The Plant Manager of the skilled nursing facility has an important role in the safety and well-being of the residents residing in the facility. The Plant Manager is responsible for maintaining the facility, grounds and equipment. In addition to that, they are usually in charge of the Life Safety Program. The title of the regulations speaks volumes about the importance of this task, as doing life safety correctly will save lives.
The holidays are approaching, and it is important to remind facility staff that decorations must be fireproof for the safety of the residents. No hay brought into the facility for fall décor. Wrapping the doors with wrapping paper and a bow looks so festive, but it is not permissible as the doors are fire doors. Our facility residents deserve a beautifully decorated home for the holidays, but it must be done safely.
F.S. 69A-3.012 Standards of the National Fire Protection Association and other Standards Adopted is the statute that specifies that Florida has adopted the 6th Edition (2017) of the Florida Fire Prevention Code which is comprised of the Florida specific edition of NFPA 101, the Life Safety Code (2015 edition). This includes Chapter 13 Security Management requirements. CMS excluded this chapter when adopting 2012 edition of NFPA but in Florida it is required.
Chapter 13 Security Management requires a security plan for the facility. The plan must include a Security Vulnerability Assessment (SVA) and shall be updated at least annually. The SVA is to evaluate the potential security risks posed by the physical and operational environment of the health care facility to all individuals in the facility. The facility shall implement procedures and controls in accordance with the risks identified by the SVA. A person shall be appointed by the leadership of the health care facility to be responsible for all security management activities. The responsibilities include:
- Provide identification for patients, staff, and other people entering the facility
- Control access in and out of security-sensitive areas
- Define and implement procedures as follows:
- Security incident
- Hostage situation
- Bomb(explosive device or threat)
- Criminal threat
- Labor action
- Disorderly conduct
- Workplace violence
- Restraining order
- Prevention of, and response to, infant or pediatric abduction
- Situations involving VIPs or the media
- Maintenance of access to emergency areas
- Civil disturbance
- Forensic patients
- Patient elopement
- National Terrorism Advisory System (NTAS) or equivalent
- Suspicious material or package
- Suspicious powder or substance
- Use of force policy
- Security staffing augmentation
- Active shooter
- Provide security at alternate care sites or vacated facilities
- Control vehicular traffic on the facility property
- Protect the facility assets, including property and equipment
- Provide policy for interaction with law enforcement agencies
- Comply with applicable laws, regulations, and standards regarding security management operations
- Educate and train the facility security force to address the following:
- Customer service
- Use of physical restraints
- Use of force
- Response criteria
- Fire watch procedures
- Lockdown procedures
- Emergency notification procedures
- Emergency communications procedures
All security-sensitive areas as identified by the SVA, shall be protected as appropriate. Pediatric and infant care areas shall have a security plan for prevention of, and response to, pediatric and infant abduction that shall include appropriate protections. Medication storage and work areas shall be secured against admittance of unauthorized personnel through the use of the following:
- Physical access control
- Unique identification for the area
- Secure storage and controlled dispensing of drugs
Dementia and behavioral health units shall be secured against the admittance or release of unauthorized personnel through appropriate protections, such as the following;
- Physical access control
- Unique identification for the area
- Procedure to prevent entry of contraband prior to a person being admitted into the unit or department
- Elopement precautions
- Maintenance of color photos with the medical information of current patients to aid in identification
Communications, data infrastructure, and medical records storage areas shall be secured against the admittance of unauthorized personnel or unauthorized release of confidential information through the use of appropriate protections, such as the following:
- Physical access control
- Unique identification for the area
- Surveillance equipment
- Data encryption and password protection
Public visitation controls shall be enforced. After-hours entrance by the public shall be restricted to designated areas, such as entrance lobbies or rehabilitation entrance. Health care facility security controls and procedures shall comply with life safety requirements for egress. Security plans for health care occupancies shall address access and egress control during periods of quarantine and other events in conjunction with emergency agencies.
The security management plan shall include procedures to accommodate media representatives. A person shall be designated for assembly of media representatives. A security or facility staff member shall remain with the media representative at all times. Media representatives shall be escorted when granted access to the health care facility outside the area designated. The security management plan shall provide procedures for crowd control for management of those demanding access to a health care facility. The procedures for crowd control shall provide for the coordination and collaboration of security and law enforcement. The security management plan shall include processes and procedures for controlling access to the health care facility. Exterior entrances shall be provided with locking devices. Locking devices shall comply with applicable federal, state, and local requirements. Locking devices shall be properly installed and be in good working order. The facility shall operate a key control program. Employers shall ensure a high level of integrity in the workplace by using the following practices:
- Background checks of employees with access to critical assets
- Background checks of outside contractors’ employees
- Drug testing program for employees
Post orders shall be written for security personnel. Security personnel training shall include, but not be limited to, the following:
- Customer service
- Emergency procedures
- Patrol methods
- De-escalation training
- Use of physical restraints
- Use of force
Periodic drills shall be conducted at various times and locations. The drills shall be critiqued for plan effectiveness and to identify opportunities for improvement. Identified opportunities for improvement shall be incorporated into the security plan. The security plan shall be evaluated at least annually. The evaluation of the security management plan shall include a review of laws, regulations, and standards applicable to the security program. The tag for the security management plan is K-1150. More resources on building your facility security plan are available on the ASPR website.
Fire Door Inspections
Another Life safety area that has been cited frequently is K-761, fire door inspections. The 2012 edition of the Life Safety Code requires nursing facilities to complete an annual inspection and testing of fire doors assemblies in accordance section 8.3.3.1. The annual inspection will be inspected and tested in accordance with the 2010 NFPA 80. The Inspection and testing of fire door assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing. NFPA 101 5.2 list the requirements that should be included in the door inspection report. A sample form is located on the FHCA website.
There are other areas of concern that have resulted in Life Safety tags. One area is the required diesel fuel test. NRPA 110-8.3.8 requires a fuel quality test shall be performed at least annually using approved ASTM standards. When testing fuel refer to the engine manufacturer’s recommendations. In the absence of manufacturer’s recommendation utilize ASTM test guide.
Fire Caulk training is not required but important for plant managers and assistants to complete. The supplier of the facility fire caulk will usually come to the facility to do the training. It is important that plant managers and staff are checking for penetrations and then caulking correctly. A good practice is to place a label next to the fire caulk site with documentation of type fire caulking used. Take a picture of the area and label for record keeping.
Florida Health Care Association has a Life Safety Advisory Group for Plant Managers, consultants and corporate life safety directors. If your plant operations staff would like to be part of the FHCA Life Safety Advisory Group, contact Deborah Franklin at [email protected] for more information.