Transcript Presentation in PowerPoint. - Texas Department of Aging and

10 MOST FREQUENTLY
CITED DEFICIENCIES
ICFs/IID –
Life Safety Code
Welcome
The Texas Department of Aging and Disability Services
(DADS) designed this computer-based training to inform
you about the 10 most frequently cited Life Safety Code
deficiencies in intermediate care facilities for individuals
with an intellectual disability or related conditions (ICFs/IID)
during fiscal year (FY) 2014.
Navigation
Click anywhere in the screen to go forward one slide at a
time.
Scroll up to go back.
Click the exit button in the top right hand corner to leave
the program.
Survey Process
Surveyors base their decisions to write deficiencies on the
U.S. Code of Federal Regulations (CFR). The CFR
authorizes the certification activities of the DADS
Regulatory Services section.
The CFR refers you to the 2000 edition of the Life Safety
Code. ICF/IIDs must comply with the code’s applicable
provisions. The CFR reference is at 42 CFR
§483.470(j)(1)(i).
The National Fire Protection Association (NFPA) publishes
the Life Safety Code.
Survey Focus
During the survey, surveyors assess how effectively the
facility’s physical environment empowers individuals,
accommodates their needs, and maintains their safety.
DADS Annual Report
State law requires DADS to compile and report survey and
enforcement data every year. DADS publishes this data in
the Regulatory Services Annual Report.
Part of this report includes the top 10 deficiencies cited
during the fiscal year covered by the report.
The DADS Annual Report is available on the Internet at:
http://www.dads.state.tx.us/providers/reports/sb190/index.h
tml.
DADS Annual Report
This training is based on the data contained in the
Regulatory Services FY14 Annual Report, which covers the
period from 9/1/13 to 8/31/14.
Other than minor changes in position within the top 10 and
two ties, all of the top 10 deficiencies listed in the FY13
report continue to be top 10 problems in FY14.
In this training, the top 10 deficiencies listed in the FY14
report appear in order from the least frequently cited (#10)
to the most frequently cited (#1).
Learning Objectives
In this course, you will:
• identify how building requirements help provide safety
from fire; and
• identify requirements that the fire safety systems in your
facility must meet.
Deficiencies Chart for FY14 and FY13
Tag Number
Tag Title
FY14
FY13
K043
Locked doors in the means of egress
10
9
K041
No acceptable primary means of
escape
10
10
K149
Receptacles for smoking materials
8
6
K120
No acceptable secondary means of
escape
8
8
K152
Evacuation drills
7
Not ranked
K147
Written fire safety plan
6
7
K053
Smoke detectors
5
5
K018
Fire safety of doors
4
4
K046
Utilities that meet the Life Safety Code
3
1
K051
Manual fire alarm
2
3
K056
Automatic sprinkler system
1
2
#10 K043
K043 Locked doors in the means of egress
42 CFR §483.470(j)(1)(i)
The facility failed to ensure that no door providing escape
from the facility in the event of fire should ever be locked.
For example, every bathroom door must be designed to
allow opening from the outside during an emergency when
locked.
This tag was ranked 10th in FY14 and 9th in FY13.
#10 K043
K043 Locked doors in the means of egress
Examples of findings cited under K043:
• The lock on the front exit door did not open with a single
releasing action.
• The emergency exit door in bedroom A had worn out
sliding wheels. The door opened only with a force of
more than 20 pounds.
• The door in the medication room had a handle that would
let the door be locked against egress.
#10 K043
K043 Locked doors in the means of egress
Observations on 5/5/14 at 10 a.m., revealed that the
separation door in the hallway adjacent to Bedroom 2 had
a malfunctioning door knob. The knob did not release the
door when the knob was turned.
In an interview on 5/5/14 at 10:15 a.m., the residential
manager stated that the door knob had no problem when
he checked it last month.
Activity: True/False
Directions: Read the statement and click either the True or
False button.
Every bathroom door must be designed to allow opening
from the outside during an emergency when locked.
true
false
Activity: True/False
The statement is true.
Exits are one of the central topics of the Life Safety Code.
Residents of a facility must be able to leave the facility
safely during a fire.
#10 K041
K041 No acceptable primary means of escape
42 CFR §483.470(j)(1)(i)
The facility failed to provide an acceptable primary means
of escape for every sleeping room as required for fire
safety. All bedrooms in each facility must have access to a
primary means of escape that provides a safe path of travel
to the outside.
This tag was ranked 10th in FY14 and 10th in FY13.
#10 K041
K041 No acceptable primary means of escape
Examples of findings cited under K041:
• The smoke door in the dining room did not self-close
because a piece of cardboard was wedged under the
door.
• Three bicycles and a barbeque pit were blocking the exit
path under the porch.
• The exit door in bedroom C was binding in its door frame.
#10 K041
K041 No acceptable primary means of escape
Observations on 5/9/14 at 8:45 a.m., revealed a three-foot
high bush growing outside the exit for bedroom 1. The
bush extended about three feet into the egress path
outside the exit. The bush was large enough to stop
individuals with a walker or in a wheelchair from using the
path safely.
During an interview on 5/9/14 at 10 am, the residential
manager said he will trim the bush.
Activity: True/False
Directions: Read the statement and click either the True or
False button.
At least half of the bedrooms in each facility must have
access to a primary means of escape that provides a safe
path of travel to the outside.
true
false
Activity: True/False
The statement is false.
All bedrooms in each facility must have access to a primary
means of escape that provides a safe path of travel to the
outside.
Similarly, every living area must have access to a primary
means of escape that provides a safe path of travel to the
outside.
#8 K149
K149 Receptacles for smoking materials
42 CFR §483.470(j)(1)(i)
The facility failed to provide appropriate receptacles for
smoking materials in all areas where smoking is permitted.
Noncombustible safety-type ashtrays are appropriate
receptacles.
This tag was ranked 8th in FY14 and 6th in FY13.
#8 K149
K149 Receptacles for smoking materials
Examples of findings cited under K149:
• The smoking area had two plastic ashtrays.
• The only ashtray in the smoking area was a tin bucket on
the floor.
• The front porch had a non-approved tower/chimney-type
ashtray. This ashtray had seven or eight cigarette butts
inside.
#8 K149
K149 Receptacles for smoking materials
Observations on 8/1/14 at 10 a.m., 10:45 a.m., 11:30 a.m.,
12 noon, 1:35 p.m., 2:05 p.m. and 2:30 p.m., revealed that
the smoking area adjacent to bedroom 2 did not have an
ashtray.
In an interview on 8/1/14 at 2:50 p.m., the qualified
intellectual disabilities professional (QIDP) stated she did
not know what happened to the ashtray that was in the
smoking area. She said that she will get a new ashtray for
the smoking area.
Activity: Multiple Choice
Directions: Read the statement and click the best option.
When smoking is permitted:
A. noncombustible safety-type ashtrays must be provided
B. ashtrays must be clearly identified
C. noncombustible ashtrays must be provided
D. ashtrays must be clearly identified and supervised
Activity: Multiple Choice
The correct answer is A.
When smoking is permitted, noncombustible safety-type
ashtrays must be provided in convenient locations.
#8 K120
K120 No acceptable secondary means of escape
42 CFR §483.470(j)(1)(i)
The facility failed to provide an acceptable secondary
means of escape for every sleeping room. For example, a
window that is a secondary means of escape must provide
a clear opening of not less than 5.7 square feet.
This tag was ranked 8th in FY14 and 8th in FY13.
#8 K120
K120 No acceptable secondary means of escape
Examples of findings cited under K120:
• The main window of bedroom B is the bedroom’s
secondary means of escape. A wooden cabinet with a
42-inch TV on top blocked the main window.
• The window in bedroom 2 was jammed in its frame. This
window is the room’s secondary means of escape.
• The two windows in bedroom 3 could not be opened more
than halfway.
#8 K120
K120 No acceptable secondary means of escape
Observations on 6/30/14, between 11 a.m. and 11:10 a.m.,
revealed that an L-shaped bed with a headboard blocked
the access to the only window in bedroom C. The
headboard was 50 inches high.
In an interview on 6/30/14 at 11:15 a.m., the residential
manager stated that someone had rearranged the
bedroom’s furniture. He stated that staff will move the bed
away from the window.
Activity: True/False
Directions: Read the statement and click either the True or
False button.
A window that is a secondary means of escape must
provide a clear opening of not less than four square feet.
true
false
Activity: True/False
The statement is false.
A window that is a secondary means of escape must
provide a clear opening of not less than 5.7 square feet.
If there is a fire in the facility, firefighters might have to
rescue individuals through the window.
#7 K152
K152 Evacuation drills
42 CFR §483.470(j)(1)(i)
The facility failed to ensure that evacuation drills were held
in the manner and with the frequency required. The facility
must conduct evacuation drills at least quarterly for each
shift of personnel and under varied conditions.
This tag was ranked 7th in FY14 and not ranked in the top
10 in FY13.
#7 K152
K152 Evacuation drills
Examples of findings cited under K152:
• The facility did not provide documentation of fire drills
conducted in March through August of 2014.
• The facility had documentation only for fire drills
conducted during the 8 a.m. to 4 p.m. shift.
• The most current fire drill documentation provided by the
facility was dated 2/10/14.
#7 K152
K152 Evacuation drills
Per facility fire drill logs, the facility has three shifts: the first
shift is from 6 a.m. to 4 p.m., the second shift is from 4 p.m.
to 10 p.m., and the third shift is from 10 p.m. to 6 a.m.
Review of the facility’s fire drill logs dated 9/1/13 through
8/31/14 indicated none of the shifts conducted fire drills in:
November 2013, February 2014, April 2014 and July 2014.
In an interview on 12/09/14 at 4:45 p.m., the QIDP stated
she had been the QIDP for ten days and knows that fire
drills had not been conducted as required.
Activity: Multiple Choice
Directions: Read the statement and click the best option.
The facility must hold evacuation drills at least quarterly for:
A. each shift of personnel
B. each shift of personnel and under varied conditions
C. each maintenance staff member
D. each maintenance staff member and under varied
conditions
Activity: Multiple Choice
The correct answer is B.
Remember to document each drill. Keep a copy of the
documentation at the facility.
#6 K147
K147 Written fire safety plan
42 CFR §483.470(j)(1)(i)
The facility failed to have a written fire safety plan that was
updated, readily available, understood by all employees,
and the subject of required periodic staff instruction. In
addition to addressing the evacuation of individuals, the
plan has to address procedures for keeping individuals in
place and for evacuating individuals to an area of refuge.
This tag was ranked 6th in FY14 and 7th in FY13.
#6 K147
K147 Written fire safety plan
Examples of findings cited under K147:
• The facility failed to train staff on the fire and evacuation
procedures at least every two months.
• Staff did not revise the fire safety plan when the facility
admitted individuals with unusual needs.
• There was no copy of the fire safety plan readily available
at all times inside the facility.
#6 K147
K147 Written fire safety plan
Review of the facility emergency management plan revealed that
the plan did not address the evacuation of three individuals who
may require special assistance. The facility’s fire drill records
identified three individuals as blind.
During an interview on 8/2/14 at 10 a.m., the residential manager
stated that the three blind individuals required help getting out of
the house or to the area of refuge. The residential manager also
stated that the other three residents also needed some
assistance. She stated that the facility would revise the plan.
Activity: True/False
Directions: Read the statement and click either the True or
False button.
In addition to addressing the evacuation of individuals from
the building, the fire safety plan has to address procedures
for keeping individuals in place and for evacuating
individuals to an area of refuge.
true
false
Activity: True/False
The statement is true.
A fire safety plan lists the duties and responsibilities of staff
members. They must be always informed about their
duties and responsibilities.
#5 K053
K053 Smoke detectors
42 CFR §483.470(j)(1)(i)
The facility failed to provide approved smoke detectors in
all the required areas, or failed to ensure that they met
requirements for power, or failed to ensure that they were
audible in all sleeping areas. For example, smoke
detectors must be positioned correctly.
This tag was ranked 5th in FY14 and 5th in FY13.
#5 K053
K053 Smoke detectors
Examples of findings cited under K053:
• The smoke detector in the central corridor failed to
activate the fire alarm when tested.
• One of the six smoke detectors in the facility was not
inspected and maintained as required.
• The medication room in the East wing did not have a
smoke detector.
#5 K053
K053 Smoke detectors
Record review of the facility’s fire alarm inspection reports
revealed that three smoke detectors failed the most recent
smoke detector sensitivity test dated 12/10/13. The three smoke
detectors were replaced with new smoke detectors on 12/10/13.
The facility did not have any documentation showing that a
sensitivity test was performed on the new smoke detectors within
one year of the installation date.
In an interview on 8/10/14 at 3 p.m., the residential manager
stated that he was not aware of the requirement for a sensitivity
test.
Activity: Multiple Choice
Directions: Read the statement and click the best option.
Smoke detectors need to:
A. have a distinct color
B. be observed correctly
C. have spares available in a cabinet
D. be positioned correctly
Activity: Multiple Choice
The correct answer is D.
Smoke detectors need to be positioned correctly.
If a smoke detector is installed too close to a wall/ceiling
intersection, particularly over a door, air currents might
cause heat and smoke to bypass the detector completely.
The fire alarm system would then not respond to the
emergency in a timely manner.
#4 K018
K018 Fire safety of doors
42 CFR §483.470(j)(1)(i)
The facility failed to meet applicable Life Safety Code
requirements for the fire safety of doors, including their
locations, construction, design and closers. For example,
no bedroom door may be arranged in a manner that
prevents people from closing the door.
This tag was ranked 4th in FY14 and 4th in FY13.
#4 K018
K018 Fire safety of doors
Examples of findings cited under K018:
• The facility failed to install automatic door closures on the
doors to bedrooms 11 and 13.
• The doors to bedroom 23 and bedroom 31 did not latch in
their frames.
• There was a round hole that went completely through the
door to bedroom A. The hole had a diameter of one inch.
#4 K018
K018 Fire safety of doors
Observations on 7/11/14 at 10 a.m., revealed that a bed in
bedroom 12 was holding open the bedroom’s corridor door.
In an interview on 7/11/14 at 10:30 a.m., the residential
manager stated that she has moved the bed several times
to a position that lets the door close. She also stated that
the individual who lives in the bedroom puts the bed back
in a position that stops the door from closing.
Activity: True/False
Directions: Read the statement and click either the True or
False button.
Only devices that can be removed with a single motion may
hold open a bedroom door.
true
false
Activity: True/False
The statement is false.
No bedroom door may be arranged in a manner that
prevents people from closing the door.
A failure to close a bedroom door could allow smoke or fire
to spread from the bedroom to other parts of the facility.
#3 K046
K046 Utilities that meet the Life Safety Code
42 CFR §483.470(j)(1)(i)
The facility failed to provide utilities that meet the
requirements of the Life Safety Code. For example, each
junction box must have a cover.
This tag was ranked 3rd in FY14 and 1st in FY13.
#3 K046
K046 Utilities that meet the Life Safety Code
Examples of findings cited under K046:
• The electrical conduit to the water heater was not firmly
secured, and the electric wiring was exposed.
• Half of the cover plate for the light switch in bedroom 3
was missing.
• When tested with a circuit tester, the electrical receptacle
in the wall next to the laundry dryer indicated “open”
ground.
#3 K046
K046 Utilities that meet the Life Safety Code
Observations on 6/22/14 at 9 a.m., revealed that the
electrical power outlet in bathroom 22 was a duplex outlet
connected to a ground fault circuit interrupter (GFCI)
breaker (located in the outside electrical panel). The
maintenance supervisor tested the GFCI and it did not
"break" or cut the electrical connection as designed.
In an interview on 6/22/14 at 9 a.m., the maintenance
supervisor said she would get the GFCI fixed.
Activity: Multiple Choice
Directions: Read the statement and click the best option.
The National Electric Code requires:
A. a cover on every junction box
B. a junction box in each room
C. flexible power cords run through doorways
D. doorways that are wide enough for a standard cart of
tools and electrical equipment
Activity: Multiple Choice
The correct answer is A.
The National Electric Code requires a cover on each
junction box.
Section 9.1.2 of the 2000 edition of the Life Safety Code
requires compliance with the 1999 edition of the National
Electric Code.
#2 K051
K051 Manual fire alarm
42 CFR §483.470(j)(1)(i)
The facility failed to provide a working manual fire alarm
system as required. For example, a circuit breaker for a
fire alarm system must be red, accessible only to
authorized staff, and identified as Fire Alarm Circuit
Control.
This tag was ranked 2nd in FY14 and 3rd in FY13.
#2 K051
K051 Manual fire alarm
Examples of findings cited under K051:
• The fire alarm system did not have all of the required
manual pull stations.
• The fire alarm system was not connected to a dedicated
branch circuit.
• The fire alarm panel did not activate a general fire alarm
when normal power was disconnected to the panel and a
manual pull station was activated.
#2 K051
K051 Manual fire alarm
Record review revealed that the last test of the fire alarm
system was on 6/5/13. There were no tags on the fire
alarm panel and no documentation to indicate that a test
had been conducted after 6/5/13.
In an interview on 8/1/14 at 2 p.m., the chief program officer
stated that he did not have any documentation of a test or
of maintenance performed on the fire alarm system.
Activity: True/False
Directions: Read the statement and click either the True or
False button.
The circuit breaker for a fire alarm system must be
identified in red, accessible only to authorized staff, and
identified as Fire Alarm Circuit Control.
true
false
Activity: True/False
The statement is true.
A fire alarm system includes a control panel, primary and
standby power supplies, devices that detect abnormal
conditions (such as a fire or smoke), and appliances that
warn of abnormal conditions.
#1 K056
K056 Automatic sprinkler system
42 CFR §483.470(j)(1)(i)
The facility failed to meet applicable requirements for
sprinkler system coverage. For example, in a small ICF/IID
that has a slow or impractical evacuation capability, an
NFPA 13D automatic sprinkler system must have a 30minute water supply.
This tag was ranked 1st in FY14 and 2nd in FY13.
#1 K056
K056 Automatic sprinkler system
Examples of findings cited under K056:
• The four sprinkler heads in the west bedroom and two
sprinkler heads in the east bedroom had rust.
• The lobby had two different types of sprinkler heads (three
quick response sprinkler heads and one ordinary fusible
link sprinkler head).
• There is no sprinkler head orifice installed at the end of
the inspector's test connection.
#1 K056
K056 Automatic sprinkler system
Observations on 6/22/14 at 9:30 a.m., revealed that the
closet in bedroom A was not protected with sprinkler heads.
Observations on 6/22/14 at 9:35 a.m. revealed that the
walk-in closet in bedroom C was not protected with
sprinkler heads.
In an interview on 6/22/14 between 10 a.m. and 10:10 a.m.,
the maintenance director stated that he would order the
installation of the missing sprinkler heads.
Activity: Multiple Choice
Directions: Read the statement and click the best option.
In a small ICF/IID that has a slow or impractical evacuation
capability, an NFPA 13D automatic sprinkler system must
have a:
A. 10-minute water supply
B. 15-minute water supply
C. 20-minute water supply
D. 30-minute water supply
Activity: Multiple Choice
The correct answer is D.
In a small ICF/IID that has a slow or impractical evacuation
capability, an NFPA 13D automatic sprinkler system must
have a 30-minute water supply.
The surveyor will ask for documentation that indicates a
30-minute water supply for the NFPA 13D automatic
sprinkler system.
Conclusion
This training has reviewed some ways to avoid the top ten
deficiencies. In addition to complying with the required
tests and maintenance, remember to meet all of the
documentation requirements. Document every relevant
detail and save your documentation.
Contact
For questions or more information:
DADS Regulatory Services
Policy, Rules and Curriculum Unit
512-438-3161
www.dads.state.tx.us