Tennessee Department of Health Bureau of Health Licensure and Regulations Division of Health Care Facilities

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1 Tennessee Department of Health Bureau of Health Licensure and Regulations Division of Health Care Facilities 1

2 Colby Henson Fire Safety Supervisor 665 Mainstream Drive 2nd floor

3 Mission Statement Promote excellence in the quality of care and quality of life of residents/patients in licensed and certified facilities by adding value to the regulatory and survey process.

4 What In The World!

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13 Topics Rules and Regulations Fire Safety Responsivities General Contractor Responsivities Progress and Final Inspections Top 3 Deficiencies for Emergency Preparedness Top 5 Deficiencies for Hospitals 13

14 Rules and Regulations Hospitals 1. Tennessee Department of Health (May 2017) 2. Nation Fire Protection Association (NFPA) 101 Life Safety Code (2012 ED) and the referenced publications per chapter International Building Code (IBC) 2012 ED 4. Facility Guidelines Institute (FGI) for Design and Construction of Health Care Facilities (2010 ED) 14

15 Fire Safety Responsivities Survey Over 2200 Facilities Hospitals Nursing Homes Ambulatory Surgical Treatment Centers Office Based Surgery Homes For The Aged Residential Hospices Assisted Care Living Facilities Dialysis Clinics Outpatient Diagnostic Centers Adult Care Homes Traumatic Brain Injury Residential Homes Birthing Centers Intermediate Care Facilities

16 Fire Safety Responsivities 1. Complaints (All Facilities) 2. CMS Certifications a) Hospitals b) Nursing Homes c) Ambulatory Surgical Treatment Centers d) Dialysis Clinics e) Intermediate Care Facilities 3. Annual State Surveys 4. Construction or renovations of Facilities

17 General Contractor Responsivities 1. General contractor and subcontractors must be Licensed in TN to preform work (provide licenses). 2. Provide a list of the individuals, approved agencies or firms intended to be retained for conducting special inspections. 3. Provide the qualifications of the special inspectors and agencies. 4. Verified all required test before inspectors verification. 5. Schedule progress inspections with department.

18 Progress Inspections Progress inspections shall be Scheduled 10 days prior to the inspection. An exit conference will be conducted after each progress inspection and a progress inspection report will be ed within 5 working days to the General contractor.

19 Progress Inspections Progress Report Date: Facility Name Address City Zip Code Project Number Are approved plans on site? Yes Fire Safety Inspector Nelson Rodriguez TDOH Plans reviewer Onsite Contact Person Phone # A. Foundation Completed 0 % G. Interior Completed 0 % B. Mechanical Completed 0 % H. Sprinkler Completed 0 % C. Electrical Completed 0 % Underground Test 0 % D. Plumbing Completed 0 % Above Ground Test 0 % E. Fire Alarm Completed 0 % I. Med Gas Completed 0 % F. Framing Completed 0 % J. Fire/Smoke Dampers 0 % K. Fire Stopping _ 0 % CD/ROM MUST BE SUBMITTED AND APPROVED 30 DAYS PRIOR TO THE FINAL INSPECTION. Comments: Revised 2/1/17

20 Emergency Preparedness Top 3 Deficiencies 1. E Subsistence needs for staff and patients 2. E-0033 Methods for sharing information 3. E-0036 EP training and testing 20

21 (CMS-2786R) 21

22 Hospitals Top 5 Deficiencies (5) K-781 Portable space heating devices shall be prohibited in all health care occupancies. Unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 22

23 Portable space heating devices in staff offices exceeded 212 degrees. 23

24 Hospitals Top 5 Deficiencies (4) K-920 Electrical Equipment Power Cords and Extension Cords Power strips (back to back) 24

25 Hospitals Top 5 Deficiencies (3) K-345 A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70 Smoke detectors within 3 feet of HVAC supper/return Blocked fire alarm pull stations 25

26 Smoke detectors within 3 feet of HVAC supper/return 26

27 Blocked fire alarm pull stations 27

28 Hospitals Top 5 Deficiencies (2) K-321 Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with ¾ hour fire rated doors) or an automatic fire extinguishing system in accordance with

29 Hazardous Areas NFPA 101, Hazardous Areas. Any hazardous areas shall be safeguarded by a fire barrier having a 1-hour fire resistance rating or shall be provided with an automatic extinguishing system in accordance with NFPA 101, An automatic extinguishing system, where used in hazardous areas, shall be permitted to be in accordance with

30 NFPA 101, * Where the sprinkler option of is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4 Are fire barriers required in existing Hazardous areas?

31 NFPA 101, No existing life safety feature shall be removed or reduced where such feature is a requirement for new constructio

32 Hazardous Areas Penetrations in fire rated barriers. Door self-closing device removed. Penetrations in fire doors Improper gaps in fire doors Damaged fire doors Fire doors not latching 32

33 Hazardous Areas

34 Hazardous Areas 34

35 Hazardous Areas

36 Hospital Top 10 Deficiencies (1) K-353 Sprinkler System Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. 36

37 Sprinkler Systems Obstructions Corroded sprinklers 37

38 Sprinklers 38

39 Sprinklers 39

40 Sprinklers 40

41 Other Deficiencies 41

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46 Questions? 46

47 Thank You Health Care Facilities Offices ETRO: (865) : Knoxville WTRO: (731) : Jackson Central Office Nashville (615) Plans Review Office (615)