Life Safety is not just another set of regulations to follow. The codes developed are important for the safety of the residents, families and the team members. The National Fire Prevention Association (NFPA) is passionate about making the world a safer place. Life Safety codes are developed by the experts in the field and then adopted by the Centers for Medicare and Medicaid Services (CMS) and the local government agencies. There are technical committees made up of experts in that area that develops the recommended code changes. These changes could be a result of something that happened that caused harm or just to adapt to the changing landscape and needs. More than 120 years ago, several small groups of people had ideas that they pursued from concept to reality. Their ideas grew into the organization we know today as the National Fire Protection Association.
Here are the National Top Ten Life Safety deficiencies for 2018
|K Tag||Description||# Cites||% of Nursing Facilities|
|K0353||Sprinkler System – Maintenance and Testing||2,222||35.5%|
|K0363||Corridor – Doors||1,325||21.2%|
|K0918||Electrical Systems – Essential Electric System||1,312||21.0%|
|K0321||Hazardous Areas- Enclosure||1,195||19.0%|
|K0920||Electrical Equipment – Power Strips and Extension Cords||1,153||18.4%|
|K0345||Fire Alarm System – Testing and Maintenance||1,040||16.6%|
|K0372||Subdivision of Building Spaces – Smoke Barrier||898||14.3%|
|K0761||Maintenance, Inspection and Testing – Doors||865||13.8%|
|K0222||Means of Egress – General||754||12.0%|
|K0923||Gas Equipment – Cylinder and Container Storage||742||11.9%|
|K0511||Utilities – Gas and Electric||674||10.8%|
|K0914||Electrical Systems – Maintenance and Testing||586||9.4%|
Some suggestions to help avoid these citations:
K353 Verify your vendor’s work and don’t just trust they are doing the tests timely. Sprinkler heads that are rusty, dirty or have paint on them should be cleaned or replaced. Keep a supply of spare sprinkler heads with the installation wrench on hand.
K363 The corridor doors must be substantial construction to resist smoke and 20-minute fire rated. Refer to CMS S&C 17-38-LSC memo for guidelines for annual fire and smoke testing.
K918 is cited for not having the circuit breaker testing and also generator testing. Ensure that the generator is maintained according to the according to the manufacturer and/or NFPA requirements.
K321 Ensure that hazardous areas shall be safe-guarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system. The door to a hazardous space is required to have automatic closer.
K920 is cited fro issues with power strips not complying with regulation. Power strips cannot be interconnected “daisy-chained” to increase length. The power strip can’t be attached to the wall or furniture as it can’t be used as permanent wiring.
K712 The facility should conduct one fire drill per month, per shift, per quarter and the times should be varying. Recommend the original fire drill records be kept in Administrator office and copy with life safety supervisor.
K 345 The facility should verify monthly that the fire alarm transmits signal to monitoring company or fire station within 90 seconds. The facility should have evidence of the required quarterly, semi-annual, and annual inspections and the related records are readily available.
K372 Confirm that all penetration in the smoke or fire barrier have been appropriately filled to resist the passage of smoke or fire. No spray foam sealants are permitted.
K 761 The facility should ensure that all fire door assemblies are annually inspected and tested. Review the PowerPoint training and inspection form on the FHCA website. This course should be included in the Maintenance Director’s new-hire orientation. NFPA 80, 18.104.22.168 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing. Qualified is a person who, by possession of a recognized degree, certificate, professional standing, or skill, and who, by knowledge, training, and experience, has demonstrated the ability to deal with the subject matter, the work, or the project.
K324 The cooktop or range of the cooking facilities should be protected with a fire suppression system listed in accordance with UL300. The suppression system is inspected, tested and maintained semi-annually according to NFPA standards. Ensure that k-type extinguisher has appropriate signage in cooking area.
K511 Ensure that all juncture boxes have appropriate covers installed for utilities. Ensure that no extension cords are used in the facility. Ensure that all generators, fuel tanks and other utility systems are protected when adjacent to parking lots or driveways with protective bollards.
K222 Confirm that doors to the corridor do not require more than one action to open and exit. Confirm that if using delay-egress lock on egress door that there is proper signage on the door stating, “Push Until Alarm Sounds” “Door Can Be Opened in 15 Seconds”
K923 Ensure the proper amount of gas and cylinder storage and all tanks are fully supported in metal racks or carts. Empty and full tanks should be kept separate. Signage should be in place stating “Medical Gases Stored Within, No Smoking”
K521 Confirm that all smoke dampers have been inspected, tested and maintained individually documented every 4 years. If the damper is equipped with a fusible link, the link shall be removed for testing and/or replacement. All inspections and testing shall be documented indicating the location of the fire damper or combination fire/smoke damper, date of inspection, name of inspector, and deficiencies discovered.
K914 Ensure that receptacles not listed as hospital-grade, at patient bed locations must be tested every 12 months.
K271 All exits have a hard pathway of crushed stone, asphalt or concrete and is level and there is no obstruction and is illuminated.
K711 Ensure the facility Fire Evacuation plan includes the required elements: use of alarms, transmission of alarms to fire department, emergency phone call to fire department, response to alarms, isolation of fire, evacuation of immediate area, evacuation of smoke compartment, preparation of floors and building for evacuation, extinguishment of fire
K741 Ensure proper smoking equipment is being used including non-combustible self-closing ashtrays.
Jim Merrill, PE, Life Safety Engineer for CMS, presented at the NFPA Annual Conference. He shared important information for providers about life safety. CMS K-tags are provided on CMS 2786 forms. CMS 2786 is intended to be a surveyor guide. There is valuable information for the provider about life safety located here.
FHCA has a Life Safety Advisory Panel for the Life Safety Directors in Florida so that we can get information out to them quickly. The group will also ask questions as they arise in the field. If you are interested in being on the advisory panel, email [email protected].