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CMS updates
Life Safety Code
The information below was sent to the association by Katherine Achor for distribution.
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
Q: Small hole in door frame?
A: Correct in that it should have been cited since the hole would not resist the passage of smoke.
NFPA Standard: Doors in corridor walls of sprinklered buildings shall be constructed to resist the passage of smoke and shall be provided with suitable means of keeping the doors closed. Doors in non-sprinklered buildings shall have doors constructed to resist the passage of smoke for at least twenty minutes and shall be provided with suitable means of keeping the doors closed. Doors should not be blocked open by furniture, doorstops, chocks, tiebacks, drop-down or plunger-type devices, or other devices that necessitate manual unlatching or releasing action. Friction latches or magnetic catches that release when the door is pushed or pulled are acceptable. Clearance between the bottom of the door and the floor covering shall not exceed 1 inch. 2000 NFPA 101, 19.3.6.3.1 and 19.3.6.3 and CMS S&C Letter 07-18
2. K62-automatic sprinkler-sprinkler system maintenance
Q: Storage 18 inches below or within of a sprinkler head?
A: 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, 5-6.6 below.
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. K62-automatic sprinkler-sprinkler system maintenance
Q: % or # of spare sprinkler heads Providers are required to have?
A: Per CMS-need to follow 1999 NFPA 13, 3-2.9.1, 3-2.9.2, 3-2.9.3.
A supply of spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced. These sprinklers shall correspond to the types and temperature ratings of the sprinklers in the property. The sprinklers shall be kept in a cabinet located where the temperature to which they are subjected will at no time exceed 100°F (38°C).
A special sprinkler wrench shall also be provided and kept in the cabinet to be used in the removal and installation of sprinklers.
The stock of spare sprinklers shall include all types and ratings installed and shall be as follows:
(1) For systems having less than 300 sprinklers, not fewer than six sprinklers
(2) For systems with 300 to 1000 sprinklers, not fewer than 12 sprinklers
(3) For systems with over 1000 sprinklers, not fewer than 24 sprinklers
4. K147-electrical wiring
Q: Amount of area around the electrical panel needs to be clear?
A: A three foot area around the panel needs to be clear so that there is easy access to the panel.
NFPA Standard: Sufficient space shall be provided and maintained about electric equipment to permit ready and safe operation and maintenance of such equipment. Where energized parts are exposed, the minimum clear work space shall not be less than 6½ feet high or less than 3 feet wide. In all cases, the work space shall be adequate to permit at least a 90 degree opening of doors or hinged panels. 1999 NFPA 70, Article 110-32
5. K25-smoke partition construction
Q: Is it in regulation that access needs to be on both sides of the smoke barrier partition?
A: Safe access needs to be provided to enable barriers to be inspected and to provide facility staff access to work.
6. K50- Fire Drills
Q: LSC states that FIRE DRILLS SHOULD BE HELD AT UNEXPECTED TIMES UNDER VARYING CONDITIONS.
A: 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.
Q: What is the definition of unexpected times?
A: Drills should be conducted throughout shifts and should not show a pattern (same time of day, same day of the month).
Q: Why do providers have to do a scenario?
A: Scenarios ensure that drills are performed under varying conditions – such as the size, type, location and timing of the fire. 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.
Q: Activation of fire alarm by employees?
A: Staff should activate the fire alarm system.
NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 18/19.7.1.2
7. K144-generators inspected/tested
Q: Where do annunciator panels need to be if following 2000 code? At nurses station?
A: They need to be in a place that is constantly attended so KSFMO such as the nurse’s station.
Per CMS, if a provider is installing new generator or providing a major upgrade they would need to follow the 2000 LSC, 1999 NFPA 70, 1999 NFPA 110, and 1999 NFPA 99 - otherwise they would follow the code when their generator was installed.
8. K46-emergency lighting
Q: If you have a generator where is emergency lighting required?
A: If the generator supplies emergency power, then battery powered emergency lighting is required at the generator.
NFPA Standard: Emergency battery light for task illumination at the generator set location shall be provided. 1999 NFPA 99, 3-4.2.2.2, 3-5.2.2.2 and 3-6.2.1
Q: Is emergency lighting required in a med room if you have a generator?
A: Not if the med room lights are powered by the generator.
A: Emergency lighting should not require manual operation (such as being switched.)
NFPA Standard: The emergency lighting system shall be arranged to provide the required illumination automatically in the event of the interruption of normal lighting, opening of a circuit breaker, or a manual act, including accidental opening of a switch controlling normal lighting facilities. 2000 NFPA 101, 7.9.2.2
9. K134-Eyewash-Emergency shower
Q: 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…?
A: This is currently under review by CMS.
10. K12-Construction type
Q: Overhang and sprinklers? Are sprinklers required under overhangs on the exterior of the building?
A: Yes, if the overhang is of combustible construction and the overhang is 4 ft or greater in width.
NFPA Standard: Requires complete sprinkler coverage for all parts of a facility with construction type V (111). 2000 NFPA 101, table 18/19.1.6.2
NFPA Standard: Sprinklers shall be installed under exterior roofs or canopies exceeding 4 feet in width. Sprinklers can be omitted where the canopy or roof is of noncombustible or limited combustible construction. 1999 NFPA 13, 5-13.8.1
NFPA Standard: Limited Combustible refers to a building construction material that has a potential heat value not exceeding 3500 Btu/lb where tested in accordance with NFPA 259, and includes materials having a structural base of noncombustible material, with a surfacing not exceeding a thickness of 1/8 inches that has a flame spread index not greater than 50; and having neither a flame spread index greater than 25 nor evidence of continued progressive combustion, and of such composition that surfaces that would be exposed by cutting through the material on any plane would have neither a flame spread index greater than 25 nor evidence of continued progressive combustion. 2000 NFPA 101, 3.3.118
Q: Can a waiver be submitted?
A: Yes a waiver can be submitted or you can use the FSES to establish equivalence, but waivers or use of the FSES will not be allowed for sprinkler deficiencies after August 13, 2013.
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
Q: What is the timeframe for maintenance to be done-if something needs to be checked every 6 months is there any leeway?
A: Per CMS they should give you a few days or so after the 6 month date before citing the kitchen hood systems. Any other maintenance checks need to be completed within the time frame.
3. Assisted living facility
Q: Inspected by FM-Does kitchen hood suppression need to be connected to fire alarm system? Yes
Q: Overhang is 50 inches does it need to be sprinkled? It is attached to the building and no cars underneath it?
A: Yes, Yes
Q: Sprinklers in freezers?
A: Yes
4. Waivers
Q: Is CMS or KSFMO granting waivers?
A: Per CMS any waivers under 6 months the KSFMO will grant and any over 6 months CMS Region 7 reviews. 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?
A: 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. Posting of the code mirrors the requirement to post the SOD. Some providers have posted signs next to their keypad doors that state 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.
Delayed 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?
A: CMS does not know why the citation rate is greater in Kansas. We are very interested in doing the quarterly calls with the associations to identify and address inconsistencies and to provide updates to the nursing home providers in Kansas. It is always better to prevent noncompliance rather than cite it. To that end, we see a lot of repeat noncompliance in Kansas, so we will concentrate on addressing those areas.
8. Tom Jaeger asked CMS about the high incidence of providers being cited for K62
Not having the 5 year obstruction investigation?
A: 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.
A: Per CMS – ask the contractor to state the reason they recommend the 5 year obstruction investigation in your paperwork. Items addressed as deficient in the sprinkler system documentation are required to be promptly corrected by the facility.
NFPA Standard: The owner or occupant promptly shall correct or repair deficiencies, damaged parts, or impairments found while performing the inspection, test, and maintenance requirements of this standard. Corrections and repairs shall be performed by qualified maintenance personnel or a qualified contractor. 1998 NFPA 25, 1-4.4
Chapter 10 Obstruction Investigation
This chapter provides the minimum requirements for conducting investigations of fire protection system piping for possible sources of materials that can cause pipe blockage.
To ensure that piping remains clear of all obstructive foreign matter, an obstruction investigation shall be conducted for system or yard main piping wherever any of the following conditions exist:
(a) Defective intake for fire pumps taking suction from open bodies of water
(b) The discharge of obstructive material during routine water tests
(c) Foreign materials in fire pumps, in dry pipe valves, or in check valves
(d) Foreign material in water during drain tests or plugging of inspector’s test connection(s)
(e) Plugged sprinklers
(f) Plugged piping in sprinkler systems dismantled during building alterations
(g) Failure to flush yard piping or surrounding public mains following new installations or repairs
(h) A record of broken public mains in the vicinity
(i) Abnormally frequent false tripping of a dry pipe valve(s)
(j) A system that is returned to service after an extended shutdown (greater than 1 year)
(k) There is reason to believe that the sprinkler system contains sodium silicate or highly corrosive fluxes in copper systems
(l) A system has been supplied with raw water via the fire department connection.
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.
NFPA Standard: Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. 1998 NFPA 25, 2-2.1.1
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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