Missouri Long-Term Care Information Update

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.

The Section for Long-Term Care Regulation will be releasing a series of Life Safety Code Information. Please see the entire document for reference.

Today’s subject is:

The Life Safety Code requires a facility with a generator to manually exercise all breakers and itemize all of the electrical panels used for the generator.

1. 1. How often does this need to occur?
   2. Does the facility have to have to follow the same procedure for all panels, even if they are not connected to the generator?

The LSC requires annual inspection and annual testing on all electrical panels attached to the generator unless the manufacturer’s guide states otherwise.

This only applies to the panels the generator utilizes (which will include the panels used for the Life Safety branches).

NFPA 99, 2012 edition:
6.4.4.1.2.1* Circuit Breakers. Main and feeder circuit breakers shall be inspected annually, and a program for periodically exercising the components shall be established according to manufacturer’s recommendations.
A.6.4.4.1.2.1 Main and feeder circuit breakers should be periodically tested under simulated overload trip conditions to ensure reliability.