Iowa State Fire Marshal LIFE SAFETY CODE REQUIREMENTS LONG TERM CARE Kyle R. Gorsh, Special Agent in Charge Iowa Department of Public Safety State Fire Marshal Division 2012 LSC & Applicable Standards National LTC Top-10 LSC Deficiencies Fire Alarm Testing Paperwork Fire Alarm / Sprinkler Outage Policies Electrical Outlet Testing Surge Protector Enforcement Fire Door Annual Testing Emergency Preparedness Plans 2 3 1
NFPA Standards Important NFPA standards NFPA 10, 2010 edition NFPA 13, 2010 edition NFPA 25, 2011 edition NFPA 72, 2010 edition NFPA 96, 2011 edition NFPA 99, 2012 edition NFPA 110, 2010 edition 4 National LTC Top 10 LSC Deficiencies FY17 K353 - Sprinkler Maintenance K363 - Corridor Doors K321 - Hazardous Areas K372 - Smoke Partitions K920 - Power Strips K712 - Fire Drills K345 - Fire Alarm Maintenance K918 - Generator Maintenance K511 - Gas and Electrical Utilities K324 - Cooking Facilities 5 Fire Alarm Testing Reports All devices connected to your fire alarm system need to have evidence that each individual device was tested. You need an accurate inventory of every device, complete with a description as to where it is located. The test report needs to list each and every individual device, a description of where it is located, and whether it passed or failed its test. Here is a list of the most common interface relays used in healthcare fire alarm systems: Magnetic hold open devices Hood suppression system Air handler shutdown Magnetic locks Fire pump Overhead rolling fire doors Smoke dampers Sprinkler dry pipe/pre-action systems Elevator Recall 6 2
Fire Alarm Impairments NFPA Standard: 2012 NFPA 101, 9.6.1.6 Where a required fire alarm 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. Pre-planned or emergency Shall be dedicated Fire watch shall be continuous Shall be trained in fire prevention Shall have means to notify the fire department Occupants notified Local fire department, Department of Inspections & Appeals, & Fire Marshal shall be notified Documentation maintained for one year 7 Sprinkler Impairments (See Handout) NFPA Standard: 2012 NFPA 101, 9.7.6 Sprinkler impairment procedures shall comply with NFPA 25. NFPA Standard: 2011 NFPA 25, 4.1.9.1 Where an impairment to a water-based fire protection occurs, the procedures outlined in Chapter 15 of this standard shall be followed, including the attachment of a tag to the impaired system. NFPA Standard: 2011 NFPA 25, 4.1.9.2 Where a water based fire protection system is returned to service following an impairment, the system shall be verified to be working properly by means of an appropriate inspection or test. 8 Sprinkler Impairments NFPA 25, 2011 Edition (Chapter 15) Assignment of an Impairment Coordinator The system shall be tagged to indicate the system has been removed from service at each FD connection, system control valve, and any other location deemed by the AHJ. Where the sprinkler system is out of service for more than 10 hours in a 24-hour period, the impairment coordinator shall arrange for the following: a) Evacuation of the building (or) portion of the building affected by the outage b) An approved fire watch c) Establishment of a temporary water supply d) Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire. 9 3
Sprinkler Impairments NFPA 25, 2011 Edition (Chapter 15) The fire department shall be notified. The insurance carrier, the alarm company, property owner or designated representative, DIA, SFM have been notified. The supervisors in the areas to be affected have been notified. A tag impairment system has been implemented (Section 15.3) All necessary tools and materials have been assembled on the impairment site. 10 Sprinkler Impairments NFPA 25, 2011 Edition (Chapter 15) 15.6 Emergency Impairments. 15.6.1 Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure. 15.6.2 When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage. 15.6.3 The coordinator shall implement the steps outlined in Section 15.5. 11 Electrical Outlet Testing NFPA 99, 2012 Edition, 6.3.4.1.1 Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device. 6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months. 12 4
Surge Protector Use SURGE PROTECTORS USED FOR PATIENT CARE RELATED EQUIPMENT (VENTILATORS, BREATHING MACHINES, OXYGEN CONCENTRATORS, FEEDING PUMPS, ETC.: MUST BE [UL 1363A (OR) UL 60601-1] POWER STRIPS USED IN PATIENT CARE VICINITY TO POWER RACK, TABLE, PEDESTAL, OR CART MOUNTED PATIENT CARE RELATED ELEC. EQUIPMENT HAVE RECEPTACLES THAT ARE PERMANATELY ATTACHED TO THE EQUIPMENT ASSEMBLY. 13 Surge Protector Use POWER STRIPS MAY NOT BE USED IN PATIENT CARE VICINITY (6 feet) TO POWER PERSONAL ELECTRONICS (Only if patient care related equipment is in use) IN RESIDENT ROOMS WITH PATIENT CARE RELATED EQUIPMENT, POWER STRIPS PROVIDING POWER TO NON-PATIENT CARE RELATED ELECTRICAL EQUIPMENT (OUTSIDE THE VICINITY) MUST BE LISTED AS UL1363. ALL OTHER SURGE PROTECTORS MUST MEET SFM POLICY. 14 Annual inspection & testing in accordance with NFPA 80, 2010 edition is required for all fire door assemblies. * Non-rated door assemblies (including corridor doors to resident rooms and smoke barrier doors) are not subject to annual inspection and testing requirements. Full compliance with annual fire door assembly inspection & testing was required by January 1, 2018. 15 5
5.2.1 Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ. 5.2.3.1 Functional testing of fire door and window assemblies shall be performed by individuals with knowledge and understanding of the operating components of the type of door being subject to testing. 16 5.2.3.2 Before testing, a visual inspection shall be performed to identify any damaged or missing parts that can create a hazard during testing or affect operation or resetting. 5.2.6 Inspection shall include an operational test for automatic-closing doors and windows to verify that the assembly will close under fire conditions. 17 5.2.4.2 As a minimum, the following items shall be verified: (1) No open holes or breaks exist in surfaces of either the door or frame. (2) Glazing, vision light frames, and glazing beads are intact and securely fastened in place, if so equipped. (3) The door, frame, hinges, hardware, and noncombustible threshold are secured, aligned, and in working order with no visible signs of damage. (4) No parts are missing or broken. 18 6
5.2.4.2 As a minimum, the following items shall be verified: (5) Door clearances do not exceed clearances listed in 4.8.4 and 6.3.1.7. (6) The self-closing device is operational; that is, the active door completely closes when operated from the full open position. (7) If a coordinator is installed, the inactive leaf closes before the active leaf. (8) Latching hardware operates and secures the door when it is in the closed position. 19 5.2.4.2 As a minimum, the following items shall be verified: (9) Auxiliary hardware items that interfere or prohibit operation are not installed on the door or frame. (10) No field modifications to the door assembly have been performed that void the label. (11) Gasketing and edge seals, where required, are inspected to verify their presence and integrity. 20 5.2.9 Hardware shall be examined, and inoperative hardware, parts, or other defects shall be replaced without delay. 5.2.13.1 Door openings and the surrounding areas shall be kept clear of anything that could obstruct or interfere with the free operation of the door. 21 7
CMS does NOT require a certified person to complete the door inspections. 3.3.95 Qualified Person. A person who, by possession of a recognized degree, certificate, professional standing, or skill, and who, by knowledge, training, and experience, has demonstrated the ability to deal with the subject matter, the work, or the project. ** Anyone who has knowledge of the subject can do the work. Training is available if a facility needs to send staff to learn how to conduct the door inspections. 22 All providers were required to be in full compliance with the new regulation by November 15, 2017. * Emergency Preparedness Checklist Handout (This will be a living document) 23 The program must include all of the elements set forth in the requirement: Emergency Plan Policies & Procedures Communication Plan Training & Testing Emergency Power Systems 24 8
Risk Assessment The emergency plan must be based on and include documented, facility-based and community-based risk assessments utilizing an all-hazards approach & include strategies for addressing emergency events identified by the risk assessment. Risk assessments should be specific to the location of the facility and consider hazards most likely to occur in the surrounding area including, but not limited to: Natural disasters Natural disasters Man-made disasters 25 Risk Assessment LTC facilities must include provisions in the emergency plan to account for missing residents. Facilities must document facility-based & community-based risk assessments. Community-based risk assessments ensure that facilities collaborate with other entities within their community to promote an integrated response to emergency events. (Health care providers, emergency management agencies, regional healthcare coalitions) 26 Emergency Plan The emergency plan is one part of the facility s emergency preparedness program. The plan will provide the framework to assist facilities in addressing patient population needs and identifying business operations necessary for support during an actual emergency. 27 9
Emergency Plan Persons at risk identified Strategies for addressing all emergency events Strategies in place to address needs of at-risk pop. Staff roles identified Services the facility must provide in an emergency Emergency plan reviewed/updated annually Delegations of authority Documentation of annual review date Succession Planning (authorized & qualified person to act in absence of Administrator Continuity of operations (essential personnel, functions, and critical resources to continue operations) 28 Cooperation & Collaboration Facility must document cooperation and collaboration with local, regional, state, and federal emergency preparedness officials to ensure an integrated response during an emergency. Document who was contacted and who participated in emergency preparedness planning efforts. 29 Policies & Procedures Basic needs of residents & staff to maintain life System to track the location of on-duty staff & residents The use of volunteers in an emergency Safe evacuation from the facility A means to shelter in place A system of medical documentation Arrangements with other facilities Policies were developed based on facility & community based risk assessments, using an all hazards approach We will verify that documentation verifies the facility reviews policies and procedures at least annually and updates them as necessary, based on results of the review. 30 10
Policies & Procedures The policies and procedures must address provisions including: Food Medical Needs Water Pharmaceutical supplies for patients/staff. Policies shall also provide adequate alternate energy sources to maintain: Temperatures to protect resident safety Extinguishing systems Safe & sanitary storage of provisions Alarm systems Emergency lighting Fire detection Sewage & waste disposal 31 Policies & Procedures Tracking Residents & Staff: Must be able to document a tracking system as part of your emergency policies & procedures. Evacuations: Must have a policy that addresses elements for safe evacuation from the facility. Sheltering in Place: Must have a policy that addresses how the facility will provide the means to shelter in place for residents, staff, & volunteers. 32 Policies & Procedures Continuity of Services: Must have copies of transfer agreements and arrangements with other facilities to receive residents in the event the facility cannot care for them in an emergency. 33 11
Communications Plan The communications plan demonstrates how the facility coordinates resident care within the facility, across health care providers, and with state and local public health departments. YES NO The communications plan demonstrates how the facility coordinates with emergency management agencies and systems to protect resident health and safety in the event of a disaster. YES NO The facility has identified alternate communications methods in the event of phone/internet failure (Examples: CB radios, short-wave radios, satellite phones). YES NO Does the communications plan include names and contact information for the following: (Facility staff, all entities providing services under the plan, Patients physicians, next of kin, guardian, or custodian, Other facilities of similar provider or supplier type? YES NO Does the facility have evidence the communications plan has been reviewed & updated (as necessary) on an annual basis? YES NO 34 Communications Plan Reviewing Contact Information: Must have a list of facilities contact information in the communication plan. This information must be reviewed and updated annually. Means of Communication: There must be a primary and alternate means to communicate with facility staff, federal, state, regional, and local emergency management agencies. 35 Sharing Information The Communication Plan must include a method for sharing resident information and documentation with other health care providers to maintain continuity during an emergency. There must be policies & procedures in place that address the means your facility will use to release resident information, including the general condition & location of residents. Facility staff should be able to explain/demonstrate how they share emergency plan information with residents & their families. 36 12
Training & Testing Could the facility document an annual full-scale community based exercise (or when not available) an individual facility-based exercise? YES NO If a full-scale community based exercise was not available, did the facility document all local and state agencies that were contacted to make such request? YES NO Did the facility document an additional exercise (full scale OR tabletop exercise that includes a group discussion led by a facilitator, using a narrated relevant emergency scenario and set of problems with prepared questions designed to challenge an emergency plan? YES NO Did the facility provide documentation of the post exercise analysis and information of revisions made to the plan? YES NO 37 Training & Testing Does the facility have a written training and testing program and review and update it annually? Y / N Documented EP training provided for all new and existing staff members, volunteers? YES NO Has the facility documented specific training for the staff? YES NO Did the facility document the method(s) used to demonstrate knowledge of the training program content? YES NO Was the facility able to verify (through staff training files) that staff members were in fact trained in EP? YES NO 38 Emergency Power Systems Does the facility have emergency power systems in place (or) plans to provide emergency power while sheltering in place during an emergency? YES NO If the facility maintains an on-site fuel source for a generator, does it have a plan to sustain generator operations during an emergency? YES NO 39 13
Annual Testing Could the facility document an annual full-scale community based exercise (or when not available) an individual facility-based exercise? YES NO If a full-scale community based exercise was not available, did the facility document all local and state agencies that were contacted to make such request? YES NO Did the facility document an additional exercise (full scale OR tabletop exercise that includes a group discussion led by a facilitator, using a narrated relevant emergency scenario and set of problems with prepared questions designed to challenge an emergency plan? YES NO Did the facility provide documentation of the post exercise analysis and information of revisions made to the plan? YES NO 40 41 14