c-6 - dan wood - leadingage iowa - dan wood.pdf · • lsc 18.3.2.1, 19.3.2.1 k211 alcohol based...

4/11/2014

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2014 LSC Training

Objectives

• Top 30 (ish) Tags

• Plans of Correction

• Other issues

• Reporting requirements

K12 Construction Deficiencies

• Common Deficiencies

– Penetrations

– Holes

– Gaps

– Room to room

• LSC 18.1.6.2, 18.1.6.3, 18.2.5.1

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K17 Corridor Separation

• Penetrations in corridor walls

• Also inside the resident room that is also a corridor wall

• LSC 18.3.6.1, 18.3.6.2, 18.3.6.5, 19.3.6.1, 19.3.6.2, and 19.3.6.5

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K18 Doors Protecting Corridor Openings


– Doors closing and latching properly

– Force to open and close

– Cannot resist the passage of smoke

– Holes in the door

– Door wedges, bricks, wires, panty hose, coat hangers, rocks, cans of food

• LSC 18.3.6.3, 19.3.6.3

Door Gaps

•No more than .25in nonsprinklered• No more than .5in sprinklered

Door Gaps

•Measurements do not apply when the door has sagged below the door jamb

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K20 Vertical Openings

• 1 hour enclosure

• Vertical penetrations


– Penetrations in stairways, elevator shafts, and chutes

– Penetrations in Basements

• LSC 8.2.5.6, 19.3.1.1

K‐25 Smoke Barriers

• 1 hour rated walls that go from floor to roof deck and from outside wall to outside wall

•NFPA requires smoke walls to have a fire resistance rating of at least a half hour and to be continuous from floor to roof deck and from outside wall to outside wall. 2000 NFPA 101, 19.3.7.3

• Common deficiencies:

• Penetrations/Holes

• Not sealed or sealed with non‐rated materials

• Incomplete construction

• Walls not extending to the roof or seams/fasteners not finished

• 18.3.7.3, 18.3.7.5, 18.1.6.3, 19.3.7.3, 19.3.7.5, 19.1.6.4

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K27 Smoke Doors

• Solid 20 minute rated 1 ¾ doors that are self closing

• Common Deficiencies– Don’t close properly

– Gap between the doors

– Parking carts, lifts, and other items including people in front of them

• LSC 18.3.7.5, 18.3.7.6, 18.3.7.8, 19.3.7.5, 19.3.7.6, 19.3.7.8, 7.2.1.14

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K29 Hazardous Rooms

• 1 hour rated room with 45 minute doors • Boiler and Fuel Fired Heater Rooms• Laundries over 100 square feet• Repair and Paint Shops• Labs if classified as a severe hazard• Combustible Storage Rooms over 50 sq feet• Trash Collection Rooms• Soiled Linen Rooms• Common Deficiencies

– Door closing properly– Door rating– Penetrations– No door closer

• Did you change the use of the room??????• LSC 18.3.2.1, 19.3.2.1

K211 Alcohol Based Hand Rub

• In a corridor at least 6 feet wide• Each dispenser cannot be over 1.2 liters• The dispensers shall be installed at least 4 feet from each other

• No more than 10 gallons can be in use in a single smoke compartment

• Dispensers shall not be installed over an ignition source such as a light switch or a outlet.

• If the floor has carpet on it the facility must be fully sprinkled

• LSC 18.3.2.7, 19.3.2.7

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K38 Exit Access

• All exits shall be accessible at all times


– Interior‐Carts, lifts, chairs, trash cans, plants, furniture, locked doors, and doors that are hard to open

– Exterior‐ lack of sidewalks, maintenance of sidewalks, locking gates

• LSC 18.2.1, 19.2.1, 7.1

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K45 2 Bulbs

• 2 bulbs fixtures must be located outside each FIRE EXIT

• Connected to emergency power or battery back up

• If it is connected to battery back up see K46

• LSC 18.2.8, 19.2.8, 7.8

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K46 Emergency Lights/ Testing

• Where do I need them? See 7.9• Testing‐ every month for 30 seconds and once a year for 90 minutes

• When you log your test results list all units seperatley and note if they were tested for 90 minutes or 30 seconds

• Common Deficiencies– Battery operated unit failed to light up– Improper documentation ( each unit not being individually listed on the report)

• LSC 18.2.9.1, 19.2.9.1

K47 Exit Signs

• Displayed in accordance with LSC 7.10

• They need to be on emergency power or battery back up

• Need to look both ways in the area and you should be able to see one in each direction

• Arrows? Left? Right? None?

• LSC 18.2.10.1, 19.2.10.1

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K48 Evacuation Plan

• A written plan for all types of emergencies that end in the facility being or possibly being evacuated

• Fires, tornados, floods, earthquakes, chemical spills…….. Anything

• Addresses each zone seperatley

• LSC 18.7.1.1, 19.7.1.1

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K50 Fire Drills

• 1 per quarter per shift

• Different times, locations, scenarios, dates

• Overnight drills may be a silent drill, HOWEVER, the signal to the monitoring company must be checked the next day

• Common Deficiencies– Same times or dates

– Not done at all

• LSC 18.7.1.2, 19.7.1.2

K51 Fire Alarm Installation Requirements

• Must meet all applicable NFPA 72 requirements

• NFPA 72 and 70


– No detection at the fire alarm panel

– Pull stations not installed properly

• LSC 9.6, 18.3.4, 19.3.4

• INSTALLATION DEFECIENCES

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K52 Fire Alarm Testing

• Must meet NFPA 70 and NFPA 72 requirements •NFPA requires a permanent record of all inspections, testing, and maintenance shall be maintained that includes periodic tests and applicable information, per the 1999 edition of NFPA 72, table 7‐3.2. and listed as required by NFPA 72, 7‐5.2.2•Inspection and testing of the devices such as initiating devices

•Inspected semi‐annually•Tested annually


• System not inspected and tested semi‐annually

• Improper documentation of the fire alarm inspection

• Fire alarm system does not indicate trouble upon disconnection of the remote automatic dialer panel

• Circuit disconnect for fire alarm system not locked and location not labeled at fire alarm control panel

• Fire alarm control panel fails to monitor failure of battery charging in panel

• Electro‐magnetic hold open devices re‐engage when the fire alarm system is placed in silence

• LSC 9.6.1.4

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K155 Fire Alarm Outage Policy

• What should it say?

– More than 4 hours in a 24 hour period

– Dedicated staff

– Continuous and at minimum in each room at least once every 30 minutes

– Call: State Fire Marshal, DIA, Local Fire Department, Insurance Company

– Include the phone numbers on the policy

– More is better!

K54 Tested per Manufactured Specifications

• Sensitivity Testing Deficiency

• Every other year

• Common deficiencies

• Smoke detector sensitivity testing not conducted at proper intervals

• Improper documentation of sensitivity testing

• LSC 9.6.1.3

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K56 Sprinkler Installation

• Per NFPA 13• All long term care regardless of construction type shall be sprinkled by August 13, 2013. No exceptions!

• Common Deficiencies– Mixed types of heads (quick response, standard response. fusible link

• NFPA 13• LSC 18.3.5, 19.3.5• INSTALLATION DEFECIENCES

K154 Sprinkler Outage Policy

• What should it say?

– More than 4 hours in a 24 hour period

– Dedicated staff

– Continuous and at minimum in each room at least once every 30 minutes

– Call: State Fire Marshal, DIA, Local Fire Department, Insurance Company

– Include the phone numbers on the policy

– More is better!

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K62 Sprinkler Testing and Maintenance

• Quarterly testing (3)

• Yearly testing (1)

• NFPA 13

• NFPA 25


• Sprinkler system not tested or inspected annually or quarterly

• Quarterly documentation fails to include all required information

• Sprinkler heads not free of paint, dirt/lint, corrosion or other foreign material

• Sprinkler heads not free of obstructions

• Failure to provide enough spare sprinkler heads

• 18 inch rule

• Side vs. ceiling

• MAINTENANCE DEFECIENCES

K64 Fire Extinguishers

• Inspected, Tested, maintained in accordance with NFPA 10

• Common Deficiencies– Not Inspected by facility monthly (sign and date card)

– Not Inspected by a trained tech yearly

– Not Maintenance every 6 years

– Not Hydro tested every 12 years

– Mounted too high? (5 feet or less) more than 4 inches off the ground)

– Blocked?

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K 66 Smoking Regulations

• You need a metal can with a self closing lid

• No Trash‐ It is not a trash can

• LSC 18.7.4, 19.7.4

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K67 Heating, Ventilating, and Air Conditioning

• Using the corridor as a return air plenum is not permitted

• NFPA 90A

• LSC 9.2, 18.5.2.1, 18.5.2.2, 19.5.2.1, 19.5.2.2

K69 Cooking Facilities

• UL 300 system (wet)

• Sprinkler heads allowed for now

• Common Deficiencies– Monthly owners checks

– Inspected by trained personnel twice a year

– Proper clearance and coverage

– Pilot lights

• NFPA 96

• LSC 9.2.3, 18.3.2.6, 19.3.2.6

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K70 Space Heaters

• Prohibited in all patient areas

• Can have them in offices

• Heating elements cannot exceed 212 degrees

• Tip over shut off feature

• LSC 18.7.8, 19.7.8

K74 Drapes, Curtains, Privacy Curtains, Furniture

• ½ inch mesh on privacy curtains

• Drapes and curtains shall be tagged and treated


• Vinyl blinds

• No documentation for fabric curtains

• Privacy curtains with < ½ mesh at the top

• Furniture NFPA 701

• LSC 10.3.1, 10.3.2 (2), 10.3.4, 18.3.5.3, 18.7.5.3, 19.7.5.3

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K76 Med Gas

• Oxygen

• Bottles stored improperly

• LSC 18.3.2.4, 19.3.2.4

• NFPA 99 4.3.1.1.2

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K141 No Smoking Signs

• Anywhere there is oxygen in use have one on each individual room or one on each of the entrance doors to the facility

• Must have a sign where oxygen is stored

• LSC 18.3.2.4, 19.3.2.4

• NFPA 99

K144 Generator Testing

• Inspected weekly NFPA 99 and 110• Exercised under load for 30 minutes (not 20 with a 10 minute cool down)

• Amps and volts are required to be documented for each “Leg”. Document when and who conducted the weekly visuals. Generator annunciator panel is required to be installed in a location that is monitored 24/7.

• NFPA 99 3.4.4.1• NFPA 110 8.4.2

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Generator Testing

• Weekly inspection to include:– Date– Initials– Fuel Level– Hoses and connections– Oil Level– Cooling System Check– Battery– Protective Panels in place– Hour Meter Reading– Exhaust System

Generator Testing

• Monthly Testing– Date– Start Time/ Stop Time– Initials– Meter Reading– Transfer Switch– Oil Pressure– Water Temp– Oil Level– Coolant Level– Voltage Legs (1,2,3)– Amp Legs (1,2,3)– LOG IT PROPERLY!

Generator Testing

• Monthly Testing NFPA 110, 6‐4.2

• Diesel, Propane, and Natural Gas

– Under normal operating temperatures or not less than 30% of the name plate rating

– Loading that maintains the minimum exhaust temperatures recommended by the manufacturer.

– If you cannot meet these and you have a DIESEL GENERATOR you can………..

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Generator Testing

• NFPA 110, 6‐4.2.2 Diesel powered generators that do not meet the requirements of 6‐4.2 shall be exercised monthly and…….

• Exercised annually with supplemental loads at 25% for 30 minutes, 50% for 30 minutes, and at 75% for 1 hour to make up the 2 hour continuous test

K147 Electrical

• In accordance with NFPA 70

• GFCI outlets

• Light switches

• Surge protectors

• Breaker panels

• Exposed wiring

• NFPA 70

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K130 Misc

• What ever doesn’t fit in the rest of the tags but is in the code or a code that is referenced

• Stuffed animals on top of bed lights

• Oxygen machines left on

Plan of Correction

• Statement at the Beginning : Accept this plan as the facilities credible allegation of compliance.

• Each tag has four parts that need answered:– 1. Who fixed it

– 2. How was it fixed (in detail)

– 3. What measure have been put in place so this doesn’t happen again

– 4. How often will the QA team review these items

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Sample POC

• Accept this plan as the facilities credible allegation of compliance.

• K12 (penetration)• 1. The repair was made by the facility maintenance director

• 2. The repair was made using ABC 123 fire caulk that has a 1 hour fire rating

• 3. Monthly inspection by maintenance staff will be conducted to assure there are no new penetrations

• 4. The QA team will review this item in their quarterly meetings

What else for a POC?

• Bids (equipment needed tags)

• Pictures (penetrations, electrical issues)

• Quotes (repairs)

• Testing reports (sprinkler, fire alarm, hood and duct, generator, emergency lights)

• Supporting documentation (we did it see!)

• Cut sheets (product sheets

• Work orders (anything you can’t show in a picture)

• In‐service notes

• Anything else that will help your cause

Fire Watch

• Used anytime your fire alarm or sprinkler system is out of service for more than 4 hours in a 24 hour period

• Know your policy

• Train on it!

• LSC 9.6.1.8 (fire alarm) and 9.7.6.1 (sprinkler)

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Fire Watch

• What should be in it?– A statement that says fire alarm or sprinkler system is out of service for more than 4 hours in a 24 hour period

– The watch must be CONTINUOUS!– Someone must be in each room once every 30 minutes– Dedicated person or persons– The facility must call: Local Department, DIA, State Fire Marshal’s Office, and the facility insurance company

– All phone numbers shall be included on the policy– Call the Local Department, DIA, State Fire Marshal’s Office, and the facility insurance company back when the watch is over

Waivers

• When a waiver is completed call or email

Reporting Requirements

• Fire alarm‐ 2 times per year• Sprinkler‐ 4 times per year• Hood and duct‐ 2 times per year/ owners inspection

monthly• Extinguishers‐ yearly/ owners inspection monthly• Generator‐ weekly inspection/ monthly load test/ yearly if

needed• Emergency lights‐ 30 seconds monthly AND 90 minutes

yearly• Fire Drills‐ At least 1 per quarter per shift• Outage policies• Evacuation policies

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QUESTIONS?

• Dan Wood

• [email protected]

• 515‐725‐6171

• Kyle Gorsh

• [email protected]

• 515‐725‐6161

c-6 - dan wood - leadingage iowa - dan wood.pdf · • lsc 18.3.2.1, 19.3.2.1 k211 alcohol based...

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