Life Safety Code Informational Release
PDF Version of BQA 06-003
(PDF, 40 KB)
Date: March 27, 2006 -- DDES-BQA 06-003
To:
Ambulatory Surgery Centers ASC
01,
Facilities Serving
People with Developmental Disabilities
FDD
- 02, Hospices HSPCE
- 02, Hospitals
HOSP - 03,
Nursing Homes
NH - 02
FROM: David Soens, Fire Authority, Provider
Regulation and Quality Improvement
Via: Otis Woods, Director, Bureau of Quality Assurance
The purpose of this memorandum is to notify the health care provider
community of common Life Safety Code NFPA 101 (LSC) items that have been
cited in recent Medicare or Medicaid surveys.
The following list is a result of the Centers for Medicare and Medicaid
(CMS) Federal Monitoring Surveys (FMS) for long term care (LTC)
facilities. CMS has concluded fiscal year 2005 FMS activities and shared
their common findings with Illinois, Indiana, Michigan, Minnesota, Ohio,
and Wisconsin state agencies on December 16-17, 2005. Overall, the federal
surveys resulted in a significant increase in deficiencies compared to the
state agency survey findings. The majority of the deficiencies are being
corrected by the facilities, resulting in an established precedent.
The Wisconsin Department of Health and Family Services (DHFS) is
attempting to address the disparity between the federal and state survey
findings by proactively notifying all providers, regulated by the Life
Safety Code, of some common items of concern. Department surveyors will
continue to look at these items based on current CMS interpretations. If
the items are not in compliance with the LSC based upon these
interpretations, the items will be identified as deficiencies. Facility
staff may presently be aware of these items, or may seek professional
consultation to identify such items so that they can proactively address
them prior to their next LSC survey. Correcting all of the items
identified in this memorandum does not guarantee a deficiency free survey
since each facility is designed, operated, and maintained differently.
Surveyors will continue to survey for all applicable regulations.
Copies of the Life Safety Code NFPA 101 are available from the National
Fire Protection Association (NFPA) at www.nfpa.org
(exit DHFS),
or by contacting NFPA at 1-800-344-3555. The following tags are
paraphrased to aid readability, but the code sections referenced should be
reviewed in their entirety to ensure a thorough understanding. The LSC
survey tags at issue are:
K18: Doors protecting corridor openings in other than required
enclosures of vertical openings, exits, or hazardous areas are substantial
doors, such as those constructed of 1-¾ inch solid-bonded core wood, or
capable of resisting fire for at least 20 minutes. Doors in sprinklered
buildings are only required to resist the passage of smoke. LSC reference:
19.3.6.3
- Scenario: The resident room corridor doors have a common gap
equal to or larger than 1/8-inch for wood doors, or 3/16-inch for
steel doors, between the door and the door frame. Similarly, a wood
corridor door has a common overlap of 1/8-inch or larger over its door
frame. This measurement is typically taken at resident room corridor
doors to ensure these openings if closed will resist the passage of
smoke and provide a reasonable barrier between a resident and the
threat of smoke inhalation.
K25: Smoke barriers are constructed to provide at least a
one-half hour fire resistance rating for existing facilities and one hour
for new construction plans approved after 9/11/2003. Pipes, conduits, bus
ducts, cables, wires, air ducts, pneumatic tubes, and similar building
service equipment that pass through smoke barriers shall be protected. LSC
references: 19.3.7.3, 19.3.7.5, 19.1.6.3, and 19.1.6.4
- Scenario: Penetrations through a smoke barrier are not
protected with a fire-stopping compound or the existing compound has
depreciated. Fire-stopping compounds ensure the integrity of the
barrier is continuous, and in the event of a fire, will reasonably
ensure that health care staff and residents have some form of safe
refuge on one side or the other of the smoke barrier. Typical
penetrations arise from new utilities, such as electrical conduit or
communication cables, among others.
K29: Hazardous areas shall be enclosed with one hour fire rated
construction (with ¾-hour fire-rated doors) or an approved automatic fire
extinguishing system. When the approved automatic fire extinguishing
system option is used, the areas are separated from other spaces by smoke
resisting partitions and doors. Doors are self-closing and non-rated. LSC
reference: 19.3.2.1
- Scenario: Combustible storage rooms, greater than 50 square
feet, shall be deemed a hazardous room. Typically, the facility is
fully sprinkler protected, and these storage rooms require a door
closer. Additionally, penetrations within a hazardous room enclosure
require the opening to be protected or sealed depending upon the wall
construction. Note the period of construction for a facility, for
example, 1973 New, 1981 New, 1985 New, and 1991 New could require both
automatic sprinkler protection and one-hour fire rated enclosed,
depending on the size of the hazardous room.
K38: Delayed-egress locks complying with section 7.2.1.6.1 shall
be permitted, provided that not more than one such device is located in
any egress path. LSC reference: 19.2.1
7.2.1.6.1 Delayed-Egress Locks. Approved, listed, delayed-egress
locks shall be permitted to be installed on doors serving low and ordinary
hazard contents in buildings protected throughout by an approved,
supervised automatic sprinkler system or an approved, supervised fire
detection system provided that the following criteria are met.
(a) The doors shall unlock upon actuation of any approved, supervised
automatic sprinkler system or upon the actuation of any heat detector or
activation of not more than two smoke detectors of an approved, supervised
automatic fire detection system.
(b) The doors shall unlock upon loss of power controlling the lock or
locking mechanism.
(c) An irreversible process shall release the lock within 15 seconds upon
application of a force to the release device that shall not exceed 15
pounds of force nor be required to be continuously applied for more than 3
seconds. The initiation of the release process shall activate an audible
signal in the vicinity of the door. Once the door lock has been released
by the application of force to the releasing device, relocking shall be by
manual means only.
(d) On the door adjacent to the release device, there shall be a readily
visible, durable sign in letters not less than 1 inch high and not less
than 1/8 inch in stroke width on a contrasting background that reads as
follows:
PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS
- Scenario: Two devices are installed within an egress path, or
the devices are not working per the requirements found in section
7.2.1.6.1. Typically, the doors will not release and open within 15
seconds, or the doors will lack the proper signage, or the doors will
require more than 15 pounds to initiate and open the doors. These
unique locking devices are allowed in health care facilities without
significant clinical or admission restrictions and provide a needed
form of elopement deterrence, but the system must operate in
compliance with all of the prescriptive requirements to provide such
flexibility.
K46: Emergency lighting of the means of egress, including the
exit discharge, is provided and arranged so that failure of any single
lighting fixture (bulb) will not leave the area in darkness. LSC
reference: 19.2.9.1
- Scenario: Emergency lighting is not provided at each exit
discharge or the facility can not substantiate that the emergency
lighting is provided. Proper emergency lighting is commonly provided
in egress corridors and at exit doors, but exterior exit paths also
require illumination to a reasonable distance (40-50 ft) from the
structure.
K48: There is a written plan for the protection of all residents
and for their evacuation in the event of an emergency. LSC references:
19.7.1.1 and 19.7.2.2
19.7.2.2 A written health care occupancy fire safety plan shall provide
for the following:
(1) Use of alarms
(2) Transmission of alarm to fire department
(3) Response to alarms
(4) Isolation of fire
(5) Evacuation of immediate area
(6) Evacuation of smoke compartment
(7) Preparation of floors and building for evacuation
(8) Extinguishment of fire
- Scenario: The written facility evacuation plan does not
include all of the items required by 19.7.2.2.; typically missing the
smoke compartment evacuation component. Additionally, some fire
emergency plans do not identify manual initiation of the building's
fire alarm system by staff.
K50: Fire drills are held at unexpected times under varying
conditions, at least quarterly on each shift. The staff is familiar with
procedures and is aware that drills are part of established routine.
Responsibility for planning and conducting drills is assigned only to
competent persons who are qualified to exercise leadership. LSC reference:
19.7.1.2
- Scenario: The facility fails to conduct a quarterly fire
drill, or, the facility may conduct all of its required drills, but
the drills for a given shift occur at approximately the same time. The
goal of this regulation is to ensure staff is properly trained on all
shifts for the unexpected occurrence of a fire.
K51: A fire alarm system with approved devices or equipment
installed in accordance with the National Fire Alarm Code NFPA 72 to
provide effective warning of fire in any part of the building. Activation
of the complete fire alarm system shall be by manual fire alarm
initiation, automatic detection or extinguishing system operation.
Electronic or written records of tests shall be available. Fire alarm
systems shall be maintained periodically and records of maintenance kept
readily available. The fire alarm system must provide automatic
notification to the local fire department through one of the approved
methods found in NFPA 72.
- Scenario: The buildings fire alarm system is not connected
per NFPA 72. Typical deficiencies result when a fire alarm signal is
initiated by the facility, the signal is sent off site to a remote or
central monitoring station, and the monitoring station calls the
facility back to confirm a fire prior to dispatching emergency forces.
CMS emphasized this point in the January 10, 2003 Federal Register
adoption of the 2000 edition of NFPA 101. Emergency services are to be
notified automatically without delay.
K52: A fire alarm system required for life safety is installed,
tested, and maintained in accordance with NFPA 70, the National Electrical
Code and NFPA 72, the National Fire Alarm Code. The system has an approved
maintenance and testing program complying with the applicable requirements
of NFPA 70 and NFPA 72. LSC reference: 9.6.1.4
- Scenario: The facility lacks documentation of conducting
quarterly fire alarm testing / inspections. Additionally, the facility
may lack smoke detector sensitivity and functional testing. These
systems can only provide their intended safety if properly tested and
maintained per NFPA 72.
K56: If there is an automatic sprinkler system, it is installed
in accordance with NFPA 13, Standard for the Installation of Sprinkler
Systems, to provide complete coverage for all portions of the building.
The system is properly maintained in accordance with NFPA 25, Standard for
the Inspection, Testing, and Maintenance of Water-Based Fire Protection
Systems. It is fully supervised. There is a reliable, adequate water
supply for the system. Required sprinkler systems are equipped with water
flow and tamper switches, which are electrically connected to the building
fire alarm system. LSC reference: 19.3.5
- Scenario: The facility lacks documentation of conducting
quarterly sprinkler testing/inspections, or if completed, often a
report will contain problems; yet the facility failed to correct the
problems. Additionally, some systems have unsupervised control valves,
have painted or obstructed sprinkler heads, do not have an adequate
supply of spare sprinkler heads or do not have a sprinkler wrench
readily available. These sprinkler systems are a major contributor to
building safety and many trade-offs in the code have been allowed, but
only if the system is properly installed, maintained, and inspected.
K69: Cooking facilities are protected in accordance with NFPA
96, Standard for Ventilation Control and Fire Protection of Commercial
Cooking Operations. LSC reference: 19.3.2.6
- Scenario: The facility has an outdated dry chemical hood
extinguishment system. An outdated system has been defined by CMS as
one requiring replacement by a UL300 wet chemical if any of the
following events occur, (1) the dry chemical has been discharged, (2)
the dry chemical has been hydrostatically retested, (3) or new cooking
appliances have been installed. Additionally, some new UL300 systems
have been installed, yet the new extinguishment system is not
connected to the building's fire alarm system, the existing hood has
mesh filters, or the existing hood construction has seams that are not
liquid-tight.
K76: Compressed gas storage and administration areas shall be
protected in accordance with NFPA 99 Standard for Health Care Facilities
section 8-3.1.11.2.
(a) Oxygen storage locations of greater than 3,000 cu. ft are enclosed
by a one-hour fire resistance barrier.
(b) Oxygen storage locations less than 3,000 cu. ft.
- A minimum distance of 20 ft. from combustibles or incompatible
materials in a non-sprinkler protected oxygen storage room, or
- A minimum distance of 5 ft. from combustible or incompatible
materials in a fully sprinkler protected oxygen storage room.
- Scenario: Oxygen storage, in a fully sprinkler building is
found within five feet of combustibles. Additionally, oxygen bottles
are not secured or full and empty bottles are not adequately
separated.
K143: Liquid oxygen transferring shall be:
(a) separated from any portion of a facility wherein residents are
housed, examined, or treated by a separation of a fire barrier of 1-hour
fire-resistance construction. Note the fire rated door to this room shall
be in the closed position while transferring so residents are not exposed
to this hazard; and
(b) the area or room formed by the fire barrier is served by functioning
mechanical ventilation, and
(c) the area or room formed by the fire barrier is fully sprinkler
protected, and
(d) the area or room formed by the fire barrier has a ceramic or concrete
floor, and
(e) the area or room formed by the fire barrier is posted with signs
indicating that transferring is occurring, and that smoking in the
immediate area is not permitted, and
(f) combustible or incompatible materials are a minimum of 5 feet distance
from the transferring operation, and
(g) ignition sources are a minimum of 5 feet distance from the
transferring operation.
Source: Health Care Facilities standard NFPA 99 section 8-6.2.5.2 and
Compressed Gas Association (CGA) Pamphlet P-2.6 and P-2.7.
- Scenario: Noncompliance with any item listed above.
K144: Generators are tested monthly and exercised under load for
30 minutes per month in accordance with NFPA 110 section 6-4.2 or the
generators are tested annually under a four hour load bank test in
accordance with NFPA 110 section 6-4.2.2.
- Scenario: The emergency generator is tested for a full 30
minutes, but not under a 30% nameplate loading. Additionally, an
emergency generator located in a building, does not have task lighting
to illuminate the work area around the generator in the event a normal
power outage occurs. Lastly, for systems on natural or synthetic gas,
the facility lacks substantiation that the supply is reliable, for
example, a non-interruptible agreement.
K154/K155: Where a required sprinkler system or fire alarm
system is out of service for more than 4 hours in a 24-hour period, the
authority having jurisdiction shall be notified, and the building shall be
evacuated or an approved fire watch system shall be provided for all
parties left unprotected by the shutdown until the sprinkler/fire alarm
system has been returned to service. 9.7.6.1, 9.6.1.8
- Scenario: The facility has a sprinkler or fire alarm system
outage and does not have a fire watch policy and procedure.
Summary:
As stated above, compliance with the above listed K-tags does not
constitute a deficiency-free survey. This memorandum is motivated by the
mutual concern of the Department and facilities for compliance with the
requirements, and to maximize safety for all residents. All LSC tags are
subject to review at each survey. If you have any questions, the following
resources are available:
Long Term Care Facilities:
- Eau Claire Region (WRO): Joe Bronner (715) 836-4753
- Green Bay Region (NERO): Interim (920) 448-5249
- Madison Region (SRO): Interim (608) 243-2374
- Milwaukee Region (SERO): Katherine Friend (414) 227-4908
- Rhinelander Region (NRO): Joanne Powell (715) 365-2802
Non-Long Term Care Facilities:
- Northern Region (WRO, NRO, NERO): Jan Heimbruch (608) 243-2086
- Southern Region (SERO, SRO): Interim (414) 227-4556
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