1. Life Safety Compliance: Most Common Surveyor Findings Presented by Brad Keyes, CHSP Jamie Crouch, BSBM, MHA

2. 2 Topics… Today, we will cover the following topics: 1.Top Ten Findings by Life Safety Surveyors 2.Frequent Issues with the Document Review Session 3.Questions you may have…

3. Top 10 Life Safety Findings The following are the top-ten findings cited by HFAP LS surveyors during regular triennial surveys during 2015.

4. Top 10 Life Safety Findings Number 1: 13.02.01 Fire Alarm System – Installation –The installation of the fire alarm system components were observed to have problems…

5. Top 10 Life Safety Findings Smoke detectors must be mounted at least 36 inches away from HVAC air diffusers; supply and return.

6. Top 10 Life Safety Findings Smoke detectors must be mounted at least 12 inches below the ceiling or deck.

7. Top 10 Life Safety Findings Access to the manual pull stations is obstructed.

8. Top 10 Life Safety Findings Number 2: 13.01.05 Signage –This primarily involves ‘Exit’ signs and there are multiple issues that were observed…

9. Top 10 Life Safety Findings There must be an inventory of every ‘Exit’ sign and they must be inspected monthly with a ‘Pass’ or ‘Fail’ notation (signature required).

10. Top 10 Life Safety Findings ‘No Exit’ signs are required to have the word ‘No’ 2 inches tall, and the word ‘Exit’ 1 inch tall. Not Acceptable Acceptable

11. Top 10 Life Safety Findings Number 3: 13.05.09 Utility Systems –Deficiencies observed with the utility systems will lead to findings. The most common findings involve the electrical system.

12. Top 10 Life Safety Findings Surveyors will look above the ceiling at your fire barrier and smoke barrier location… They will cite any junction-box without a cover.

13. Top 10 Life Safety Findings Make sure access to all electrical equipment and panels is free and clear for 36 inches.

14. Top 10 Life Safety Findings Number 4: 13.00.05 Facility Demographic Report –Common problems with the FDR involve unanswered questions, or answers that do not contain basic NFPA nomenclature

15. Top 10 Life Safety Findings The construction type is not listed in NFPA 220 nomenclature, such as: Occupancy classification is not listed in NFPA nomenclature, such as: –Healthcare occupancy –Business occupancy –Ambulatory healthcare occupancy Type I (443)Type I (332)Type II (222)Type II (111)Type II (000) Type III (211)Type III (200)Type IV (2HH)Type V (111)Type V (000)

16. Top 10 Life Safety Findings It appears that un-qualified people are completing the FDR… This is a document that should be completed by an engineer, architect, or someone with adequate knowledge of the NFPA codes and standards, and your facility. HFAP does not accept IBC nomenclature in lieu of NFPA nomenclature.

17. Top 10 Life Safety Findings Number 5: 13.02.02 Fire Alarm System - Testing –HFAP requires testing of the fire alarm system to comply with the NFPA 72-1999 standard. This means all devices are tested in accordance with Table 7-3.2 in NFPA 72-1999.

18. Top 10 Life Safety Findings Interface relays are often overlooked and not accounted for by the fire alarm testing contractor. They are usually mounted above the ceiling and are out of sight and therefore, out of mind. Their purpose is to connect other systems to the fire alarm system.

19. Top 10 Life Safety Findings Every device on the fire alarm system (and any other feature of life safety) must be inventoried as to their location and whether or not the ‘Passed’ or ‘Failed’ their test. The report must be signed by the service technician and must identify the NFPA standard and edition used during the test (hint: NFPA 72- 1999)

20. Top 10 Life Safety Findings Number 6: 13.04.07 Fire Rated Door Assemblies –Issues with doors that are required to be fire rated, do not qualify as such.

21. Top 10 Life Safety Findings The labels on fire-rated doors cannot be covered by paint, hinges, or other means.

22. Top 10 Life Safety Findings Either the door or the frame is not labeled in a fire- rated barrier.

23. Top 10 Life Safety Findings Number 7: 13.05.04 Generator Inspection –The NFPA 110-1999, 6-4.1 requirement is weekly inspections of the generator will be conducted. Surveyors are finding that either the hospitals are not doing this weekly inspection, or they are not doing it correctly.

24. Top 10 Life Safety Findings Hospitals are not recording the electrolyte levels (specific gravity) on generator batteries. Refractometer Hydrometer

25. Top 10 Life Safety Findings Sealed lead acid batteries: We have reports that some state agencies surveying on behalf of CMS do not permit them, but HFAP will, provided a conductive test is performed in lieu of recording the electrolyte levels.

26. Top 10 Life Safety Findings Number 8: 13.01.01 Doors –Doors are required to function properly. Surveyors are finding multiple issues with doors, concerning their ability to latch, fully open, and obstructions created by the door swing.

27. Top 10 Life Safety Findings Surveyors often find corridor doors that do not latch, due to staff disabling the latching mechanism

28. Top 10 Life Safety Findings Often times, doors will be observed that do not open fully (at least 90 degrees)

29. Top 10 Life Safety Findings Surveyors will cite a door that obstructs more than ½ the width of the corridor / aisle / stairwell landing while the door is being opened.

30. Top 10 Life Safety Findings Number 9: 13.06.04 Life Safety Drawings –Drawings of your rated wall system are critical to proper maintenance. They are imperative to properly assessing your facility for compliance with the Life Safety Code. –If you provide the surveyor with incorrect or poor drawings, it will affect the outcome of your survey.

31. Top 10 Life Safety Findings Surveyors often find that the Life Safety drawings do not include all of the required features: –Rated walls and barriers; –Smoke compartment boundaries and total area; –Travel distances to smoke barriers and to exits; –Suite boundaries and total area; –Exits, exit enclosures, horizontal exits, exit discharges; –Hazardous rooms; –Smoke partitions, such as non-rated corridor walls and hazardous areas.

32. 32 Life Safety drawings (such as this sample) need to include all of these requirements….

33. Top 10 Life Safety Findings Number 10: 13.01.02 Door Locks –Doors in the path of egress are not permitted to be locked, with the following exceptions: Clinical needs locks Delayed egress locks Access-control locks –Surveyors will cite the organization if they do not comply with these exceptions

34. Top 10 Life Safety Findings Doors in the path of egress may be locked where the clinical needs of the patients require specialized security measures for their safety. This is interpreted for behavioral health units, such as psychiatric units and Alzheimer’s units. These types of locks are not permitted for infant security, or any other purpose.

35. Top 10 Life Safety Findings Delayed egress locks are permitted, but only in buildings fully protected with sprinklers or fully protected with smoke detectors. Common deficiencies cited by the surveyors are for delayed egress locks in buildings that are neither fully smoke detected or sprinklered.

36. Top 10 Life Safety Findings Another frequent citing is a delayed egress lock without the proper signage with 1 inch tall lettering that says: “PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS”

37. Top 10 Life Safety Findings Access-control locks are a misnomer… they are not locks in the path of egress. They are required to have a motion sensor on the egress side that detects a person approaching and automatically unlocks the door.

38. Top 10 Life Safety Findings They are also required to have a “Push to Exit” button mounted on the wall of the egress side, within 5 feet of the door, that unlocks the door when depressed. Frequent findings by surveyors identify hospitals that do not have one or the other, or neither.

39. Top 10 Life Safety Findings So… it’s important to understand that doors in the path of egress cannot be locked, unless they meet the prior exceptions. If cited, it will be an automatic Condition Level Deficiency (aka known as a CoP out), and if the door is an actual exit (i.e. a door to the exterior or a door to a stairwell) it will likely be an Immediate Jeopardy decision.

40. Top 10 Life Safety Findings There is a CMS categorical waiver (see S&C memo 13-58) that allows hospitals to use section 19.2.2.2.5.2 of the 2012 Life Safety Code, for special locking arrangements to lock doors for infant security (and ICU and ER doors as well) provided they meet the requirements: –Building must be fully sprinklered –The locked area must be fully smoke detected –Staff must be able to unlock the doors at all times.

41. Transition… So those are the top-ten findings by surveyors for Life Safety. Now let’s transition to the common problems found during the document review session….

42. The Most Common Problems With the Document Review Session The most common problems with the fire alarm test report, are: Not all of the required testing is performed, most often the interface devices and occupant notification devices The testing company does not provide a list of locations for all items tested, and whether or not they passed or failed their test The hospital frequently does not read the test report and therefore does not act on deficiencies identified in the report

43. The Most Common Problems With the Document Review Session The most common problems with the fire pump test report, are: The weekly fire pump tests are not always conducted each week The annual waterflow test is not always conducted at peak capacity (150% of nameplate capacity) The annual waterflow test is not always conducted under emergency power at peak capacity (electric pumps only)

44. The Most Common Problems With the Document Review Session The most common problems with the sprinkler test and inspection report, are: Not all sprinklers and associated piping are inspected on an annual basis, or the documentation is not clear Not all sprinklers are cleaned when dust and dirt accumulate on them Main drain tests are not conducted at the system risers Check valves are not inspected internally (5-Year) Pressure gauges are not calibrated or replaced (5-Year)

45. The Most Common Problems With the Document Review Session The most common problems with the fire extinguisher test and inspection report, are: Not all fire extinguishers are inspected monthly Not all fire extinguishers have their annual maintenance within the + 30 day window Fire extinguishers are required to be mounted, or placed in cabinets, at least 4 inches above the floor and no more than 60 inches above the floor

46. The Most Common Problems With the Document Review Session The most common problems with the Alternative Life Safety Measures (ALSM) policy, are: The policy is based on old standards and is not kept up to date The policy does not contain written criteria for evaluating when and to what extent the hospital follows special measures to compensate for increased risk to life safety

47. The Most Common Problems With the Document Review Session The most common problems with the fire damper test reports, are: The report does not adequately identify the location of each fire damper The organization fails to implement ALSMs for deficient fire dampers The organization fails to meet the 6-Year window for testing

48. The Most Common Problems With the Document Review Session A comment about fire dampers: You are required to test all dampers, regardless if they are accessible or inaccessible. If they are inaccessible, then they must be made accessible and retested. There is no NFPA code or standard that allows inaccessible dampers to remain inaccessible and not be tested.

49. The Most Common Problems With the Document Review Session The most common problems with the overhead rolling fire door test reports, are: The report does not identify the location of each overhead rolling fire door The organization fails to act on deficiencies identified in the report, including ALSMs

50. The Most Common Problems With the Document Review Session The most common problems with the emergency power generator test reports, are: The generators are not load tested within the 20 – 40 day window each month (still required by HFAP and CMS) The monthly load test does not meet the 30% nameplate rating capacity The annual and 3-Year load tests are not conducted at the appropriate load capacities and within the time required

51. The Most Common Problems With the Document Review Session The most common problems with battery powered emergency light testing, are: The emergency lights are not tested for 30 seconds every month The emergency lights are not tested for 90 minutes once per year

52. The Most Common Problems With the Document Review Session The most common problems with medical gas test reports, are: The medical gas alarm panel is not tested according to the hospital’s policy on frequency The purity of the medical gas is not tested after modifications have been made to the system

53. QUESTIONS 53 |

54. Want to ask Questions later? Contact Brad Keyes at: bkeyes@hfap.org 815-629-2240 Or, please submit questions to: info@hfap.org

55. Certificate of Attendance ___________________________ Awarded 1.0 contact hours Life Safety Compliance: Most Common Surveyor Findings A 60 minute audio-conference April 28, 2016 _________________ Brad Keyes, Presenter HFAP Engineering Advisor