Delayed-Egress Locking Systems

Delayed-Egress Locking Systems

National Fire Protection Association (NFPA) 101 2012 Delayed-Egress Locking Systems. 7.2.1.6.1.1  shows: Approved listed delayed-egress locking systems shall be permitted to be installed on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6 or an approved supervised automatic sprinkler system in accordance with Section 9.7 and where permitted in Chapters 11 through 43, provided that all of the following criteria are met:

  1. The door leaves shall unlock in the direction of egress upon actuation of one of the following:
    1. Approved, supervised automatic sprinkler system in accordance with Section 9.7
    2. Not more than one heat detector of an approved, supervised automatic fire detection system in accordance with Section 9.6
    3. Not more than two smoke detectors of an approved, supervised automatic fire detection system in accordance with Section 9.6
  2. The door leaves shall unlock in the direction of egress upon loss of power controlling the lock or locking mechanism.
  3. *An irreversible process shall release the lock in the direction of egress within 15 seconds, or 30 seconds where approved by the authority having jurisdiction, upon application of a force to the release device required in 7.2.1.5.10 under all of the following conditions:
    1. The force shall not be required to exceed 15 lbf (67N).
    2. The force shall not be required to be continuously applied for more than 3 seconds.
    3. The initiation of the release process shall activate an audible signal in the vicinity of the door opening.
    4. Once the lock has been released by the application of force to the releasing device, relocking shall be by manual means only.
  4. *A readily visible, durable sign in letters not less than 1 in. (25 mm) high and not less than 1⁄8 in. (3.2 mm) in stroke width on a contrasting background that reads as follows shall be located on the door leaf adjacent to the release device in the direction of egress: PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 (or 30) seconds.

 

Facilities may receive approval for 30 second release egress doors from the Authority Having Jurisdiction.  For the facility to receive 30 second release approval, the facility must submit in writing to the Section for Long-Term Regulation (SLCR), a letter detailing the risk(s) to the residents and/or hardship.  It will be the SLCR’s final decision on the approval of the extension and will be reflected in a letter to the facility.  It will be the facility’s responsibility to retain the SLCR approval letter for future reference.

 

Failure to obtain an approval letter from the SLCR will place the facility in noncompliance with Federal participation requirements and in the event of a recertification survey or federal monitoring survey for life safety code, result in a citation.

 

The facility letter detailing the risk(s) to the residents and/or hardship and facility layout indicating affected doors, can be submitted to be Scott.Wiley@health.mo.gov

NFPA Notes

NFPA Notes

All areas of the building shall be accessible:  All areas of the facility must be accessible during all shifts by the charge nurse (or another designated staff, i.e. security) so that in the case of a fire, staff (including emergency response staff) can find and fight the fire (when possible). Reports show that recently facilities in varying areas of the country have had fires in areas that were locked (such as laundry rooms or the kitchen) during the evening/night shifts. When the fire alarm system sounded, staff did not have a key accessible to gain entry into the locked areas causing a delay in the response time.

 

  • NFPA 2012 101, 19.7.2.1.1

For health care occupancies, the proper protection of patients shall require the prompt and effective response of health care personnel.

 

  • NFPA Standard: 2012 NFPA 101, 19.1.1.3.1

All health care facilities shall be designed, constructed, maintained, and operated to minimize the possibility of a fire emergency requiring the evacuation of occupants.

 

  • NFPA 101 2012, 4.8.2.1

Emergency plans shall include the following:

(1) Procedures for reporting of emergencies

(2) Occupant and staff response to emergencies

(3) Evacuation procedures appropriate to the building, its occupancy, emergencies, and hazards (see Section 4.3)

(4) Appropriateness of the use of elevators

(5) Design and conduct of fire drills

(6) Type and coverage of building fire protection systems

(7) Other items required by the authority having jurisdiction

 

  • NFPA 2012 101, 7.2.1.1.3.2

Where means of egress doors are locked in a building that is not considered occupied, occupants shall not be locked beyond their control in buildings or building spaces, except for lockups in accordance with 22.4.5 and 23.4.5, detention and correctional occupancies, and health care occupancies.

Fire Reporting

Fire Reporting

19 CSR 30-85.022 (2) (F) for Skilled Nursing Facilities/Intermediate Care Facilities (SNFs/ICFs) and 19 CSR 30-86.022 (2)(C) for Residential Care Facilities (RCFs) and Assisted Living Facilities (ALFs) require that all facilities shall notify the department immediately after the emergency is addressed if there is a fire in the facility or premises and shall submit a complete written fire report (attached) to the department within seven (7) days of the fire, regardless of the size of the fire or the loss involved.

 

The Section for Long-Term Regulation defines fire as used in relation to fire/safety requirements as follows:  Fire is the active principle of burning, characterized by combustion.  This energy is evident when heat and/or smoke and/or light are present as the result of combustion.  Smoke is a product of combustion, and any time smoke is given off, combustion has occurred whether or not there has been a visible flame. Besides the obvious, some often-overlooked examples of fire include but are not limited to the following:

  • Smoking air conditioner unit or heater (whether or not the fire department responded);
  • Smoking pads or mop heads in the dryer (whether or not the fire department responded); and
  • Smoking trash in a waste receptacle (whether or not the fire department responded).

 

The facility submitted fire report must include the following:

  • A brief narrative of the event in the comments section of the report or in an attachment;
  • Documentation regarding whether or not the fire alarm and/or sprinkler system activated (if applicable) and if/when the system was back in service (if applicable);
  • In addition, the narrative must show whether or not fire extinguishers were used, and if so, when they were recharged or replaced;
  • A copy of the fire department report if the fire department responded; and
  • If a fire can be attributed to a particular person, the report must include identifying information for that person.

Emergency Protocol Update/Reminder

Emergency Protocol Update/Reminder

SLCR developed a protocol for communication between long-term care homes and the Section for Long-Term Care Regulation (SLCR), in the event a disaster occurs that results in a loss of a necessary service (electricity, water, gas, telephone, etc.). This protocol was established to streamline communication so that homes can focus on what is most important – the safety and well-being of the residents.

 

The phone number for Region 5 (Macon) has changed. This is the only change to the document attached.

MLN Emergencies, Disasters, and Lessons Learned: Are You Really Ready?

MLN Emergencies, Disasters, and Lessons Learned: Are You Really Ready?

  • November 16, 2016:  Macon
  • November 17, 2016:  Jefferson City

This presentation will discuss emergencies, disasters, risk assessment, and lessons learned from case studies. The presentation will provide participants with specific suggestions to help be better prepared in the event a disaster does occur.

Please see the Workshop brochure and more information including registration here.

Hurricane Sandy: A Lesson in Survival

Why it is important to have an emergency plan in place.  This article focuses on October 22, 2012 and sometime following, when the largest Atlantic hurricane on record left the East Coast in a state of emergency.  Read and understand what it was like as nursing homes were evacuated.  You also get a description of some challenges crews faced as well as the lessons learned from the experience.

Please see the full article from Long Term Living – July/August 2015 here.

Missouri Severe Weather Awareness Week

March 3 – 7, 2014:  Missouri Severe Weather Awareness Week

March 4, 2014:  Annual Missouri Severe Weather Drill

The annual drill will be held on March 4th, 2014, at 1:30 p.m.  In case of actual severe weather on March 4th, the drill will be postponed until Thursday, March 6th, also at 1:30 p.m.  For more information, visit SEMA at http://sema.dps.mo.gov/.

Emergency Preparedness Winter Weather Special Update February 4, 2014

LTC Information Special Update  February 04, 2014 

The Section for Long-Term Care Regulation is sending the following weather-related reminders in light of Missouri’s considerable snowfall and ice accumulation across the state.  Please take time to familiarize yourselves with your home’s emergency plan, double-check your emergency reserves of food and other disaster-related preparedness items, and know that your service to the elderly in all types of weather is appreciated.

Winter Weather Information

http://health.mo.gov/emergencies/ert/naturaldisasters.php

http://stormaware.mo.gov/

http://www.nws.noaa.gov/view/states.php?state=MO

Emergency Protocol for Long-Term Care Homes

The Emergency Protocol was developed in 2007 for communication between long-term care homes and the Section for Long-Term Care Regulation, in the event a disaster occurs that results in a loss of a necessary service.  (Electricity, water, gas, telephone, etc.)  This protocol was established to streamline communication so that homes can focus on what is most important – the safety and well-being of the residents.

This protocol provides the cellular telephone number corresponding to the region in which your home is located if you experience a loss in a necessary service that has the potential to affect resident safety or well-being.  You are encouraged to contact the regional main office telephone number during normal business hours, as survey staff carry the emergency cell phone and may be conducting a survey or inspection during working hours and may not answer immediately.

Please remember, this protocol is NOT to be used to self-report incidents normally reported to the Elderly Abuse & Neglect Hotline (1-800-392-0210).

Region Main Office Emergency Only Cell Number
#1 Springfield (417) 895-6435 (417) 425-8780
#2 Poplar Bluff (573) 840-9580 (573) 778-6495
#3 Kansas City (816) 889-2818 (816) 719-0089
#4 Cameron (816) 632-6541 (816) 632-9371
#5 Macon (660) 385-5763 (660) 651-1468
#6 Jefferson City (573) 751-2270 (573) 619-3338
#7 St Louis (314) 340-7360 (314) 623-2852

Missouri regional map: http://health.mo.gov/seniors/nursinghomes/providerinfo.php – click on Long Term Care Regions

Disaster and emergency planning resources: http://health.mo.gov/emergencies/

If you have any questions about the Emergency Protocol for Long-Term Care Homes, please contact the Section for Long-Term Care Regulation at 573-526-8524.

Ensure Your Local EMD has a Copy of Your Home’s Current Emergency Plan

Missouri is again experiencing extreme weather conditions, and there is a chance of even more inclement weather in the forecast.  The Section for Long-Term Care Regulation would like to remind you there are emergency preparedness representatives in your community to help you with emergency planning and are there to help in the event of a disaster.

You can find your local emergency management director (EMD) on the State Emergency Management Agency’s (SEMA) website at www.sema.dps.mo.gov.  Scroll down to Contact Your Local Emergency Management Agency and choose your county.

State regulations require all long-term care homes to provide a copy of their emergency plan to their local EMD.  Please reference the following regulations:

19 CSR 30-85.022 (33) and 19 CSR 30-86.022 (5)(A) All facilities shall have a written plan to meet potential emergencies or disasters and shall request consultation and assistance annually from a local fire unit for review of fire and evacuation plans.  If the consultation cannot be obtained, the facility shall inform the state fire marshal in writing and request assistance in review of the plan.  An up-to-date copy of the facility’s entire plan shall be provided to the local jurisdiction’s emergency management director.

For additional information regarding emergency preparedness, please contact Melissa Hope, Planner II, Division of Regulation and Licensure at melissa.hope@health.mo.gov.

Resources are also available on the Department of Health and Senior Services website, http://health.mo.gov/emergencies/readyin3/adultcare.php.

Health Update: January 31, 2014 Influenza in Missouri

Health Alerts, Advisories and Updates

Health Update:  January 31, 2014

SUBJECT: Influenza in Missouri, 2013-2014

On December 26, 2013, the Missouri Department of Health and Senior Services (DHSS) issued a Health Advisory containing information on the current influenza season as well as recommendations on diagnostic testing and the use of antiviral drugs (http://health.mo.gov/emergencies/ert/alertsadvisories/pdf/HAd122613.pdf).

This Health Update summarizes influenza activity in Missouri through late January, and provides information on how medical providers and facilities can access DHSS’ Weekly Influenza Report.  Health Alerts, Advisories, and Updates are available on the DHSS website.  For the most current information, please visit: http://health.mo.gov/emergencies/ert/alertsadvisories/index.php.

Ensure Your Local EMD has a Copy of Your Home’s Current Emergency Plan

Missouri has experienced extreme weather conditions this winter, and there is a chance of more inclement weather in the forecast.  The Section for Long-Term Care Regulation would like to remind you there are emergency preparedness representatives in your community to help you with emergency planning and are there to help in the event of a disaster.

You can find your local emergency management director (EMD) on the State Emergency Management Agency’s (SEMA) website at www.sema.dps.mo.gov.  Scroll down to Contact Your Local Emergency Management Agency and choose your county.

State regulations require all long-term care homes to provide a copy of their emergency plan to their local EMD.  Please reference the following regulations:

19 CSR 30-85.022 (33) and 19 CSR 30-86.022 (5)(A) All facilities shall have a written plan to meet potential emergencies or disasters and shall request consultation and assistance annually from a local fire unit for review of fire and evacuation plans.  If the consultation cannot be obtained, the facility shall inform the state fire marshal in writing and request assistance in review of the plan.  An up-to-date copy of the facility’s entire plan shall be provided to the local jurisdiction’s emergency management director.

For additional information regarding emergency preparedness, please contact Melissa Hope, Planner II, Division of Regulation and Licensure at melissa.hope@health.mo.gov.

Resources are also available on the Department of Health and Senior Services website, http://health.mo.gov/emergencies/readyin3/adultcare.php.

MDS and Flu Season

CMS posts the public Quality Measures on Nursing Home Compare, and consumers are able to view the percentage data that your nursing home offered and administered the flu vaccine during the current or most recent influenza season.

The 3.0 Resident Assessment Instrument (RAI) manual does not provide specific dates for influenza season.  This has prompted Missouri facilities to ask what dates are considered the influenza season in Missouri, in order to correctly code the MDS, which will be reflected in their Quality Measures.  Seasonal flu monitoring and reporting to the CDC in Missouri begins in early October and extends well in to the month of May.

For MDS coding purposes, if the resident is not in the facility between October 1 and May 31, you should code in Section O:  “Resident not in facility during this year’s flu season.”  For residents who are in the facility from October 1 through the last week of May, the facility is required to offer the flu vaccine as long as it is “reasonably available,” which means that it is still available to be ordered from your local pharmacy or supplier.

If you have any questions, you may contact Joan Brundick, State RAI Coordinator, at 573-751-6308 or email joan.brundick@health.mo.gov.

Health Advisory: pH1N1 Influenza

Health Advisory:  Pandemic pH1N1 Virus-Associated Illnesses and the Influenza Season in Missouri (12.26.13)

CDC Health Advisory:  Notice to Clinicians: Early Reports of pH1N1-Associated Illnesses for the 2013-14 Influenza Season (12.24.13)

Health Alerts, Advisories, and Updates are available on the Department of Health and Senior Services website.  For the most current information, please visit: http://health.mo.gov/emergencies/ert/alertsadvisories/index.php.

Flu Season is Here

Homes are required to offer the flu vaccine to all of their residents.  Vaccination of your healthcare workers, although not mandated, is also important in preventing the spread of flu in your home.  Encouraging your staff to receive the vaccination can also help reduce absenteeism due to illness and reduce the costs of care associated with ill residents. 

Flu season information is available on the CDC website at www.cdc.gov/flu/index.htm.

Safety Reminders: Holiday Decorations

It is that time of year when people are decorating their homes and businesses with festive décor and anticipating upcoming holiday celebrations.  Residents and staff in your care home also look forward to festivities and enjoy holiday decorations.  It is important for residents, staff and visitors to carry on traditions and to feel a sense of joy and peace we all want this time of year.

The Section for Long-Term Care Regulation (SLCR) wants to help you and your residents have a safe holiday season by sending out the following safety tips, references and regulatory reminders.

Fires or other accidents are not something anyone wants! 

Safe decorations include:

  • Artificial Christmas trees, and decorations that are non-combustible or flame retardant.
  • UL approved decorative lighting (use in supervised areas and turn off when not in use).
  • UL approved outdoor lighting.
  • Holiday decorations, including evergreen wreaths, ornaments, photos, etc. can be used on resident’s doors, and in hallways, as long as they do not exceed 3 ½” in depth and they are not blocking the entrances or exits.*

*Any combustible decorations hung from doors or walls in corridors may be used with a waiver.  Non-rated combustible decorations cannot exceed 20% of the wall space in an exit egress corridor.

SLCR published an article regarding holiday decorating in the winter 2011 edition of the quarterly newsletter.  Please visit http://health.mo.gov/seniors/nursinghomes/providerinfo.php.

Although the 2000 Edition National Fire Protection Association (NFPA) 101® Life Safety Code (LSC) is the official reference, the 2012 Edition contains some less restrictive requirements.  Please refer to the CMS memo regarding waivers here: CMS Memo S&C 13-58-LSC 2000 Edition National Fire Protection Association (NFPA) 101® Life Safety Code (LSC) Waivers, or visit the CMS website at www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions.html.

Prohibited decorations include displays, hangings, and other decorations that block exits, visibility of exits, or fire protection appliances.  Never hang decorations from fire sprinkler heads or pipes.

NFPA 101, Section 19.7.5.4:  Combustible decorations shall be prohibited in any health care occupancy unless they are flame retardant.

NFPA 101, Section 7.1.10.1:  Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

NFPA 101, Section 7.1.10.2.1:  No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress therefrom, or visibility thereof.

 

Please note, some county or city local ordinances may also require compliance with more restrictive standards, including the International Fire Code (IFC).

 

  • F323:  Electrical Safety – Any electrical device, whether or not it needs to be plugged into an electric outlet, can become hazardous to the residents through improper use or improper maintenance.  Electrical equipment such as electrical cords can become tripping hazards.  Halogen lamps or heat lamps can cause burns or fires if not properly installed away from combustibles in the resident environment.  The Life Safety Code prohibits the use of portable electrical space heaters in resident areas.

 

 

  • Can candles be used in nursing homes under supervision, in sprinklered facilities?

CMS Memo S&C-07-07:  Nursing Home Culture Change Regulatory Compliance Questions and Answers

Answer: Regarding the request to use candles in sprinklered facilities under staff supervision, National Fire Protection Association data shows candles to be the number one cause of fires in dwellings.  Candles cannot be used in resident rooms, but may be used in other locations where they are placed in a substantial candle holder and supervised at all times while they are lighted.  Lighted candles are not to be handled by residents due to the risk of fire and burns.

This holiday season, consider using battery-operated flameless candles.  They look and smell real!  Learn more about candle fire safety from the U.S. Fire Administration at www.usfa.fema.gov/citizens/home_fire_prev/holiday-seasonal/holiday.shtm.

If you have any questions regarding the Life Safety Code, please contact SLCR at 573-526-8524.  We wish you a wonderful and safe holiday season.

Tuberculin Skin Test Antigen Available – Shortage Resolved

The national shortage of TUBERSOL® used in the administration of PPD tuberculin skin tests appears to be resolved and is now widely available.  Providers should administer PPD tuberculin skin tests that were deferred due to the shortage.  Please make every effort to complete all deferred testing within the next 30 days.  If you are unable to meet this timeframe, please work with your Regional Office to establish an acceptable timeframe to complete your deferred testing.  If you have any questions, you may also contact Joan Brundick at 573-751-6308 or send an email to joan.brundick@health.mo.gov.

posted December 6, 2013