Tennessee Department of Health Bureau of Health Licensure and Regulations Division of Health Care Facilities.

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Presentation transcript:

Tennessee Department of Health Bureau of Health Licensure and Regulations Division of Health Care Facilities

Fire Safety Supervisor (615)306-8424 East Stuart Hurwitz Facilities Construction Director (615)741-6998 Bill Harmon Nelson Rodriguez Fire Safety Supervisor (615)306-8424 East Stuart Hurwitz Fire Safety Specialist 2 (865)320-8922 Dustin Phillips Fire Safety Specialist 1 (865)320-8921 Larry Stafford (615)806-4720 Jim McCall (865)320-8916 Middle Jendy Avens (615)806- Colby Henson (615)306-5856 Donald Tate (615)306-1133 Alexander Warner (615)306-0257 West Ricky Gore (731)513-1270 Wanda Browning (731)571-0313 Brandon Maness (731)571-1665 (731)511-1303 Vacant

Topics Rules and Regulations Progress and Final Inspections Top 5 Deficiencies for Hospitals

Rules and Regulations Hospitals Tennessee Department of Health 1200-08-01 (June 2015) Nation Fire Protection Association (NFPA) 101 Life Safety Code (2000 Ed) and the referenced publications per chapter 2. (CMS) Nation Fire Protection Association (NFPA) 101 Life Safety Code (2012 Ed) and the referenced publications per chapter 2. International Building Code (IBC) 2012 Ed

WWW.cms.gov (CMS-2786R) 5

Progress and Final Inspections Phasing a project UL systems Fire Stop systems Fire/Smoke Dampers Med Gas Sprinklers Fire Alarm Final Inspection

Fire Dampers

Hospitals Top 5 Deficiencies (5) K-130 Miscellaneous List in the REMARKS sections, any items that are not listed previously, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.

Penetrations

Penetrations

Penetrations

Hospitals Top 5 Deficiencies (4) K-77 Piped in medical gas systems comply with NFPA 99, Chapter 4.

NH Top 10 Deficiencies (3) K-147 Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2 Broken outlet covers Power strips (back to back) Exposed electrical junction boxes Electrical panels blocked with equipment

Power Strips in Patient Care Areas S&C: 14-46-LSC DATE: September 26, 2014 SUBJECT: Categorical Waiver for Power Strips Use in Patient Care Areas

Hospitals Top 5 Deficiencies (2) K-29 One hour fire rated construction (with ¾ hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protects hazardous areas. When the approved automatic fire extinguishing system option is used, the areas are separated from other spaces by smoke resisting partitions and doors. Doors are self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. 19.3.2.1

K-29 Penetrations in fire rated walls. Door self-closing device removed. Penetrations in fire doors Improper gaps in fire doors Damaged fire doors Fire doors not latching

NH Top 10 Deficiencies (1) K-62 Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. NFPA 101, 19.7.5, NFPA 13, and NFPA 25. No quarterly No annuals Obstructions Corroded sprinklers

Sprinklers

Sprinklers

Sprinklers

Sprinklers

Other Deficiencies

Questions?

Health Care Facilities Offices Thank You Health Care Facilities Offices ETRO: (865) 594-9396: Knoxville WTRO: (731) 984-9684: Jackson Central Office Nashville (615) 741-7221 Plans Review Office (615) 741-6998