The Section for Long-Term Care Regulation will be releasing a series of Life Safety Code Information. You may also view the entire Life Safety Code document for reference.

Today’s subject is:

What if a sprinkler head gets paint on it or has corrosion?

No one can successfully remove paint or corrosion from a sprinkler head and the facility must replace those sprinkler heads. There is currently not any UL listed paint remover.

NFPA 25, 2011 edition:
5.2.1.1 Sprinklers shall be inspected from the floor level annually.
5.2.1.1.1 Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendent, or sidewall).
5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced:

(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5) Loading
(6) Painting unless painted by the sprinkler manufacturer

5.2.1.1.3 Any sprinkler that has been installed in the incorrect orientation shall be replaced.
5.2.1.1.4 Any sprinkler shall be replaced that has signs of leakage; is painted, other than by the sprinkler manufacturer, corroded, damaged, or loaded; or is in the improper orientation.
5.2.1.1.5 Glass bulb sprinklers shall be replaced if the bulbs have emptied.

The Section for Long-Term Care Regulation will be releasing a series of Life Safety Code Information. You may also view the entire Life Safety Code document for reference.

Today’s subject is:

           What kind of documentation should a facility provide to the surveyor when on a fire watch?

Most facilities have one fire watch policy. If a facility has one policy, then the policy must have all the items in Chapter 15 within NFPA 25, 2011 edition. If the facility has two separate policies, the sprinkler system fire watch policy is required to include all the items in Chapter 15.

NFPA 25, 2011 edition:
Minimum Requirements
15.1.1.1 This chapter shall provide the minimum requirements for a water-based fire protection system impairment program.
15.1.1.2 Measures shall be taken during the impairment to ensure that increased risks are minimized and the duration of the impairment is limited.
Impairment Coordinator
15.2.1 The property owner or designated representative shall assign an impairment coordinator to comply with the requirements of this chapter.
15.2.2 In the absence of a specific designee, the property owner or designated representative shall be considered the impairment coordinator.
Tag Impairment System
15.3.1 A tag shall be used to indicate that a system, or part thereof, has been removed from service.
15.3.2 The tag shall be posted at each fire department connection and the system control valve, and other locations required by the authority having jurisdiction, indicating which system, or part thereof, has been removed from service.
Impaired Equipment
15.4.1 The impaired equipment shall be considered to be the water-based fire protection system, or part thereof, that is removed from service.
15.4.2 The impaired equipment shall include, but shall not be limited to, the following: Sprinkler systems, Standpipe systems, Fire hose systems, Underground fire service mains, Fire pumps, Water storage tanks, Water spray fixed systems, Foam-water systems, Fire service control valves
Preplanned Impairment Programs
15.5.1 All preplanned impairments shall be authorized by the impairment coordinator.
15.5.2 Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented:

(1) The extent and expected duration of the impairment have been determined.
(2) The areas or buildings involved have been inspected and the increased risks determined.
(3) Recommendations have been submitted to management or the property owner or designated representative.
(4) Where a required fire protection system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for one of the following:

(a) Evacuation of the building or portion of the building affected by the system out of service
(b) An approved fire watch
(c) Establishment of a temporary water supply
(d) Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire

(5) The fire department has been notified.
(6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified.
(7) The supervisors in the areas to be affected have been notified.
(8) A tag impairment system has been implemented. (See Section 15.3.)
(9) All necessary tools and materials have been assembled on the impairment site.

Emergency Impairments
15.6.1 Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure.
15.6.2 When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage.
15.6.3 The coordinator shall implement the steps outlined in Section 15.5.
15.7 Restoring Systems to Service
When all impaired equipment is restored to normal working order, the impairment coordinator shall verify that the following procedures have been implemented:

(1) Any necessary inspections and tests have been conducted to verify that affected systems are operational. The appropriate chapter of this standard shall be consulted for guidance on the type of inspection and test required.
(2) Supervisors have been advised that protection is restored.
(3) The fire department has been advised that protection is restored.
(4) The property owner or designated representative, insurance carrier, alarm company, and other authorities having jurisdiction have been advised that protection is restored.
(5) The impairment tag has been removed.

The Section for Long-Term Care Regulation will be releasing a series of Life Safety Code Information. You may also view the entire Life Safety Code document for reference.

Today’s subject is:

The facility must test receptacles (outlets) annually.

1. 1. What are the four test needed on non-hospital grade outlets?
   2. Are facilities required to document each electrical outlet annually?
   3. What documentation should the facility retain for each electrical receptacle?
   4. What happens if an outlet fails the inspection?
   5. What inspections does the facility need for hospital-grade outlets?

NFPA 99, 2012 edition:
6.3.3.2 Receptacle Testing in Patient Care Rooms.
6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle (except locking-type receptacles) shall be not less than 115 g (4 oz.).

The facility needs to document every outlet in the patient areas. The inspection report needs to show every outlet tested and includes areas such as resident rooms. The facility staff need to complete all four tests annually. These inspections may be a pass/fail for the four tests; however, the pass/fail must be for each specific test (e.g. grounding, polarity), and the pass/fail cannot just be for the outlet.

If the facility does not label every outlet, then there needs to be a system so everyone reading the documentation will know which outlet was tested. An example could be starting at the entrance, going around the room clockwise/counter clockwise, and naming the first outlet A, the second B and so on, until all outlets are recorded on the inspection sheet. The facility needs to document their system and use the same system throughout the facility. If one or more of the outlets in a room/area are hospital grade, the facility staff may document it on the form to show why annual testing did not occur (if applicable).

When an outlet fails any of the four tests, the facility needs to replace the outlet with a hospital grade outlet and staff need to document they replaced the outlet on the inspection sheet.

For any hospital grade outlet, the facility must create a system to complete a risk assessment and decide how often they want to complete the maintenance/testing, which can be longer than annually. The risk assessment system must be in place as soon as the facility has a hospital grade outlet. When due for an inspection and testing, these outlets must also be individually itemized on the documentation.

NFPA 99, 2012 edition:
10.3 Testing Requirements – Fixed and Portable.
10.3.1* Physical Integrity. The physical integrity of the power cord assembly composed of the power cord, attachment plug, and cord-strain relief shall be confirmed by visual inspection.
10.3.2* Resistance.
10.3.2.1 For appliances that are used in the patient care vicinity the resistance between the appliance chassis, or any exposed conductive surface of the appliance, and the ground pin of the attachment plug shall be less than 0.50 ohm under the following conditions:

(1) The cord shall be flexed at its connection to the attachment plug or connector.
(2) The cord shall be flexed at its connection to the strain relief on the chassis.

10.3.2.2 The requirement of 10.3.2.1 shall not apply to accessible metal parts that achieve separation from main parts by double insulation or metallic screening or that are unlikely to become energized (e.g., escutcheons or nameplates, small screws).
10.3.3* Leakage Current Tests.
10.3.3.1 General.
10.3.3.1.1 The requirements in 10.3.3.2 through 10.3.3.4 shall apply to all tests.
10.3.3.1.2 Tests shall be performed with the power switch ON and OFF.
10.3.3.2 Resistance Test. The resistance tests of 10.3.3.3 shall be conducted before undertaking any leakage current measurements.
10.3.3.3* Techniques of Measurement. The test shall not be made on the load side of an isolated power system or separable isolation transformer.
10.3.3.4* Leakage Current Limits. The leakage current limits in 10.3.4 and 10.3.5 shall be followed.
10.3.4 Leakage Current – Fixed Equipment.
10.3.4.1 Permanently wired appliances in the patient care vicinity shall be tested prior to installation while the equipment is temporarily insulated from ground.
10.3.4.2 The leakage current flowing through the ground conductor of the power supply connection to ground of permanently wired appliances installed in general or critical care areas shall not exceed 10.0 mA (ac or dc) with all grounds lifted.
10.5.2.1 Testing Intervals.
10.5.2.1.1 The facility shall establish policies and protocols for the type of test and intervals of testing for patient care–related electrical equipment.
10.5.2.1.2 All patient care–related electrical equipment used in patient care rooms shall be tested in accordance with 10.3.5.4 or 10.3.6 before being put into service for the first time and after any repair or modification that might have compromised electrical safety.
10.3.5.4 Touch Leakage Test Procedure. Measurements shall be made using the circuit, as illustrated in Figure 10.3.5.4, with the appliance ground broken in two modes of appliance operation as follows:

(1) Power plug connected normally with the appliance on
(2) Power plug connected normally with the appliance off (if equipped with an on/off switch)

The Section for Long-Term Care Regulation will be releasing a series of Life Safety Code Information. You may also view the entire document for reference.

Today’s subject is:

What is expected in a facility’s smoke compartment zone evacuation plan?

The facility needs to have a smoke compartment evacuation plan if they don’t plan to evacuate everyone immediately to the outside (meeting point) when the fire alarm sounds. The plan should begin with staff determining the need to evacuate. If evacuation is necessary, staff should begin evacuating residents in the immediate surrounding area of the fire, then the triangle of rooms around the room of fire origin (next to and across the hall from the room of origin), then the remaining rooms in the smoke compartment working away from the room of origin, trying not to cross the line of fire with the residents. Consider the fire exposure and Jack and Jill bathrooms. Some residents may be evacuated outside while others may be evacuated beyond a set of smoke doors.

The goal is to get all residents evacuated around the area of fire regardless of ambulatory status. After evacuation of the smoke compartment or origin and into another smoke compartment or an area of refuge; then it is determined whether an evacuation is needed further away (such as outside or a different smoke compartment). It may be prudent to evacuate based on ambulation status after evacuation of the zone of origin (ambulatory, wheelchair, bedridden). If the facility has a separate fire and evacuation plan, ensure the plans are consistent with the zone evacuation concept.

It would be wise to keep the plans simple and to have a written smoke compartment plan for every smoke zone in the building. Facilities may use things such as color-coded map/layouts. The facility needs to ensure when doing a zone evacuation, the residents are going to another smoke section, not just through a double door in the corridor (not all double doors are smoke/fire doors).

NFPA 101, 2012 edition:

4.7.3 Orderly Evacuation. When conducting drills, emphasis shall be placed on orderly evacuation rather than on speed.

The Section for Long-Term Care Regulation will be releasing a series of Life Safety Code Information. You may also view the entire document for reference.

Today’s subject is:

Acceptable Plans of Correction

 A plan of correction (POC) must be submitted within 10 calendar days from the date the facility receives its Form CMS-2567. According to the State Operations Manual (SOM) §7317, an acceptable POC must:

Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice;

Ensure every example, especially for those tags that encompass multiple deficient practices, has been addressed. K918 for example, covers generator installation, testing, maintenance, records, fuel, connections, and electrical mains and circuit breakers. If the SOD contains an example of the facility not completing the monthly 30 minute load bank test, an example of the diesel fuel not tested annually, and an example of the main and circuit breakers not inspected/tested annually, then each example needs to be identified on the POC and needs to state in detail what will be done to ensure each example is corrected.

Address how the facility will identify other residents having the potential to be affected by the same deficient practice;

How will all residents at risk for the deficient practice be identified? How will the deficient practice be corrected for all residents, not just the cited examples? For example, if five sprinkler heads are identified as having paint on them and cited as examples under K353, all sprinkler heads in the facility that have paint on them will need to be replaced, not just the five cited examples.

Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur;

Has the deficient practice that caused the deficiency been identified? What changes will occur to prevent the deficient practice from reoccurring? For example, if K363 was cited on the SOD for examples of corridor doors not latching and having penetrations and gaps, all corridor doors shall be maintained to resist the passage of smoke. Who is responsible for inspecting the corridor doors and how often? Is there a system for direct care staff to report maintenance issues to the maintenance department? What in-services need to occur and who needs to be involved in the training.

Indicate how the facility plans to monitor its performance to make sure that solutions are sustained and;

How will the monitoring be accomplished? Who is responsible for monitoring and what are their qualifications? What is the frequency of monitoring? For example, K923 was cited for not securing oxygen cylinders within the oxygen storage room. Although this is considered a LSC issue due to the risk of fire, nursing staff are the primary handlers of the oxygen cylinders and typically access the oxygen storage room more than maintenance staff. In this case, the maintenance staff may have not been monitoring the oxygen storage room and relying on nursing to ensure the oxygen cylinders are secured. The POC should then identify who will monitor the oxygen storage room moving forward (Maintenance, Charge Nurse, DON, etc…?). What form will the individual use to document their monitoring and how often will monitoring occur (Daily, Weekly, etc…?). Do policies need to be revised related to who will monitor, how often, what forms will be used, and who will oversee to ensure the monitoring is being completed? Does the POC state whether the deficient practice is being addressed with the QA Committee on a regular basis?

Include dates when corrective action will be completed.

Is there a date for completion of the corrective action? Is the timeframe reasonable given the work that is being done? Remember, the deficient practice is not completely corrected until all work is finished. A deficiency cannot be corrected if an item has been ordered but not yet installed. An invoice or confirmation of a future installation or inspection will not put the facility back into compliance. Is a time limited waiver needed to accomplish this? If so, the facility should reach out to the department to discuss a waiver. For example, a facility was cited for not having access to their smoke barriers and their POC states they are adding an access door through the ceiling, the completion date on the POC should reflect when the access door will be physically installed and not just scheduled. Each specific deficiency should include a corrective action date and the facility should adhere to those dates as stated on the POC. Staff education should also be considered when determining the corrective action completion dates.