1. Are there any annual sprinkler head inspection forms available? No, there are none available at this time.

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1 Sprinkler 1. Are there any annual sprinkler head inspection forms available? No, there are none available at this time. 2. Does the annual sprinkler head inspection have to be done by a licensed technician vs. facility staff? The sprinkler head inspection can be completed by facility staff. The key will be the identification and documentation that each sprinkler head has been inspected. 3. What is the frequency of the sprinkler internal inspection? NFPA requirements have been strengthened over the years for the inspection, testing and maintenance of sprinkler systems. NFPA adopted a code requiring that an internal inspection of piping be conducted every 5 years, or when conditions indicate the need for an internal inspection. This type of inspection may identify microbiologically influenced corrosion (MIC), rust, or slime that may obstruct the piping and compromise the system. If the facility has not done an inspection previously, then the first one is due by July 5, 2021, otherwise it is due 5 years since the last one completed. 4. What are the sprinkler testing annual inspection intervals? Sprinkler head professional inspection criteria is below. The facility is required to test 1% or 4 heads whichever is greater at the following intervals: a. Dry heads 10 years b. Quick response 20 years c. Standard response 50 years. Non-Hospital Grade Receptacle Testing 1. For electrical receptacles, does the inspection only apply to resident rooms or does it cover all plugs in the building? No, it only applies to receptacles within 6 of the patient s bed in the patient s room. 2. Is there a form for the electrical testing? Yes, there is a receptacle testing form attached to this Q&A. 3. Do the receptacles have to be labeled? No, but it is the recommended way to individually identify each for the inspection and testing documentation. 4. Where do we find the tool to measure receptacle retention? Electrical or internet suppliers such as granger.com or amazon.com.

2 Hazardous Spaces How do you determine if the load of a room exceeds capacity and needs a closer to avoid a K-29 (K 321)? This is a very subjective standard, but any room that appears to have a load that exceeds the facility design would be considered hazardous storage if the room is generally 50 sq. ft. or larger. The code reference is LSC 18/ , which for new facilities requires a 1-hr separation and for existing facilities requires separation that resists the passage of smoke. In both new and existing facilities there needs to be self-closing or automatic closing doors to hazardous areas including: a. Combustible Storage > 50 sq. ft b. Laundries > 100 sq. ft c. Boiler Room d. Repair, Maintenance & Paint Shops e. Trash Collection Rooms > 64 gallons f. Soiled Linen Rooms > 64 gallons Fire and Smoke Door Inspection 1. Does this training make us qualified to do our own door inspection? Yes, in most cases. The ability to be qualified is a combination of experience and training. This training along with being an experienced Facility/Maintenance Manager is adequate to perform the door inspection. NFPA 80 allows for individuals on the facility staff to perform this function if they are performed by individuals with knowledge and understanding.. 2. What about scrapes from wheel chairs? Can we cover it up with protective barrier (plastic or metal)? Damage on doors will be subjective. Scrapes should not be considered non-compliance as long as they are superficial. Yes, plates may be installed on smoke doors and for fire doors; check with manufacturer or door retailer on permitted in-field modifications. 3. Regarding fire and smoke door seals: is there a specification that must be met or can we get the seals at Ace Hardware for instance? Check with door retailers on appropriate gasketing/seals for smoke and fire doors. 4. What if there is a label indicating UL certification but not fire rated with hour rating? If this is discovered the door would not be considered fire rated labeled door. Each fire rated labeled door will indicate the amount of time the door is rated.

3 5. Do resident room doors that are not fire rated need to be inspected, and do we have to inspect restroom door a joining resident rooms? No, these are not a required door to be inspected and tested. The fire/smoke door inspection requirement Life Safety Code, NFPA 101 Section requires all fire and smoke doors to be inspected and tested, including: a. Fire rated labeled doors b. Doors in exit enclosures - typically stairwells and exit passageways c. Doors in smoke barriers d. Doors in other fire resistance rated walls such as hazardous areas and fire pump enclosures 6. The gap between the door and the floor is as follows: a. Fire rated and labeled doors ¾ b. Non-fire rated doors is 1 7. What is the door inspection regulation for an assistant living facility? The Ohio Fire Code does not require this inspection for Residential Care Facilities. 8. Can you use astragal on the door? Yes, in existing facilities with older door assemblies in with the two doors rely on each other to function there must be a coordinator and astragal which manages the two doors with one appropriately closing first. 9. Would it be permissible to have wood doors with a mail pocket screwed to the door? Yes, no, maybe It really depends on the door s use and whether it is fire rated and labeled or not. If it is a simple door which is not fire rated labeled then it may be permissible so long as it does not affect the door s function or the ability for the door to resist the passage of smoke. If the door is fire rated/labeled then this would likely not be permissible. 10. What if door hardware does not have a label on it? I am unsure how the state intends to determine the UL rating. Often obtaining the as built plans will provide you with the documentation regarding the fire door hardware. 11. Is a piano hinge acceptable? The requirement for fire rated doors is ball-bearing hinges that are UL rated. Need to check with the door retailer to see if there are appropriate piano hinge for the door installation. 12. I was informed by door repair company that if only one door of double doors is damaged that both door would have to be replaced. That may or may not be accurate but first consider the door s function when determining whether it can be repaired. Also clarify the nature of the damage and research if it can be repaired before concluding that both have to be replaced. 13. Is there any grandfathering of the door requirements? No, the requirements are applied for all doors in new and existing healthcare facilities.

4 Other 1. Will there be a webinar on CO2 detectors for a nursing facility? It is anticipated that CO2 protection will be required later this year as part of revisions to NH licensure. Education will be provided at that time. 2. During the weekly generator inspection does the generator have to be run? No, the weekly requirement is for a visual inspection of all of the parts of the generator, fuel level, oil level and battery. An example of a weekly inspection is attached. 3. Is there an example of a NFPA 99 Risk Assessment? Yes, the one developed by OHCA is attached. 4. How do you document an emergency light test when your lights are hard wired into the generator system? There is no requirement for emergency lighting devices to be tested monthly. Only those that have a battery in them are required to be tested 30 seconds monthly/90 minutes annually. There is a requirement that there be a battery powered emergency lighting at the generator/ transfer switch if indoors which would be tested in this fashion. Emergency lighting that is on the generator should be inspected monthly during the exercising of the generator to ensure lighting units are working. 5. What are the requirements for two locking/ delayed egress doors in the exit pathway? This is permitted in the Life Safety Code but may not be permitted by Ohio Fire Code. Some State Fire Marshals may still enforce the single device standard. The NFPA requirements for lock on doors in the path of egress is not permitted unless complies with: Clinical needs locks where individuals pose a security risk provided staff can unlock doors (dementia and psychiatric units) Delay egress locks permitted if the facility is fully sprinklered or smoke detected Provisions must exist for rapid removal Remote control locks Keys carried by ALL staff Other reliable means Smoke detection throughout secured area OR remote unlocking at CONSTANTLY supervised location Smoke and/or sprinkler activation will release the locks Locks release with loss of power 18/ and 18/ The requirements for delayed egress locks: 1. Releases with/in 15 seconds or 30 seconds per AHJ 2. <15 lb. for < 3 seconds to initiate 3. Unlocks with the loss of power 4. Unlocks with the initiation of fire alarm and/or smoke detector 5. Emergency lighting at door 6. Instructional sign at the door 7. Required signage: 8. PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS

5 6. Are gated patios or courtyards required to have alarms/ releasing devices on them? 7. Yes, if the patio or courtyard is an established fire egress pathway. 8. What are the requirement for the Fire Safety Evaluation Survey? The FSES was developed by the National Bureau of Standards at the request of the Department of Health and Human Services (DHHS) as an alternative method of determining compliance with the LSC. Facilities that pass the FSES may be certified for participation in the Medicare/Medicaid program even though they have repeat deficiencies reflected on the CMS The FSES is required when a facility has a serious building construction deficiency(s) that would make it difficult or impossible to correct reasonably and prevents the facility from technically meeting NFPA requirements such as hallway width, number of stories, wrong building type, inadequate number of exits etc. The FSES is no longer completed by state surveyors and the facility must hire a trained expert to complete. The 2013 FSES will be used in place of the 2001 FSES which was previously approved for use (Survey and Certification policy memorandum, S&C-03-21, dated May 8, 2003) with the 2000 LSC. The 2013 FSES has been updated by the NFPA and is calibrated to the requirements found in the recently adopted 2012 LSC. This will allow for a more accurate determination of LSC equivalencies.

6 Life Safety Documentation Is there a list of required inspection or documents for facilities to maintain? Yes, the following is a list of the commonly requested inspection and documentation by Ohio LSC Surveyors. The documentation should be kept in an orderly fashion such as in a 3-ring binder, and separated by each item topic. The binders should be maintained in an area where they are easily retrievable by key staff when the survey begins. Each binder should reflect required documentation for the current year or compliance cycle. When documentation is greater than annually then maintain the most recent testing or maintenance documentation available. Remove all older documentation and maintain separately. Only include documents that actually demonstrate a test or an inspection. Do not include copies of invoices, purchase orders, or any other document that is not relevant for testing and inspection. When required testing and maintenance is performed and there are recommendations for repairs and follow up work attach copies of work orders, contractor test reports, or work tickets that demonstrate the device was repaired/replaced, and re-tested. Have a copy of this document stapled to the test report so you don t have to spend time looking for it. Complete all documentation in pen (no pencil) or have it typed. Make sure the documents are legible You may need to requests originals where carbonless copies are not readable. Again, each item should be a topic tab for the facility s Life Safety Notebook. 1. Facility Layout Up to date facility floor plan of all levels of the building which shows the rooms and spaces the facility is currently utilizing (not necessarily as was originally constructed). The layout should identify features of fire protection including exits, pull stations, smoke and fire barriers. 2. NFPA 99 Risk Assessment Include the facility s completed risk assessment. 3. Emergency battery operated lighting Document the testing of all emergency battery operated lighting fixtures for 30 second each month and 90 minutes once a year. 4. Fire Alarm System Include the documentation, normally from licensed contractor, of the quarterly, semi-annual and annual testing of the fire alarm and corresponding components including smoke detectors, heat detectors, magnetic hold open devices, alarms, strobes, etc. 5. Smoke and fire dampers Include the documentation of the required smoke and fire damper testing and maintenance minimally done every 4 years. 6. Automatic Sprinkler System quarterly and annual inspections documentation. 7. Automatic Sprinkler System recording of the air pressure gauge reading MONTHLY for wet system. Note the gauge(s) should be tested or replaced every five years. The gauge itself should have install date identified on it. 8. Automatic Sprinkler System recording of the air pressure gauge reading WEEKLY for dry system. Note the gauge(s) should be tested or replaced every five years. The gauge itself should have install date identified on it.

7 9. Automatic Sprinkler System Annual sprinkler head inspection including piping and fittings completed by contractor of facility staff. Must be documented. Also ensure that the facility has a minimum of 6 spare sprinkler heads for each type utilized by the facility and the installation tool provided. 10. Automatic Sprinkler System Internal inspection conducted every 5 years. 11. Automatic Sprinkler System Back flow testing conducted annually. 12. Automatic Sprinkler System Where the system is utilizing anti-freeze the facility shall have system tested annually by qualified individual. Following the annual test, a tag must be attached to the riser indicating the date of the last test, the type and concentration of antifreeze solution, the date the antifreeze was replaced (if applicable). 13. Smoke detector Annual functional testing (normally included with annual fire alarm testing). 14. Smoke detector Sensitivity testing which is required by NFPA 72 requires smoke detectors to be sensitivity tested upon installation, first year afterwards and then every two years subsequently and all test results must be documented. 15. Smoke and Fire Door testing Doors required to be inspected and tested potentially including: Labeled fire rated doors Doors in exit enclosures -typically stairwells and exit passageways Doors in smoke barriers Doors in other fire resistance rated walls such as hazardous area and fire pump enclosure 16. Exits Signs Monthly inspection of all emergency and exit signs and lighting systems to ensure they are appropriately functioning. Annual testing of all emergency and exit lighting systems 17. Fire Drills There should be a minimum of 12 fire drill annually. Maintain documentation concerning fire drills that shows at least the following: Differing times for drills conducted on each shift. Drills should be conducted at various times throughout the shift to avoid patterns. Fire drills that occur within one hour may be considered as having occurred at the same time. One drill per shift per quarter. Varying conditions of drill. A drill conducted at mealtime is an example of a varying condition. Differing days of the week including weekends. Involvement of all departments. Documented observations of staff response.

8 Record of equipment functioning such as the release of doors and alarms sounding. Between the hours of 9:00 PM to 6:00 AM a silent alarm may be used instead of the audible alarm. 18. Fire Alarm Testing Document the time the alarm monitoring company received the alarm (within 90 seconds of alarm). When conducting a silent alarm, ensure that the alarm is tested the following morning noting the time the alarm signal was received. 19. Fire Pump Testing Fire pumps shall be tested under minimum, rated, and peak flows of the fire pump by controlling the quantity of water discharged through approved test devices annually. A monthly test of electric motor-driven fire pump assemblies shall be conducted without flowing water. This test shall be conducted by starting the pump automatically. The pump shall run a minimum of 10 minutes. A weekly test of a diesel engine-driven fire pump assemblies shall be conducted without flowing water. This test shall be conducted by starting the pump automatically, and the pump shall run a minimum of 30 minutes. 20. Policies Include as appropriate Fire- Evacuation Fire watch Facility disaster plan Smoking Use of space heaters Limiting Access to alcohol-based hand Rub 21. Generators Weekly visual inspection minimum, should include a check of the following: Fuel (check main and day tank fuel supply levels; day tank float switch; piping, hoses and connectors; operating fuel pressure; and for any obstructions to tank vents and overflow piping) Oil Cooling system Exhaust system Battery system (check specific gravity, electrolyte level and battery charger) Electrical Prime Mover/Generator and components 22. Generators Monthly exercise for a minimum of 30 minutes not including the warm up or cool down time at under operating temperature conditions and at not less than 30 percent of the generator s nameplate kw rating (diesel generators). For diesel generators that do not operate at 30% of nameplate rating a facility may use a Load Bank test (generator is exercised annually for 90 minutes [30 50% and 60 75%])

9 23. Generator Type 1 and 2 generators shall be exercised 4 hours every 36 months 24. Generator Diesel generators shall have the fuel tested annually and documented according to ASTM standards. 25. Kitchen Range hood system Inspect and maintain the hood suppression system in accordance with NFPA 96 semi-annually. 26. Kitchen Range Hood system inspect monthly including: Ensure system is in its proper place; Manual actuators are not obstructed; Tamper seals and indicators are intact; Maintenance tag is in place; No obvious physical damage that might prevent operation; Ensure pressure gauge is in operable range; Nozzle blow-off caps are intact and undamaged; The protected equipment has not been replaced, modified or relocated 27. Non-Hospital Grade Receptacles Testing non-hospital-grade receptacles at patient bed locations at intervals not exceeding 12 months and documentation should include: The physical integrity of each receptacle shall be confirmed by visual inspection The continuity of the grounding circuit in each electrical receptacle shall be verified Correct polarity of the hot and neutral connections in each receptacle shall be confirmed The retention force of the grounding blade of each receptacle shall not be less than 4oz. 28. Elevator Fire Fighter Service Requirements found in ASME/ANSI A17.3 Safety Code for Existing Elevators and Escalators requires testing monthly with a written record documented. The facility shall also have elevator inspected and maintenance performed not less than annually. 29. Electrical Equipment Servicing and Maintenance- Facility should develop maintenance program including testing intervals for testing patient care related electrical equipment based on manufacture guidelines and normally not less than annually. Testing will normally include: Physical integrity and Resistance. 30. Certificate State Boiler Certification 31. Certificate State Elevator Certification 32. Elevator annual maintenance and servicing

10 33. Elevator monthly recall testing documentation. 34. Medical gas End User Certificate 35. Other If required by jurisdiction fire hydrants on facility property may need to have required testing and maintenance. 36. Other - HVAC Filter inspection and replacement 37. Other Portable fire extinguishers devices are to be inspected monthly by facility staff and the attached card initialed and dated. Annually these devices shall have maintenance performed by licensed contractor 38. Other Providers with natural gas generators who do not have a backup fuel source must be able to demonstrate that the reliability of natural gas fuel will not be interrupted to maintain compliance. This can be proven with a letter from natural gas vendor that contains: A statement the fuel source is reasonable reliably Description supporting the reasonable reliability assertion A statement of the low likelihood of an interruption Description supporting the low interruption assertion Signature from technical personnel 39. Other Documentation of in-service of staff on facility Fire/ Disaster policy and procedure annual 40. Other Documentation of in-service of all staff you use and/or handle medical gases annual 41. Other ODH Self Inspection form completed monthly

11 Final Thoughts Is the presentation available? Yes, the door inspection PowerPoints are attached. Yes, you can print the presentation. List of additional documents attached: Receptacle Testing Form Weekly Generator Inspection Form NFPA 99 Risk Assessment For additional question, please contact: Kenn Daily