fix– FSES
• Credits offset deficiencies
• Not automatic
• Reviewed each year
• Entire building analysis
• 2013 NFPA 101A
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Summary
State resources
Federal updates
LSC data – Top 10
Systems approach
Correction
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Thank You
Wisconsin Dept of Health Services www.dhs.wisconsin.gov
David Soens(608) 266-8016
