In October, the Department of Inspections, Appeals, & Licensing (DIAL) completed a total of 39 life safety code surveys with 37 being recertification and 2 being complaint surveys. 35 of the 37 recertification surveys resulted in an average of 3.9 deficiencies, while 2 were deficiency free. The 2 complaint surveys resulted in 1 and 8 deficiencies cited during the on-site inspection.
Emergency Preparedness:
During the life safety code surveys, there were 13 deficiencies cited related to emergency preparedness. The two most commonly cited deficiencies were E004 and E039.
E004 relates to the emergency preparedness plan (EPP) being reviewed and/or updated annually in nursing homes. Examples of cited deficiencies include:
- The EPP wasn’t reviewed/updated in the last 12 months.
- Copies of policies weren’t included in the paper version of the EPP and therefore were not available to all staff (such as overnight and weekend staff).
E039 relates to the full scale and additional exercises that must be completed annually for nursing home providers. Examples of cited deficiencies include:
- The full scale and/or additional exercise wasn’t completed within the last 12months.
- The documentation of a post exercise analysis wasn’t completed or didn’t contain all required elements.
Life Safety Code:
The top cited deficiencies for life safety code surveys include K353, K712, and K918.
K353 includes the maintenance and testing of the sprinkler system and deficiency examples include:
- Excessive dust, lint, and debris on sprinkler heads.
- Corroded sprinkler heads.
- Items stored within 18 inches of the sprinkler heads.
- Missing quarterly sprinkler system inspections.
- Missing 5-year internal obstruction inspections.
- Inspection reports included identified deficiencies that weren’t repaired/corrected prior to survey.
- Missing monthly inspection/testing of the electric fire pump.
- Missing escutcheon rings which cause a penetration in the ceiling.
- The dry sprinkler system was missing the 3-year dry trip testing.
K712 relates to the nursing home’s fire drills. Fire drills must be completed on each shift every quarter, the times must be varied, the conditions of the drill must be varied, and documentation must include several elements. Examples of deficiencies include:
- Missing fire drills.
- Drills were conducted at approximately the same time. (Note the drills must be at least two hours before or after the other drills. A best practice for ensuring your drills are under varied times include conducting all drills on odd or even hours consistently.)
- The fire drill documentation lacked the name and/or operator identification number of the monitoring company operator who verified the monitoring company received the signal.
- Didn’t complete a critique of the drill to identify positive and negatives from the exercise.
- The documentation lacked signatures of those who participated in the drill.
- Documentation didn’t include that the fire alarm was tested following a silent drill. (Note the fire alarm must be tested the day after a silent drill was conducted. Silent drills are only appropriate during the overnight hours – 9 p.m. to 6 a.m.)
K918 relates to the emergency generator testing and inspection. Examples of deficiencies include:
- Monthly load testing wasn’t completed.
- Weekly inspections weren’t completed.
- Documentation lacked the following elements:
- Whether the transfer switch was used.
- Specific Gravity testing or battery conductance testing for lead-acid batteries.
- Amperages at each leg of the testing.
- Start and end times of monthly load tests.
- Missing annual testing and inspection of the main and feeder circuit breakers.
- Missing annual fuel quality testing.
In late September, Kellie Van Ree, Vice President of Clinical Services and Education Strategy attended provider/surveyor training in Missouri. During this training, the life safety code representative expressed that the Centers for Medicare & Medicaid Services have been focused on doors in the nursing home. There are a few different regulations that relate to or can be cited for doors including K321 relates to hazardous areas or enclosures but can be cited when doors to hazardous rooms fail to fully close and positively latch, K363 which relates to corridor doors, and K761 which relates to fire/smoke door testing and maintenance. In general, you should ensure that all doors fully close and positively latch without the use of excessive force, don’t have penetrations in the door which would allow for the spread of fire and/or smoke, and don’t have gaps around the doors between the door and the door frame. I would encourage you to include auditing the doors in your building as a quality assurance monitor to ensure that all doors are in compliance.