In the month of August there were 38 recertification life safety code surveys completed. Of these 38, 32 were cited with deficiencies averaging 5 each while 6 were deficiency free. Outside of recertification surveys there were 2 revisit surveys that weren’t passed and 1 complaint survey that no deficiencies were cited.
During these surveys, there were 19 deficiencies cited under emergency preparedness including the following examples:
- The emergency preparedness plan (EPP) wasn’t reviewed and/or updated in the last 12 months.
- The EPP included contact information of the former administrator and previous contractors.
- A hazard vulnerability analysis wasn’t completed with review and update of the EPP.
- There weren’t policies and procedures on:
- Cybersecurity
- 1135 waivers
- Contact information for staff wasn’t updated in the last 12 months.
- There weren’t examples of training that was provided to staff.
- Full-scale and/or additional exercises weren’t completed as required in the last 12 months.
- The EPP included information on back-up generators but the building didn’t have a back up generator.
Most of the deficiencies cited in the life safety code surveys were very common problems. The sprinkler system testing and maintenance (K353) continued to be the deficiency cited the most often. Examples of non-compliance from August included:
- Missing 5-year internal obstruction inspection.
- Sprinkler heads were not replaced or tested in a recommended time frame. This includes dry sprinkler heads every 10 years, quick response every 20 years, and standard sprinkler heads every 50 years.
- Weekly testing and inspection of the fire pump was not completed.
- The 3-year dry sprinkler system testing was not completed.
- Deficiencies were identified during inspections that were not repaired.
- Sprinkler heads had excessive dust and debris.
- Items were stored within 18 inches of the sprinkler heads.
- Sprinkler heads weren’t flush with the ceiling or were missing escutcheon rings which causes a penetration in the ceiling.
- Quarterly sprinkler inspections weren’t completed.
- The sprinkler system inspections were completed by someone internally and not by a contractor or someone qualified to do so.
- The sprinkler system riser lacked the hydraulic name plate.
The second most frequently cited deficiency was K712 for fire drills and examples included:
- Fire drills weren’t completed each shift every quarter as required.
- Drills were conducted at approximately the same time. As a note on this, you’re required to spread your drills out so that they are at least two hours from the prior drills. A best practice could be to time the drills out so that they are on even hours or all odd hours to help ensure compliance.
- Fire drill documentation that the monitoring company was contacted, or the fire alarm was tested following silent drills. A note on this is that the monitoring company should be contacted and the documentation should include the operator number/identification and the time that the signal was received.
Outside of these common life safety code deficiencies there weren’t any new or different examples of deficiencies that providers need to be alert for.