5/19/2011. Fire Safety Survey. Hi, we re from the Health Department and would like to speak with the Administrator and Maintenance Director

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1 APRIL 2011 The Survey Process and Your Surveyors Presented by State of Connecticut Department of Public Health Facilities Licensing & Investigations Building & Fire Safety Unit 410 Capitol Avenue Hartford, CT Phone (860) Fax (860) Irving Moy, PHSM Ken Anton, BFSI 2, Allen Beebe, BFSI 2, Anthony Bruno, BFSI 2 Chris Doyle, BFSI 2, David Kromas BFSI 2 Fire Safety Survey Objectives: Give you a better understanding of what the BFSU does and what we look for and what is expected as a provider. Clear up any confusion of the Federal/State Survey Process. Answer any questions in general. Ken Anton, & Christopher Doyle, BFSI II s Hi, we re from the Health Department and would like to speak with the Administrator and Maintenance Director 1

2 The CMS survey process: The facility has elected to enroll to become a provider in the Medicare program, which is a voluntary program. Part of the program has to ensure resident safety through annual survey both clinical review and life safety. State / Federal Survey Fire Safety Survey K-tags Deficiencies - Federal Violations State Form CMS-2786R FIRE SAFETY SURVEY REPORT 2000 CODE HEALTHCARE Public Health Code D8t (u) - Emergency Preparedness D8t(v) - Physical Plant CCNH - Chronic & Conv. Nursing Home RHNS - Rest Home w/ Nursing Supervision SNF - Skilled Nursing Facility NF - Nursing Facility Public Health Code D8t(f)(3)(A) - The administrator shall be responsible for the overall management of the facility and shall have the following powers and responsibilities: Enforcement of any applicable local and state regulations, any federal regulations that may apply to federal programs in which the facility participates, and facility by-laws; Public Health Code D8t(v)(4) Review of plans. Plans and specifications for new construction and rehabilitation, alteration addition, or modification of an existing structure shall be approved by the Department on the basis of compliance with the Regulations of Connecticut State Agencies after the approval of such plans and specifications by local building inspectors and fire marshals, and prior to the start of construction. 2

3 Life Safety Code Edition CMS adopted 2000 of NFPA 101 Published January 10, 2003 in Federal Register 42 CFR Part 483 Requirements for States and Long Term Care Facilities, Subpart B Requirements for Long Term Care Facilities, Section Physical Environment, (a) Life Safety From Fire Focuses on maintenance of systems Surveying under new code began September 11, 2003 Life Safety Code Edition The Federal LSC Certification Survey Entrance (Survey Team) Documentation Review Fill in Documentation work Sheet Tour of the Facility Fire Drill Generator Exit Documentation Review & Maintenance Requirements Fire Extinguishers NFPA Chap Inspect - visual 30 day intervals / as needed & Maintenance- Annual / 6 year maintenance / 12 year hydrostatic Sprinklers NFPA Chap. 2 Table 2.1 Wet / Dry Systems 2.2 Inspection- weekly / monthly / quarterly / annual 2.3 Testingmonthly / quarterly / annual 2.4 Maintenance- as needed / annual / 5 years Dry Systems Inspection- weekly gauges; monthly valve external visual; annual valve internal visual; internal visual of strainers, filters, orifices every 5 years Testing- priming water quarterly: partial trip test valve annually; full trip test 3 years; Quick opening device / low air pressure alarm quarterly; low temperature alarm / automatic air pressure maintainer annually; as needed Maintenance- internal valve cleaning with annual trip test; Low point draining after each operation of system and before onset of cold weather 3

4 Standpipes NFPA Chap. 3 Table 3.1 & Inspection- quarterly visual of all components; Weekly/monthly visual of control valves in accordance w/ Table 9.1; cabinet & hoses per NFPA Testing- 5 year flow test & hydrostatic test; valves tested in accordance w/ Table 9.1; Alarm devices-quarterly; Hose & nozzles annually; Main drain - annually 3.4 Maintenance- Table Hose Testing (standpipes) NFPA (Occupant Use Hose) NFPA Chap. 3 Table 3.1 & annual / 3 years / 5 years Chap & & & Inspection hose / gaskets removed inspected re-racked/re-reeled - annually Testing- service test initially after 5 years & every 3 years thereafter in accordance w/ Chap Maintenance- hose protected from weather / environmental conditions, heat, mechanical damage, & rodents Fire Pumps NFPA Chap. 5 Table & Inspection weekly visual 5.3 Testing weekly run of electric motor for 10 minutes (no water flow); annual flow test 5.5 Maintenance preventive maintenance program established and initiated Water Storage Tanks NFPA Chap. 6 Table Inspection- water level monthly; exterior tank and components quarterly; interior of tank every 5 years (3 years if no corrosion prevention or if a pressure tank); air pressure monthly; heating system daily (during cold season); Expansion joints annually 6.3 Testing Water level indicators & pressure gauges calibrated- 5 years; High/low level alarms- 6 months; Interior testing every 5 years 6.4 Maintenance exterior/interior free of foreign materials: Sediment drained 6 months; Tank drains opened/closed & tanks vents cleaned annually Control Valves NFPA Chap. 9 Table Inspection weekly / monthly / quarterly / annual / 5 years Testing quarterly / 6 month / annually/ 3 years / 5 years Maintenance - annual Fire Alarm System NFPA Chap. 7 Table & & test frequencies based on requirements for each individual device Smoke Detectors NFPA Chap & Table & & Semi-annual visual inspection; Annual functional test; 2 year sensitivity test after 1 year initial install; Heat Detectors NFPA Chap Table & & two or more on each initiating circuit annually; All heat detectors tested by 5 years Fire Doors & Windows NFPA Chap. 15 Frequent inspection of doors and hardware; closing mechanisms and hardware in proper working condition at all times; Kitchen Exhaust Hood Extinguishment System NFPA Chap Inspection & Servicing - 6 months; Fusible link & sprinkler heads replaced annually; tanks follow NFPA 10 requirements Kitchen Exhaust Hood NFPA Cleaning frequency based on use; High volume cooking quarterly; Moderate volume cooking 6 month; Low- volume cooking - annually 4

5 Smoke / Fire Dampers NFPA 90A 1999 B.2 Inspection - 2 year recommended visual inspection Maintenance - 4 year link removal and damper maintenance Fire Drills NFPA Quarterly on each shift Employees instructed in life safety procedures & equipment Evacuation & Relocation Plan NFPA Plan in place and written copies available to all staff at all times; Staff periodically instructed as to their duties under the plan; Standard of Practice Review by local Fire Marshal and administrative staff at least annually and as needed to keep plan current & up to date Medical Gases (oxygen) NFPA Chap Storage Compressed gases Storage & use Liquefied gases Standards of Practice Annual inspection of alarms, outlets, & equipment Piped Medical Gas Systems CGA E-10 Recommended Minimum Maintenance Schedule Emergency Generators NFPA Chap times/year: >20 days & <40 days Standard of Practice (a) Exercise (typ. weekly) per manufacturers recommendations & before impending storm Circuit Breakers- tested annually & program for periodic exercising of components established Batteries inspected weekly NFPA Chap. 6 Maintenance & Testing & Inspect weekly; Load test at least monthly for a minimum of 30 minutes & Transfer switch operated monthly and maintenance program established & initiated; Electrical Receptacles NFPA Chap. 3 Receptacle Testing in Patient Care Areas (including GFCIs) Physical integrity, continuity, polarity, & retention force (115g or 4 oz) shall be tested; GFCIs shall trip at >6 ma Maintenance & Testing Frequency: Upon initial installation, replacement, or servicing; Additional testing performed at frequencies defined by documented performance data ; Non-hospital grade receptacles shall be tested at 12 month intervals NFPA 70 Article 517 Health Care Facilities installation & replacement requirements Patient Care Related Electrical Appliances & Equipment NFPA Chap & Testing Requirements: testing for physical integrity, resistance, & leakage current; Frequency: before initial use and repair or modification & retested at intervals based on location: General Care Areas = 12 months Critical Care & Wet Areas = 6 months Appliances Used in Patient Areas NFPA Chap (b) Before initial use and after repair or modification Emergency Lighting NFPA Refers to Chap Testing: functional test for 30 seconds every 30 days; 1 ½ hour test- annually Exit Signs (battery back-up) NFPA Refers to Chap & & Inspection: visual every 30 days Testing: functional test for 30 seconds every 30 days; 1 ½ hour test- annually Smoke Barriers NFPA Fire Barriers NFPA Finishes / Furnishings NFPA Fire resistance rating of not less that ½ hour maintained Penetrations sealed with material that maintain smoke resistance of barrier Doors are maintained as self closing and/or automatic closing Fire resistance rating of fire barrier maintained at all times Penetrations sealed with materials having the same fire rating as the barrier Doors are self closing and positively latch & Finishes: Class A, B, (or C if sprinklered); Newly installed materials - Class A & Draperies/Curtains: Flame resistant in accordance with NFPA & Upholstered Furniture: in accordance with NFPA (2) & 260, 261, 266; Except patient owned furniture in rooms with smoke detector Mattresses: in accordance with NFPA 267; Except &10.3.2(2) patient owned mattress in room with smoke & detector Combustible decorations: PROHIBITED Soiled Linen/Trash collection receptacles: cannot exceed 32 gallon capacity; >32 gallons located in hazardous area protected room 5

6 K 48 There is a written plan for the protection of all patients and for their evacuation in the event of an emergency , K 50 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. Where drills are conducted between 9:00 PM and 6:00 AM a coded announcement may be used instead of audible alarms , Fire Drills / Evacuation Procedures * Fire exit drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms. Exception: The movement of infirm or bedridden patients to safe areas or to the exterior of the building shall not be required. Fire Drills / Evacuation Procedures A written facility fire safety plan shall provide for Use of alarms Transmission of alarm to fire department Response to alarms Isolation of fire Evacuation of immediate area Evacuation of smoke compartment Preparation of floors and building for evacuation Extinguishment of fire. Fire Drills / Evacuation Procedures All facility personnel shall be instructed in the use of and response to fire alarms, and, in addition, they shall be instructed in the use of the code phrase to ensure transmission of an alarm under the following conditions: When the individual who discovers a fire must immediately go to the aid of an endangered person. During a malfunction of the building fire alarm system. Personnel hearing the code announced shall first activate the building fire alarm using the nearest manual alarm station and then shall execute immediately their duties as outlined in the fire safety plan. 6

7 Public Health Code D8t (u) - Emergency Preparedness (u) Emergency preparedness plan. (1) The facility shall have a written emergency preparedness plan which shall include procedures to be followed in case of medical emergencies, or in the event all or part of the building becomes uninhabitable because of a natural or other disaster. The plan shall be submitted to the local fire marshal or, if none, the state fire marshal for comment prior to its adoption. (2) The plan shall specify the following procedures: (A) Identification and notification of appropriate persons; (B) Instructions on locations/use of emergency equipment and alarm systems; (C) Tasks and responsibilities assigned to all personnel; (D) Evacuation routes; (2) The plan shall specify the following procedures: (E) Procedures for relocation and/or evacuation of patients; (F) Transfer of casualties; (G) Transfer of records; (H) Care and feeding of patients; (I) Handling of drugs and biologicals. Kitchen hood/ cook line requirements: K 69 Cooking facilities shall be protected in accordance with , , NFPA 96 7

8 Kitchen Exhaust Hood Extinguishment System NFPA Chap Inspection & Servicing - 6 months; Fusible link & nozzles/replaced annually; tanks follow NFPA 10 requirements Kitchen Exhaust Hood NFPA Cleaning frequency based on use; High volume cooking quarterly; Moderate volume cooking 6 month; Low- volume cooking - annually Allen Beebe, BFSI II Everything you ever wanted to know about Fire & Smoke Barriers and how to stay tag free Fire Barriers & Smoke Barriers K 11 If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a two hour fire resistance rating constructed of materials as required for the addition. Communicating openings occur only in corridors and shall be protected by approved self-closing fire doors , , , K EXISTING Corridors are separated from use areas by walls constructed with at least 1/2 hour fire resistance rating. In sprinklered buildings, partitions are only required to resist the passage of smoke. In non-sprinklered buildings, walls properly extend above the ceiling. (Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Charting and clerical stations, waiting areas, dining rooms, and activity spaces may be open to corridor under certain conditions specified in the Code. Gift shops may be separated from corridors by non-fire rated walls if the gift shop is fully sprinklered.) ,

9 K EXISTING Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4 inch sold-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. There is no impediment to the closing of the doors. Doors shall be provided with a means suitable for keeping the door closed. Dutch doors meeting are permitted Roller latches are prohibited by CMS regulations in all health care facilities New Doors protecting corridor openings shall be constructed to resist the passage of smoke. Doors shall be provided with positive latching hardware. Dutch doors meeting are permitted. Roller latches shall be prohibited K EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least one hour. An atrium may be used in accordance with , NEW Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least two hours connecting four stories or more. (One hour for single story building and sprinklered buildings up to three stories in height.) An atrium may be used in accordance with K 21 Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier or hazardous area enclosure shall be permitted to be held open only by devices arranged to automatically close all such doors by zone or throughout the facility upon activation of: _ (a) The required manual fire alarm system and _ (b) Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system and _ (c) The automatic sprinkler system, if installed , , K EXISTING Exit components (such as stairways) are enclosed with construction having a fire resistance rating of at least one hour, are arranged to provide a continuous path of escape, and provide protection against fire or smoke from other parts of the building , NEW Exit components (such as stairways) in buildings four stories or more are enclosed with construction having a fire resistance rating of at least two hours, are arranged to provide a continuous path of escape, and provide a protection against fire and smoke from other parts of the building. 9

10 K EXISTING Smoke barriers shall be provided to form at least two smoke compartments on every sleeping room floor for more than 30 patients , NEW Smoke barriers shall be provided to form at least two smoke compartments on every floor used by inpatients for sleeping or treatment, and on every floor with an occupant load of 50 or more persons, regardless of use. Smoke barriers shall also be provided on K 24 The smoke compartments shall not exceed 22,500 square feet and the travel distance to and from any point to reach a door in the required smoke barrier shall not exceed 200 feet , K EXISTING Smoke barriers shall be constructed to provide at least a one half hour fire resistance rating and constructed in accordance with 8.3. Smoke barriers shall be permitted to terminate at an atrium wall. Windows shall be protected by fire-rated glazing or by wired glass panels and steel frames. A minimum of two separate compartments shall be provided on each floor , , , NEW Smoke barriers shall be constructed to provide at least a one hour fire resistance rating and constructed in accordance with 8.3. Smoke barriers shall be permitted to terminate at an atrium wall. Windows shall be protected by fire-rated glazing or by wired glass panels in approved frames. A minimum of two separate compartments shall be provided on each floor , , K 26 Space shall be provided on each side of smoke barriers to adequately accommodate those occupants served , K EXISTING Door openings in smoke barriers have at least a 20 minute fire protection rating or are at least 13/4 inch thick solid bonded core wood. Non-rated protective plates that do not exceed 48 inches from the bottom of the door are permitted. Horizontal sliding doors comply with Doors shall be self-closing or automatic-closing in accordance with Swinging doors are not required to swing with egress and positive latching is not required , , NEW Door openings in smoke barriers have at least a 20 minute fire protection rating or are at least 13/4 inch thick solid bonded core wood. Non-rated protective plates that do not exceed 48 inches from the bottom of the door are permitted. Horizontal sliding doors comply with Swinging doors shall be arranged so that each door swings in an opposite direction. Doors shall be self-closing and rabbets, bevels or astragals are required at the meeting edges. Positive latching is not required , ,

11 K 104 Penetrations of smoke barriers by ducts are protected in accordance with K EXISTING One hour fire rated construction (with 3/4 hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with and/or protects hazardous areas. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors. Doors shall be self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted Boiler and Fuel-Fired Heater Rooms, Laundries (greater than 100 sq feet) Repair Shops and Paint Shops, Laboratories (if classified a Severe Hazard - see K31) Combustible Storage Rooms/Spaces (over 50 sq feet) Trash Collection Rooms, Soiled Linen Rooms 2000 NEW Hazardous areas are protected in accordance with 8.4. The areas shall be enclosed with a one hour fire-rated barrier, with a 3/4 hour fire-rated door, without windows (in accordance with 8.4). Doors shall be self-closing or automatic closing in accordance with Boiler and Fuel-Fired Heater Rooms, Laundries (greater than 100 sq feet) Repair, Maintenance and Paint Shops, Laboratories (if classified a Severe Hazard - see K31) Combustible Storage Rooms/Spaces (over 50 and less than 100 sq feet) Trash Collection Rooms, Soiled Linen Rooms Combustible Storage Rooms/Spaces (over 100 sq feet) Requirements & Testing of Generators Types of Testing Weekly Typically exercised (not required) Monthly full load test 11

12 Two methods Dropping street power best simulation not required facility policy Test / Simulator Switch puts load on generator but does not cut street power only switches to generator legs of transfer switch Documentation logs need to show minimum requirements monthly under load for 30 minutes annual testing of main electrical switch Generator Serviced semi-annually (level 1 major level 2 minor) Generator under load must achieve 30% of name plate rating when tested or must be load banked annually Construction / Renovations 12

13 Public Health Code D8t(v)(4) Review of plans. Plans and specifications for new construction and rehabilitation, alteration addition, or modification of an existing structure shall be approved by the Department on the basis of compliance with the Regulations of Connecticut State Agencies after the approval of such plans and specifications by local building inspectors and fire marshals, and prior to the start of construction. David Kromas, BFSI II Everything I can do not to alarm you about the testing requirements for your Fire Alarm and Sprinkler Systems System Components smoke detectors Sprinklers supervision & flow pull stations horns / strobes smoke barriers / smoke doors magnetic holders tied to fire alarm release on activation fire department notification / monitoring company 13

14 K EXISTING A fire alarm system with approved component, devices or equipment installed according to NFPA 72, National Fire Alarm Code 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. Pull stations in patient sleeping areas, may be omitted provided that manual pull stations are within 200 ft of nurse s stations. Pull stations are located in the path of egress. Electronic or written records of tests shall be available. A reliable second source of power must be provided. Fire alarm systems shall be maintained periodically and records of maintenance kept readily available. There shall be annunciation of the fire alarm system to an approved central station , 9.6 K 52 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. Also, shall have an approved maintenance and testing program complying with applicable requirement of NFPA 70 and K 155 Where a required 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 shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service K 54 All required smoke detectors, including those activating door hold-open devices, are approved, maintained, inspected and tested in accordance with the manufacturer s specifications

15 Fire Alarm System NFPA Chap. 7 Table & & test frequencies based on requirements for each individual device Smoke Detectors NFPA 72 Chap. 7 Table & & Semi-annual & visual inspection; Annual functional test; 2 year sensitivity test after 1 1 year initial install; Heat Detectors NFPA Chap. 7 Table & & two or more on each initiating circuit annually; All heat detectors tested by 5 years Fire Doors & Windows NFPA 80 Chap. 15 Frequent inspection of doors and 1999 hardware; closing mechanisms and hardware in proper working condition at all times; Kitchen Exhaust Hood NFPA 96 Chap. 8 Inspection & Servicing - 6 months; 1998 Extinguishment 8.2 Fusible link & sprinkler heads System replaced annually; tanks follow NFPA 10 requirements Kitchen Exhaust Hood NFPA Cleaning frequency based on use; High volume cooking quarterly; Moderate volume cooking 6 month; Low- volume cooking - annually Smoke / Fire Dampers NFPA 90A B.2 Inspection - 2 year recommended visual 1999 inspection Maintenance - 4 year link removal and damper maintenance * Fire Alarm System Shutdown. Where a required fire alarm system is out of service for more than 4 hr in a 24-hr period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service The personnel assigned to a fire watch should consist of trained personnel who only job/responsibility shall be to continuously patrol the effected area. Ready access to fire extinguishers and the ability to promptly notify the fire department are important items to consider. During the patrol of the area, the person should not only be looking for fire, but making sure that the other fire protection features of the building such as egress routes and alarm systems are available and functioning properly. Frequency of rounds determined by impairment and area effected Documentation of rounds to be logged and maintained. Fire Watch (2000 NFPA 101) * Fire Alarm System Shutdown. Where a required fire alarm system is out of service for more than 4 hours in a 24-hr period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. A A fire watch should at least involve some special action beyond normal staffing, such as assigning an additional security guards to walk the areas affected. These individuals should be specially trained in fire prevention and in occupant and fire department notification, and in understanding the particular fire safety situation for public education purposes. Some authorities having jurisdiction require fire fighters to be assigned to the area, with direct radio communication to the local fire department. 15

16 K EXISTING There is an automatic sprinkler system installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, standard approved type to provide complete coverage for all portions of the building. If partial system, indicate location of sprinklers. The systems shall be properly maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. It shall be fully supervised. There shall be 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 NEW There is an automatic sprinkler system installed in accordance with NFPA13, Standard for the Installation of Sprinkler Systems, with approved components, device and equipment, to provide complete coverage of all portions of the facility. The systems shall be maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. It shall be a reliable, adequate water supply for the systems. Systems are equipped with water flow and tamper switches, which are connected to the fire alarm system Sprinklers NFPA Chap. 2 Table 2.1 Wet / Dry Systems 2.2 Inspection- weekly / monthly / quarterly / annual 2.3 Testing- monthly / quarterly / annual 2.4 Maintenance- as needed / annual / 5 years Dry Systems Inspection- weekly gauges; monthly valve external visual; annual valve internal visual; internal visual of strainers, filters, orifices every 5 years Testing- priming water quarterly: partial trip test valve annually; full trip test 3 years; Quick opening device / low air pressure alarm quarterly; low temperature alarm / automatic air pressure maintainer annually; as needed Maintenance- internal valve cleaning with annual trip test; Low point draining after each operation of system and before onset of cold weather Standpipes NFPA Hose Testing (standpipes) NFPA (Occupant Use Hose) NFPA Chap. 3 Table 3.1 & Inspection- quarterly visual of all components; Weekly/monthly visual of control valves in accordance w/ Table 9.1; cabinet & hoses per NFPA Testing- 5 year flow test & hydrostatic test; valves tested in accordance w/ Table 9.1; Alarm devices-quarterly; Hose & nozzles annually; Main drain - annually 3.4 Maintenance- Table Chap. 3 Chap & & & Table 3.1 & annual / 3 years / 5 years Inspection hose / gaskets removed inspected re-racked/rereeled - annually Testing- service test initially after 5 years & every 3 years thereafter in accordance w/ Chap Maintenance- hose protected from weather / environmental conditions, heat, mechanical damage, & rodents 16

17 Fire Pumps NFPA Water Storage Tanks NFPA Control Valves NFPA Chap. 5 Table & Inspection weekly visual 5.3 Testing weekly run of electric motor for 10 minutes (no water flow); annual flow test 5.5 Maintenance preventive maintenance program established and initiated Chap. 6 Table Inspection- water level monthly; exterior tank and components quarterly; interior of tank every 5 years (3 years if no corrosion prevention or if a pressure tank); air pressure monthly; heating system daily (during cold season); Expansion joints annually 6.3 Testing Water level indicators & pressure gauges calibrated- 5 years; High/low level alarms- 6 months; Interior testing every 5 years 6.4 Maintenance exterior/interior free of foreign materials: Sediment drained 6 months; Tank drains opened/closed & tanks vents cleaned annually Chap. 9 Table Inspection weekly / monthly / quarterly / annual / 5 years Testing quarterly / 6 month / annually/ 3 years / 5 years Maintenance - annual K 60 Initiation of the required fire alarm systems shall be by manual means in accordance with and by means of any required sprinkler system water flow alarms, detection devices, or detection systems , , K 61 Required automatic sprinkler systems shall have valves supervised so that at least a local alarm will sound when the valves are closed. NFPA 72, , NFPA 25 K 62 Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically , , , NFPA 13, NFPA 25, K 62 Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically , , , NFPA 13, NFPA 25, K 63 Required automatic sprinkler systems have an adequate and reliable water supply which provides continuous and automatic pressure , NFPA 13 Fire Watch & (2000 NFPA 101) K 154 Where a required automatic sprinkler 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 be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service Where the required automatic sprinkler system is out of service for more than 4 hours in a 24-hr period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service. 17

18 Irving Moy, PHSM It has been a pleasure to work with you the Canpfa group and this in-service has been my gift to you. I hope this will help you, and help provide a smoother survey process & provide a better environment for the residents we serve What to do if you receive a deficiency letter and CMS 2567 Statement of Deficiencies Filing a plan of correction. The following are the directions for filing a plan of correction Plans of Correction Written on form CMS 2567 Statement of Deficiencies. Plan of correction shall include: What measures will be put in place or systematic changes made to ensure that the deficient practice is corrected. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur. Identify the staff member by title who has been designated the responsibility for monitoring the individual plan of correction submitted for each deficiency Completion Date (X5) Signature of Provider Representative/Administrator (X6) 18

19 STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH March 31, 2011, Administrator Facility Name 000 street Any Town, CT Dear Mr. And/or Ms.: An unannounced survey was conducted at the above facility by the State of Connecticut Department of Public Health, Facility Licensing & Investigations Section, Building & Fire Safety Unit on (date of survey) to determine if your facility was in compliance with federal requirements for safety from fire in nursing homes participating in the Medicare and/or Medicaid programs. The findings of the survey indicate that standards were out of compliance. Based on the findings of this survey, the facility is not certifiable at this time. The attached Statement of Deficiencies (form CMS 2567) identifies the apparent deficiencies noted during the course of the visit. An "Enforcement Cycle" has been initiated based on the citation of deficiencies at a D level or greater at your facility. All statutory/mandatory enforcement remedies are effective based on the beginning survey of the Enforcement Cycle. Facilities are expected to achieve and maintain continuous substantial compliance. Your facility has an "opportunity to correct" the deficiencies noted. Remedies will be recommended for imposition by the Centers for Medicare and Medicaid Services (CMS) Regional Office and the State of Connecticut Department of Social Services, if your facility has failed to achieve substantial compliance by (90 days). It is advised that an acceptable plan of correction be prepared and implemented as expeditiously as possible. The consideration for continued certification will be based on the correction of deficiencies. Please respond by (10 days) with an acceptable plan of correction. The plan of correction must be written on the Statement of Deficiencies (form CMS 2567). Attachments may not replace the plan of correction. A completion date is required for each item of each deficiency and should be documented in the designated column (X5). A signature is required at the bottom of the first page of the Statement of Deficiencies in the designated row (X6). Please address each deficiency with a prospective plan of correction that includes the following components: a. What measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; b. How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not reoccur, i.e., what program will be put into place to monitor the continued effectiveness of the systemic change; c. Identify the staff member by title, who has been designated the responsibility for monitoring the individual plan of correction submitted for each deficiency. The Plan of Correction serves as your allegation of compliance. We may accept the written allegation of compliance and presume compliance until substantiated by a revisit or other means. In such a case, neither the CMS Regional Office nor the State of Connecticut will impose any recommended remedies at that time. If, upon the subsequent revisit, your facility has not achieved substantial compliance, we will recommend that the appropriate remedies be imposed by CMS and the State of Connecticut beginning on March 24, 2011 until substantial compliance is achieved. Additionally, the CMS Regional Office or the State of Connecticut may impose revised remedies, based on changes in the seriousness of the noncompliance at the time of the revisit, if appropriate. A temporary waiver of time frames to implement denial of payment for new admissions and/or termination of the provider agreement can be requested for LSC deficiencies requiring more than ninety (90) days to correct. This waiver request must be made on the plan of correction for each individual deficiency that will require an extended completion date beyond these time frames. In accordance with , you have one opportunity to question cited deficiencies through an informal dispute resolution process. To be given such an opportunity, you are required to send your written request, along with the specific deficiencies being disputed, and an explanation of why you are disputing those deficiencies (or why you are disputing the scope and severity assessments of deficiencies which have been found to constitute SQC or immediate jeopardy), to this office. This request must be sent during the same 10 day period you have for submitting a PoC for the cited deficiencies. Informal dispute resolution in no way is to be construed as a formal evidentiary hearing. It is an informal administrative process to discuss deficiencies. If you will be accompanied by counsel, you must indicate this in your request for informal dispute resolution. You will be advised in writing of the decision related to the informal dispute. Informal dispute resolution for the cited deficiencies will not delay the imposition of the enforcement actions recommended or revised as appropriate. You will note that these deficiencies pertain to Fire Safety and we request that your response to these deficiencies be returned directly to: State of Connecticut Department of Public Health Facility Licensing & Investigations Section, Building & Fire Safety Unit 410 Capitol Avenue, MS #12 HFC P.O. Box Hartford, CT If you have any questions, please do not hesitate to contact this office at (860) Sincerely yours, Irving D. Moy, A.B., M.Arch, M.A. Public Health Services Manager Facility Licensing & Investigations Section c: certification file Enclosures STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH September 8, 2008, Administrator Facility name Ave Town, CT Dear Mr. Or Ms: An unannounced visit was made to the above facility on August 25, 2008 by a representative of the Facility Licensing & Investigations Section, Building and Fire Safety Unit for the purpose of conducting certification and/or licensure inspection. Attached are the violations of the regulation of Connecticut State Agencies and/or General Statutes of Connecticut, which were noted during the course of this visit. You may wish to dispute the violations and you may be provided with the opportunity to be heard. If the violations are not responded to by September 22, 2008 or if a request for a meeting is not made by the stipulated date, the violations shall be deemed admitted. Please address each violation with a prospective plan of correction which includes the following components: a. Measures to prevent the recurrence of the identified violation, (e.g., policy/procedure, in service program, repairs, etc.). b. Date corrective measures will be effected. c. Identify the staff member, by title, who has been designated the responsibility for monitoring the individual plan of correction submitted for each violation. If there are any questions, please do not hesitate to contact this office at (860) Sincerely yours, Irving D. Moy, A.B., M.Arch, M.A. Public Health Services Manager Facility Licensing & Investigations Section Enclosures c: licensure file FACILITY: Page 1 of 2 19

20 DATE(S) OF VISIT: THE FOLLOWING VIOLATION(S) OF THE REGULATIONS OF CONNECTICUT STATE AGENCIES AND/OR CONNECTICUT GENERAL STATUTES WERE IDENTIFIED The following is (are) (a) (an) violation (s) of the Regulations of Connecticut State Agencies Section 19-13D8t(f)(3): 1. During a tour of the facility Thank You For Your Time And Patience If you have any further questions after the question and answer session, please feel free to contact any of the Building and Fire Safety Inspectors at