| Conducting Effective and Compliant Fire Drills | https://publish.ahcancal.org/News-and-Communications/Blog/Pages/Conducting-Effective-and-Compliant-Fire-Drills.aspx | Conducting Effective and Compliant Fire Drills | | | | | 3/1/2024 5:00:00 AM | | Fire drills are a key component of any fire safety program. While the Life Safety Code® (LSC) requirements for fire drills are not complicated, fire drill compliance consistently lands on the list of top cited deficiencies during life safety surveys (K-712). As such, let's walk through the key requirements and best practices around fire drills.<br><br>Fire drills in healthcare occupancies are required to be conducted quarterly on each shift. This is commonly accomplished by facilitating a fire drill each month on a different shift. However, there is nothing that precludes an organization from running multiple fire drills in a single month as long as each shift receives a drill during the quarter. <br><br>Fire drills should be conducted at varying times and under varying conditions. While the LSC is not specific regarding what constitutes “varying times," it is wise to consider varying drills by at least one hour for drills conducted on the same shift. Similarly, drills should be facilitated in different parts of the building and with different scenarios. Simulating the same fire scenario in the same location limits the involvement of staff from other areas of the building. It can be beneficial to develop a fire drill schedule at the on-set of each year that outlines fire drill dates, time, locations, and scenarios. This will provide a helpful roadmap to the fire drill facilitator and ensure compliance is maintained regarding the variance in time, location, and conditions. <br><br>While not specifically required by the LSC, there is an implied expectation that fire drills will be documented. Documentation is your mechanism to prove fire drill compliance during survey. An effective fire drill report will include all the details around the drill including date, time, location, facilitator, and actions taken by staff…specifically any areas for improvement. The reports can be an effective tool for assessing staff competency and identifying trends. It is also wise to maintain a sign-in sheet for each drill to document the staff that were involved. <br><br>Fire drills require activation of the fire alarm system including the normal audible and visual notification devices. However, for nighttime fire drills that occur between the hours of 9:00pm-6:00am, a coded announcement (commonly an overhead page) is permitted in lieu of activating the fire alarm system audible devices. Visual devices are still required to be activated. If and when CMS adopts a newer edition of the LSC, both audible and visual devices will be permitted to be omitted during overnight fire drills. Overnight fire drills always require staff response and implementation of the fire procedures. <br><br>Compliance aside, fire drills can be an extremely effective educational opportunity. Realtime implementation of the fire procedures in a staff member's normal work area can be more memorable and impactful than a training lecture, video, or on-line course. Completing the drill may check the compliance box, but investing the time to facilitate a well-organized drill that includes a comprehensive staff critique will pay dividends during a true fire emergency occurrence. <br><br>As always, knowledge of the applicable codes and standards is your best tool for ensuring compliance. You can purchase a copy of the Life Safety Code® (NFPA 101) online at <a href="http://www.nfpa.org/" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">www.nfpa.org</a>. The <a href="/Survey-Regulatory-Legal/Pages/Fire-Life-Safety.aspx" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">AHCA/NCAL website</a> is also a good source for on-going life safety education, tools, and resources. <br><br> | | |
| Managing Hazardous Area Compliance – Life Safety Compliance | https://publish.ahcancal.org/News-and-Communications/Blog/Pages/Managing-Hazardous-Area-Compliance-Life-Safety-Compliance.aspx | Managing Hazardous Area Compliance – Life Safety Compliance | | | | | 2/22/2024 5:00:00 AM | | <div><div>The Life Safety Code® has long required special protections for “hazardous areas." Locations commonly considered under this designation include storage rooms, soiled utility rooms, boiler rooms, maintenance workshops, and bulk laundry areas. While the provisions for these areas have not greatly changed in the Life Safety Code® over the years, compliance with the requirements specific to hazardous areas continues to be a top five finding nationally (K-321). <br><br>For existing hazardous areas (in place prior to July 2016), these spaces are required to be enclosed with smoke resisting construction (assuming the room is provided with sprinkler protection). This means no louvers, half-walls, open alcoves, or any type of unprotected opening to the corridor. Doors shall be self-closing and positive latching. However, doors are not required to be rated. <br><br>If the hazardous area was constructed after July 2016, or the space lacks sprinkler protection, a 1-hour fire resistance rated enclosure is required. This includes a ¾ hour rated door assembly that is self-closing and positive latching.<br><br>Like so many new focus areas and challenges brought on by the pandemic, the emphasis on personal protective equipment (PPE) has created some unintended consequences regarding Life Safety Code® compliance. With various states mandating significant PPE quantities to be on-hand, some organizations have been forced to create new storage locations. This sometime involves the repurposing of existing spaces that were utilized differently in the past. In many cases, this essentially creates “new" hazardous areas.</div><div><br></div><div>Historically, if an organization looked to convert an existing space into a storage room, for PPE or any type of combustible storage, the conversion of the space triggered the provisions for “new" construction in the Life Safety Code®. However, such rooms or spaces usually do not have 1-hour rated enclosures. <br><br>The 2012 edition of the Life Safety Code® provides some potential relief to organizations who are converting existing spaces into storage areas. The 2012 edition includes a new chapter (Chapter 43 – Building Rehabilitation) that clarifies the requirements applicable when implementing repairs, renovations, changes of use, or even changes in occupancy type. In particular, Section 43.7.1.2(2) provides guidance on the requirements around converting existing spaces into newly designated hazardous areas. Essentially, a 1-hour enclosure of the newly created hazardous area is not necessary if the following criteria are met:<br><ul><li>The area is not greater than 250 square feet.</li><li>The room is being converted to a location used for storage.</li><li>The building is fully sprinklered.</li></ul>This provision in Chapter 43 provides much more flexibility when reallocating space and developing additional storage locations, a common practice as organizations continue to maintain greater stocks of PPE. All door provisions for hazardous areas still apply. <br><br>As always, knowledge of the applicable codes and standards is your best tool for ensuring compliance. You can purchase a copy of the Life Safety Code® (NFPA 101) online at <a href="http://www.nfpa.org/" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">www.nfpa.org</a>. </div><div> </div><div>The <a href="/Survey-Regulatory-Legal/Pages/Fire-Life-Safety.aspx" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">AHCA/NCAL website</a> is also a good source for on-going life safety education, tools, and resources.</div><br></div> | | |
| Why Sprinklers Keep Leading to Survey Tags | https://publish.ahcancal.org/News-and-Communications/Blog/Pages/Why-Sprinklers-Keep-Leading-to-Survey-Tags.aspx | Why Sprinklers Keep Leading to Survey Tags | | | | | 2/6/2024 5:00:00 AM | | Since August 2013, CMS has required all regulated nursing homes to be fully sprinklered. This has resulted in a decline in serious healthcare facility fires, along with the injuries and fatalities that can be associated with them. However, the increase in sprinkler systems has accompanied an increase in life safety deficiencies. CMS K-tags related to sprinkler system design, components, inspection, testing, and maintenance are consistently in the top five K-tag findings list nationally. <br><br>There are two (2) commonly cited K-tags that address sprinkler systems. K351 addresses sprinkler system installation and K353 addresses sprinkler system maintenance. <br><br>Common survey findings related to sprinkler system installation (K351) include:<br><ul><li>Obstructions (18" rule) – Items are not permitted to be stored within 18" of sprinkler heads. This is a common problem in areas such as commissaries and storage rooms. Placing items too close to a sprinkler head could impede the spray pattern from the head. However, the requirement does not limit the ability to have shelving and storage around the perimeter of a room that extends to the ceiling assuming there are no sprinkler heads directly above the storage or shelf. </li><li>Piping – Wire, conduit, cables, and similar items are not permitted to be attached to, supported from, or even laid across sprinkler piping. This is a common issue above the ceiling. </li><li>Overhangs / Awnings – Any overhang or awning considered combustible and spanning more than four (4) feet from the side of the building is required to have sprinkler protection provided to the space below. This can include porticos, porte-cochères, and entry/exit awnings and overhangs. There are special designs and specialty sprinklers that can be utilized to protect these unique areas. </li></ul>Common survey findings related to sprinkler inspection, testing, and maintenance (K353) include:<br><ul><li>Testing, Inspection, and Maintenance – NFPA 25 outlines very prescriptive inspection, testing, and maintenance (ITM) requirements for sprinkler systems. Survey findings often relate to incomplete documentation, missing ITM components, or lack of remediation when the vendor identifies an issue. Make sure your vendors are using the 2011 edition of NFPA 25, providing comprehensive documentation, and clearly notifying you if there is a problem requiring attention. </li></ul><ul><li>Sprinkler Head Testing or Replacement – NFPA 25 also dictates when sprinkler heads must either be tested or replaced. The interval depends on the type of sprinkler head. Standard response sprinklers require testing at the 50-year mark and then again every 10 years thereafter. Fast response sprinklers, including quick response heads that are commonly found in healthcare facilities, require testing 25 years after installation and then again every 10 years thereafter. Rather than send out a grouping of sprinkler heads to be tested, you can also replace them at the first or subsequent testing mark. This will reset the clock for future testing requirements. Your sprinkler vendor should be knowledgeable in determining the age of your sprinkler heads, when they require testing/replacement, and what labs can provide the testing service. </li><li><span style="font-size:11pt;">Painted / Dirty Sprinkler Heads – Sprinklers may not operate as intended if they are dirty, grease laden, or painted. Usually, a simple cleaning or dusting does the trick. However, if paint or grease won't remove easily, the heads may need to be replaced. </span></li></ul><div><span style="font-size:11pt;">Sprinklers are proven to save property and lives. Ensuring they are installed and maintained appropriately will keep you in compliance and keep your system in a state of readiness should a fire occur. </span><br></div><div><br><span style="font-size:11pt;"></span><div>Detailed sprinkler system requirements can be accessed via the National Fire Protection Association's (NFPA) website at <a href="http://www.nfpa.org/" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">www.nfpa.org</a>. The <a href="/Survey-Regulatory-Legal/Pages/Fire-Life-Safety.aspx" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">AHCA/NCAL website</a> is also a great resource for on-going life safety education, tools and resources. <br><br></div></div> | | |
| Navigating “Safety” in Long Term Care Centers: Separating the Roles of OSHA and the CMS requirements for Emergency Preparedness | https://publish.ahcancal.org/News-and-Communications/Blog/Pages/Navigating-Safety-in-Long-Term-Care-Centers-Separating-the-Roles-of-OSHA-and-the-CMS-requirements-for-Emergency-Preparedn.aspx | Navigating “Safety” in Long Term Care Centers: Separating the Roles of OSHA and the CMS requirements for Emergency Preparedness | | | | | 2/6/2024 5:00:00 AM | | <p><strong style="font-size:11pt;">Continuation: </strong><br></p><div><span style="font-size:11pt;">In this third article regarding the connection between the Occupational Safety and Health Administration (OSHA) and the Centers for Medicare & Medicaid Services (CMS) Life Safety and Emergency Preparedness (EP) Requirements, the focus will be on how OSHA’s regulations overlap with CMS’ EP requirements, found in 42 CFR 483.73 (Appendix Z). </span><br></div><div> </div><div>It’s important to note that CMS’ EP requirements <strong>do NOT</strong> apply to assisted living, however any OSHA requirements do apply. </div><div> </div><div><strong>Emergency Preparedness-Overview:</strong> </div><div><br></div><div><ul><li><strong>Emergency Preparedness:</strong> CMS established specific requirements for emergency preparedness in nursing communities that became effective in 2017. The CMS rule, commonly known as the Emergency Preparedness Rule, applies to various health care providers, including nursing communities. Emergency preparedness is typically surveyed by the state survey agency in conjunction with the Life Safety Code survey. <br><br>Key components of the CMS Emergency Preparedness Rule for nursing communities <span style="font-size:11pt;">include, but are not limited to: </span></li><p><span style="font-size:11pt;"><br></span></p></ul><ol><ol><li><span style="font-size:11pt;"></span><span style="font-size:11pt;"></span><span style="font-size:11pt;"><span style="text-decoration:underline;">Emergency Plan</span>: Providers are required to develop and maintain an emergency plan that addresses potential emergencies specific to their geographic location. This plan should include strategies for addressing both natural and man-made disasters. </span></li><li><span style="font-size:11pt;"><span style="text-decoration:underline;">Policies and Procedures</span>: Nursing homes must have policies and procedures in place to implement the emergency plan. These should cover various aspects, including communication, patient tracking, and coordination with local emergency management agencies. </span><br></li><li><span style="font-size:11pt;"><span style="text-decoration:underline;">Communication Plan</span>: Nursing homes are required to establish a communication plan that ensures timely and effective communication during emergencies. This includes communication with staff, residents, families, and external entities. </span><br></li><li><span style="font-size:11pt;"><span style="text-decoration:underline;">Training and Testing</span>: Nursing home providers must conduct regular training for staff to ensure they are familiar with emergency procedures. Additionally, they are required to conduct regular testing and drills to assess the effectiveness of their emergency plans. </span><br></li><li><span style="font-size:11pt;"><span style="text-decoration:underline;">Integrated Healthcare Systems</span>: Nursing home communities are encouraged to coordinate their emergency plans with other health care providers and community resources to ensure a seamless response to emergencies. </span></li></ol></ol><ul><li><strong>OSHA:</strong> OSHA does not have regulations or standards that specifically address emergency preparedness in long term care communities, including assisted living. However, OSHA does have general requirements that may indirectly relate to emergency preparedness and employee safety during emergencies, such as emergency evacuation procedures, personal protective equipment, infection control and respiratory protection. </li></ul></div><div><br></div><div><strong>Emergency Preparedness - Compare and Contrast of Key Compliance Items: </strong></div><div><br></div><div><ol><li><strong>Emergency Evacuation Plans:</strong> <br><br></li><ol><ul><li><span style="font-size:11pt;"></span><span style="font-size:11pt;"></span><strong>Emergency Preparedness</strong>: CMS mandates the development and implementation of comprehensive emergency evacuation plans that consider various potential emergencies, including fires and natural disasters. These plans outline procedures for the safe and orderly evacuation of residents, including the identification of evacuation routes and the assignment of responsibilities to staff members. <br><br></li><li><span style="font-size:11pt;"><strong>OSHA</strong>: OSHA's Emergency Action Plan standard <a href="https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.38" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">1910.38 - Emergency action plans. | Occupational Safety and Health Administration (osha.gov) </a>requires employers to develop and implement emergency action plans. These plans must include procedures for the evacuation of employees and, where applicable, residents during emergencies. <br></span><br></li></ul></ol><li><span style="font-size:11pt;"><strong>Communication Systems: <br></strong></span><br></li><ol><ul><li><span style="font-size:11pt;"></span><strong>Emergency Preparedness</strong>: CMS emphasizes the importance of effective communication during emergencies. Communities are required to have communication systems in place to relay information to staff, residents, and, if necessary, external emergency response entities. This includes methods for notifying individuals about emergencies and providing clear instructions. <br><br></li><li><span style="font-size:11pt;"><strong>OSHA</strong>: OSHA regulations also highlight the importance of communication during emergencies (29 CFR 1910.38). Emergency action plans must include procedures for reporting emergencies, including a method for employees to report emergencies or other dangerous situations. <br></span><br></li></ul></ol><li><span style="font-size:11pt;"><strong>Training and Drills: <br></strong></span><br></li><ol><ul><li><span style="font-size:11pt;"></span><strong>Emergency Preparedness</strong>: CMS has specific requirements for training and drills to ensure that staff and residents are familiar with emergency procedures. This includes conducting evacuation drills, training on the use of emergency equipment, and educating individuals on their roles and responsibilities during emergencies. <br><br></li><li><span style="font-size:11pt;"><strong>OSHA</strong>: OSHA's Emergency Action Plan standard emphasizes the need for employee training (29 CFR 1910.38). Employers, including long-term care centers, must ensure employees are familiar with the emergency action plan, including evacuation procedures, and conduct regular drills to evaluate its effectiveness. </span><br></li></ul></ol></ol></div><div><br></div><div><span style="font-size:11pt;"><strong>Differences and Synergies: </strong></span></div><div><br></div><div>The CMS rules and OSHA regulations overlap on certain aspects of emergency preparedness, yet each has distinct focuses. Both emphasize the importance of comprehensive emergency preparedness in health care settings, including long term care centers. </div><div> </div><div>CMS rules, particularly the Emergency Preparedness Rule, require providers to develop and implement plans addressing various emergencies. This encompasses evacuation procedures, communication plans, and coordination with external entities. </div><div> </div><div>OSHA, while not having specific regulations dedicated to health care emergency preparedness, mandates general emergency action plans for workplaces, emphasizing evacuation procedures and employee training. </div><div> </div><div><strong>Conclusion: </strong></div><div> </div><div>The CMS rules specifically address the safety and needs of health care recipients and their caregivers, ensuring continuity of care during emergencies, while OSHA's focus encompasses the safety of employees. Aligning with both sets of regulations ensures a universal approach to emergency preparedness, safeguarding the well-being of both health care recipients and staff in health care settings. </div><div> <br></div><p></p> | In this third article regarding the connection between OSHA and CMS Life Safety and EP Requirements, the focus will be on how OSHA’s regulations overlap with CMS’ EP requirements, found in 42 CFR 483.73 (Appendix Z).
| |