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Associations meet with CMS---Life Safety Code
LSC Questions and Answers from the Meeting December 2, 2008
Review of 1st qtr 2008 and 3rd qtr 2008 2567’s
1. K18-construction of doors and latching-Small hole in door frame? Correct in that it should have been cited since the hole would not resist the passage of smoke.
2. K62-automatic sprinkler-sprinkler system maintenance-
Storage 18 inches below or within of a sprinkler head? AHCA says yes as long as storage is along wall and not directly below sprinkler head. Tom Jaeger says: The 18" rule does not always apply to storage along the perimeter of the room, see extract from 1999 NFPA 13 below.
A-5-6.6
The 18-in. (0.46-mm) dimension is not intended to limit the height of shelving on a wall or shelving against a wall in accordance with 5-6.6. Where shelving is installed on a wall and is not directly below sprinklers, the shelves, including storage thereon, can extend above the level of a plane located 18 in. (0.46 mm) below ceiling sprinkler deflectors. Shelving, and any storage thereon, directly below the sprinklers cannot extend above a plane located 18 in. (0.46 mm) below the ceiling sprinkler deflectors.
3. % or # of spare sprinkler heads Providers are required to have? Per CMS-need to follow NFPA 13. (up to 6) and at least one of every different type of sprinkler head you use.
4. K147-electrical wiring-
Clarification-Amount of area around the electrical panel needs to be clear? A three foot area around the panel needs to be clear so that there is easy access to the panel.
5. K25-smoke partition construction-
Is it in regulation that access needs to be on both sides of the firewall? Yes Providers should have an access panel on either side of a firewall.
6. K50- Fire Drills-
What is the definition of unexpected times? Random? LSC states that FIRE DRILLS SHOULD BE HELD AT UNEXPECTED TIMES UNDER VARYING CONDITIONS. KSFMO will cite providers for not random or unexpected times if you hold a fire drill the first day of the month every quarter and if you do not vary your time more than 2-3 hours.
Why do providers have to do a scenario? Important to have someone else help relay information back to the Administrator on how staff and residents performed during the fire drill and for the administrator to include this in his/her scenario.
Activation of fire alarm by employees? Staff should also activate the fire alarm system.
7. K144-generators inspected/tested-
Where do annunciator panels need to be if following 2000 code? At nurses station? They need to be in a place that is constantly attended so KSFMO recommends the nurses station.
If a generator was installed in 1988-2003 would they use 85 code?
If a generator was installed in 1903-present would they use 2000 code?
If a generator was installed in 1970-1976 would they use 67 code?
Per CMS, if a Provider is upgrading a generator they would need to follow 2000 code otherwise they would follow the code when their generator was installed.
8. K46-emergency lighting-
If you have a generator where is emergency lighting required? Only at the generator. Keep in mind if your emergency lighting is tied into the generator and you have not taken down your battery operated lights, KSFMO will expect you to maintain them and will cite you if you do not.
Is emergency lighting required in a med room if you have a generator? No
If you have a generator and a manual switch can you cover the switch with a hard plate or do you have to hard wire it to the generator? This is currently being reviewed by the KSFMO.
9. K134-Eyewash-Emergency shower
Should any eyewash documentation or other be cited by FM using K134?
If so then what specifically do providers need to comply with? FM started writing eyewash and only documentation issues, now they write for tepid water, requires more than one motion to operate, being behind locked doors…? CMS reported that they quit writing this tag 2 months ago.
10. K12-Construction type-
Overhang and sprinklers? Can a waiver be submitted? If your overhang is 4 ft. or more it will need to be sprinkled.
MISC
1. Documentation cites-K69,K130,K62,K46-
Providers cited for documentation not being readily and immediately available? Federal surveyors allow the provider to fax in documents why can’t the state? Two providers were cited twice for this when the documentation was in the book but misfiled. One of the providers IDR’d and KSFMO denied it. KSFMO said that all LSC surveys should start with an entrance interview. It was brought to KSFMO’s attention that this was not happening. KSFMO will instruct all their inspectors to begin with an entrance interview. If during this interview you determine that some of your documentation is out of order, the inspector should allow you to gather this information by the exit interview and not cite you. You have to have the documentation in order before the inspector leaves.
2. K69 documentation cite-what is the timeframe for maintenance to be done-if something needs to be checked every 6 months is there any leeway? Per CMS they should give you a week or to after 6 months before they cite you for kitchen hood systems. Any other maintenance checks needs to be completed within the time frame.
3. An assisted living facility-inspected by FM-Does kitchen hood suppression need to be connected to fire alarm system? Yes
Overhang is 50 inches does it need to be sprinkled? It is attached to the building and no cars underneath it? Yes
Sprinklers in freezers? Yes
4. Waivers-Is CMS or KSFMO granting waivers? Per CMS any waivers under 6 months the KSFMO will grant and any over 6 months CMS Region 7 approves. We have asked CMS for the statute where this is cited.
5. IDR’s- In 2007 there were 23 IDR’s total and 23 total tags were IDR’d. Of these, 61% were removed and 39% stand.
In 2008-Jan1 through Oct 1 there were 23 IDR’s initiated involving 35 total tags. Of these, 49% were removed and 51% stand.
KHCA will have the KSFMO update the membership on the LSC IDR process at Winter Conference. KHCA will encourage all providers to use the IDR process.
6. Clarification on keypad doors and posting of the code? Per CMS as long as you are giving cognitively aware residents the code, the staff the code and any visitors the code, you should not be cited for this deficiency. ie.. Some providers have posted signs next to their keypad doors that state that any visitors need to check in at the front desk. This is where they would get the code. Some providers have stated that they give the code to their cognitively aware residents and document it in their chart. Exception to the rule provider has delayed egress at the path of egress the above does not apply and provider must post appropriate signage reading push until alarm sounds door will open in 15 seconds.
7. Why do they think that Kansas is 2-3 times higher than the national average on the top ten deficiencies cited? Per CMS they think they are cited accurately in Kansas and it is the other regions that are inaccurate.
8. Tom Jaeger asked CMS about the high incidence of providers being cited for K62 not having the 5 year obstruction investigation? Per Tom, under NFPA 25, a 5 year obstruction investigation is only needed if there is an obstruction. CMS responded that providers would be cited if the inspector found decreased flow or pressure drops as well as if the sprinkler contractor's report said that an obstruction investigation needs to be done in 5 years. Tom explained to CMS that sprinkler contractors will get the business so that it is in their best interest to put this in the paperwork. Make sure if you are cited for this that you ask the inspector why? If they cite the contractors paperwork (in the absence of an obstruction) then be sure to IDR it.
9. Many providers were cited for green sprinkler heads. The brass oxidizes to form the green film and per CMS will only cite you if it is heavy.
10. Tom asked CMS about the high incidence of providers being cited for penetration of the ceiling. In general Tom stated that 84% of the homes are sprinkled in Kansas and are one story buildings and their ceilings would not be part of a fire rated assembly so therefore you should not be cited. You should only be cited for
penetration of the ceiling if the ceiling is part of a fire rated assembly. KSFMO will speak to their inspectors about this issue.
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