Transcript Presenation in PowerPoint - Texas Department of Aging and

10 MOST FREQUENTLY
CITED DEFICIENCIES
Nursing Facilities 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 nursing facilities 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. Nursing facilities must comply with the code’s
applicable provisions. The CFR reference is at 42 CFR
§483.70(a).
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 residents,
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,
nine 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
K064
Portable fire extinguishers
10
Not ranked
K018
Corridor doors
9
7
K069
Commercial cooking equipment
8
9
K144
Emergency electrical power
7
8
K029
Hazardous areas
6
6
K147
Electrical wiring and equipment
5
5
K025
Smoke barriers
4
3
K062
Automatic sprinkler systems
3
4
K038
Means of egress
2
2
K067
Air conditioning/ventilating equipment
1
1
#10 K064
K064 Portable fire extinguishers
42 CFR §483.70(a)
The facility failed to provide and/or maintain portable fire
extinguishers in order to meet the requirements of the
NFPA. For example, each portable fire extinguisher must
be inspected at approximately 30-day intervals and receive
maintenance at least every year.
This tag was ranked 10th in FY14 and was not ranked in the
top ten in FY13.
#10 K064
K064 Portable fire extinguishers
Examples of findings cited under K064:
• The facility does not have the required number of portable
fire extinguishers.
• There is corrosion on the surface of some portable fire
extinguishers.
• The portable fire extinguisher at the nurses’ station has a
cracked hose.
#10 K064
K064 Portable fire extinguishers
Review of the tag attached to the portable fire extinguisher
in the Sunflower Hall (between room 25 and room 27)
revealed that the extinguisher had its last annual
maintenance on October 2012.
During an interview on 6/21/2014 at 1 p.m., the
maintenance supervisor stated that he did not know why
the extinguisher had failed to receive a subsequent annual
maintenance.
Activity: True/False
Directions: Read the statement below and click either the
True or False button.
A portable fire extinguisher must be inspected every three
months and receive maintenance at least every year.
true
false
Activity: True/False
The statement is false.
A portable fire extinguisher must be inspected at
approximately 30-day intervals and receive maintenance at
least every year.
Remember to keep documentation of each inspection and
maintenance performed.
#9 K018
K018 Corridor doors
42 CFR §483.70(a)
The facility failed to ensure that doors protecting corridor
openings are substantial enough to resist fire for at least 20
minutes. If there is a fire inside a room that has such a
door, you can delay the spread of the fire when you close
the door.
This tag was ranked 9th in FY14 and 7th in FY13.
#9 K018
K018 Corridor doors
Examples of findings cited under K018:
• A corridor door has a hole. The hole goes completely
through the door.
• Two corridor doors drag against the floor and cannot
close.
• A drop-down device is attached to a corridor door and the
device keeps the door open.
#9 K018
K018 Corridor doors
Observations on 5/12/14 between 9:30 a.m. and 9:50 a.m.,
revealed that the facility failed to ensure that four of 36
corridor doors (the doors to bedrooms 17, 23, 25 and 39)
would latch into their frames and resist the passage of
smoke.
In an interview on 5/12/14, at 10 a.m., the maintenance
director stated he would repair the latch of each of the four
doors.
Activity: Multiple Choice
Directions: Read the statement below and click the best
option.
How do closed corridor doors help fire safety?
A. Closed corridor doors help minimize panic among
residents.
B. Closed corridor doors delay the spread of fire and
smoke.
C. Closed corridor doors simplify the task of extinguishing
a fire.
D. None of the above.
Activity: Multiple Choice
The correct answer is B.
A closed corridor door can stop a fire from moving out of a
room quickly. This result lets residents have time to reach
a safe place and gives emergency crews time to rescue
residents.
All facility staff can help ensure that corridor doors work
properly. For example, they can look for beds and furniture
that stop doors from closing. They can also look for holes
in doors and doors that do not close.
#8 K069
K069 Commercial cooking equipment
42 CFR §483.70(a)
The facility failed to provide commercial cooking equipment
that meets the requirements of the NFPA. For example,
exhaust hoods must be at least 18 inches from combustible
material.
This tag was ranked 8th in FY14 and 9th in FY13.
#8 K069
K069 Commercial cooking equipment
Examples of findings cited under K069:
• The grease filters are not positioned at least 45 degrees
from the horizontal.
• The exhaust system has not been inspected
semiannually.
• The hoods and the grease filters have an excessive
accumulation of grease.
#8 K069
K069 Commercial cooking equipment
Observation on 6/18/14 at 3 p.m., revealed that the upper
interior seams of the range hood had not been sealed to
prevent accumulation and capture of grease.
During an interview on 6/18/14 at 3 p.m., the maintenance
director said she would have the seams sealed
immediately.
Activity: True/False
Directions: Read the statement below and click either the
True or False button.
Every exhaust hood must be at least 12 inches from
combustible material.
true
false
Activity: True/False
The statement is false.
Every exhaust hood must be at least 18 inches from
combustible material.
Remember that grease can become fuel for a fire.
#7 K144
K144 Emergency electrical power
42 CFR §483.70(a)
The facility failed to inspect and test its generators as
required by NFPA 99 (the Standard for Health Care
Facilities). For example, the working space around each
generator must be at least 30 inches.
This tag was ranked 7th in FY14 and 8th in FY13.
#7 K144
K144 Emergency electrical power
Examples of findings cited under K144:
• When the normal electric power was interrupted, the
transfer switch failed to automatically connect the
emergency lighting load to emergency power within 10
seconds.
• The generator’s starting battery is not of the maintenancefree variety.
#7 K144
K144 Emergency electrical power
Observations on 4/22/14, from 9 a.m. to 9:20 a.m.,
revealed that the nursing home did not have spares for
generator parts that have a high mortality rate.
During an interview on 4/22/14 at 10 a.m., the maintenance
supervisor confirmed that the nursing home did not keep
spares for generator parts that have a high mortality rate.
Activity: Multiple Choice
Directions: Read the statement and click the best option.
Around each generator there must be a working space.
How wide must this space be?
A. 1 foot
B. 30 inches
C. 2 feet
D. 18 inches
Activity: Multiple Choice
The correct answer is B.
There must be a working space of at least 30 inches
around each generator.
Disasters (such as tornados and hurricanes) can leave a
nursing home without regular utility power. During such an
event, a well-maintained generator ensures that designated
areas and functions of the facility remain with electrical
power.
#6 K029
K029 Hazardous areas
42 CFR §483.70(a)
The facility failed to separate hazardous areas by
construction that provides at least a one-hour fire
resistance rating and/or with a sprinkler system as
specified by the Life Safety Code. A hazardous area is any
area of a building that poses a degree of hazard greater
than normal to the residents and staff of the building.
This tag was ranked 6th in FY14 and 6th in FY13.
#6 K029
K029 Hazardous areas
Examples of findings cited under K029:
• The facility’s mechanical room has a gas-fired central
heating unit. The door to the room did not close because
its self-closing hinges were not installed correctly.
• The back wall of the gas-fired water heater closet had four
round holes. Each hole had a one-inch diameter.
• The mechanical room had a gap approximately six inches
in diameter around a duct in the ceiling.
#6 K029
K029 Hazardous areas
Observations on 11/8/14 between 2 p.m. and 2:15 p.m.,
revealed that vacant bedroom #45 was used to store a
large amount of combustible supplies, such as plastic
chairs, wood tables and benches, a four-foot high pile of
cardboard and paper goods, and maintenance tools. The
room’s corridor door was not a self-closing or automaticclosing door. The room has 160 square feet.
In an interview on 11/8/14 at 10:50 a.m., the maintenance
supervisor said he intended to move all the items to a
storage building that will be built soon.
Activity: True/False
Directions: Read the statement and click either the True or
False button.
A hazardous area is any area of a building that poses a
degree of hazard greater than normal to the residents and
staff of the building, such as areas used to store toxic
materials.
true
false
Activity: True/False
The statement is true.
Areas used for the storage or use of combustible or
flammable substances; noxious or corrosive materials; or
heat-producing appliances are also hazardous areas.
#5 K147
K147 Electrical wiring and equipment
42 CFR §483.70(a)
The facility failed to ensure that electrical wiring and
equipment is in accordance with NFPA standards and
national electrical codes. For example, receptacles with
grounding contacts must have those contacts effectively
grounded.
This tag was ranked 5th in FY14 and 5th in FY13.
#5 K147
K147 Electrical wiring and equipment
Examples of findings cited under K147:
• The ground-fault circuit interrupter next to the sink in the
physical therapy room was burnt and did not work.
• Two large boxes of juice concentrate were blocking the
electrical panel in the kitchen dry storage closet. The
boxes did not allow access to the panel door.
• The breakers in the emergency breaker box were not
labeled correctly.
#5 K147
K147 Electrical wiring and equipment
Observation on 6/22/14 at 10 a.m., revealed exposed
wiring in an open junction box installed in the attic
space above office A. The junction box was four
inches by three inches.
In an interview on 6/22/14 at 10:05 a.m., the
maintenance supervisor said he would install a cover
on the open junction box.
Activity: Multiple Choice
Directions: Read the statement and click the best option.
Receptacles with grounding contacts must be:
A. legibly marked
B. completely enclosed
C. effectively grounded
D. provided with a nameplate
Activity: Multiple Choice
The correct answer is C.
Receptacles with grounding contacts must have those
contacts effectively grounded.
Electricity creates hazards. One aim of the National
Electric Code (NFPA 70) is to protect people from those
hazards.
#4 K025
K025 Smoke barriers
42 CFR §483.70(a)
The facility failed to provide smoke walls that have the
required fire-resistance rating. When there is a fire in a
facility, such walls let staff move residents safely to an area
of refuge within the facility.
This tag was ranked 4th in FY14 and 3rd in FY13.
#4 K025
K025 Smoke barriers
Examples of findings cited under K025:
• A smoke barrier had a conduit penetration that had been
sealed with non-fire-rated foam sealant.
• A duct penetration of a required smoke barrier failed to
have a smoke damper.
• A required smoke damper did not close when a smoke
detector activated.
#4 K025
K025 Smoke barriers
Observations on 2/1/14 at 9:45 a.m., revealed that the twohour smoke barrier wall in the lobby adjacent to the
community room had three unsealed penetrations. Two
penetrations had a diameter of one inch and one
penetration had a half-inch diameter.
In an interview on 2/1/14 at 9:45 a.m., the maintenance
director stated that the smoke barrier walls were checked a
week earlier and no one noticed any holes.
Activity: True/False
Directions: Read the statement and click either the True or
False button.
When a fire occurs inside a facility, smoke barriers give
staff the option to move residents safely to an area of
refuge within the facility.
true
false
Activity: True/False
The statement is true.
Smoke barriers divide a facility into smoke compartments.
If a fire occurs in a smoke compartment, staff might move
the residents of the compartment to another compartment
within the same facility.
Fire-rated smoke barriers often fail as barriers because of a
lack of attention to penetrations (or holes) in the barriers.
Look for penetrations both above and below suspended
ceilings.
#3 K062
K062 Automatic sprinkler systems
42 CFR §483.70(a)
The facility failed to ensure that the required sprinkler
systems are maintained in reliable operating condition and
are inspected and tested periodically. For example, a
hydraulically-designed sprinkler system must have a
hydraulic nameplate attached to the riser. This nameplate
is a permanent record of the design parameters.
This tag was ranked 3rd in FY14 and 4th in FY13.
#3 K062
K062 Automatic sprinkler systems
Examples of findings cited under K062:
• The alarm did not activate when water flowed in the pipes
of the automatic sprinkler system.
• The facility failed to maintain the spare sprinkler head
cabinet with a minimum of two for each type and
temperature rating installed.
• The facility did not have the check valve tested every five
years.
#3 K062
K062 Automatic sprinkler systems
Observation on 6/21/14, between 10 a.m. and 10:30 a.m.,
revealed that two sprinkler heads in the kitchen, next to the
dishwashing area, were green and corroded. Also, the
sprinkler head in the therapy bathroom, adjacent to room
23, had the deflector bent upward at a 90 degree angle.
In an interview on 6/21/14, at 10:30 a.m., the maintenance
manager stated that he had not noticed the corroded
sprinkler heads and the bent deflector.
Activity: Multiple Choice
Directions: Read the statement and click the best option.
A hydraulically-designed sprinkler system must have a
hydraulic nameplate attached to the riser. This nameplate
is a permanent record of:
A. the design parameters.
B. the company that provides maintenance to the system.
C. the date of the system’s installation.
D. the fire department that will respond to an alarm
activated by the system.
Activity: Multiple Choice
The correct answer is A.
This nameplate is a permanent record of the design
parameters. The nameplate must be attached securely
and be legible.
#2 K038
K038 Means of egress
42 CFR §483.70(a)
The facility failed to ensure that arrangements of exits are
provided and/or maintained such that exits are readily
accessible at all times. For example, a single action or
step must unlatch doors in the means of egress.
This tag was ranked 2nd in FY14 and 2nd in FY13.
#2 K038
K038 Means of egress
Examples of findings cited under K038:
• The latching hardware on a door’s panic bar did not
release when an attempt was made to open the door.
• The exit sign at the kitchen’s exit access door pointed to a
location that did not have an exit.
• The exit doors had magnetic locking devices that failed to
meet the headroom clearance requirement. The devices
extended below the 6'-8" underside of each door head
opening.
#2 K038
K038 Means of egress
Observations on 12/5/14, at 11 a.m., revealed that the exit
door in Wing A was binding in its frame and was hard to
open.
In an interview on 12/5/14, at 11:05 a.m., the maintenance
director stated he checks doors every day but had not
noticed that the door was binding.
Activity: True/False
Directions: Read the statement and click either the True or
False button.
Doors in the means of egress may require up to two
releasing operations to open when locked.
true
false
Activity: True/False
The statement is false.
A single action or step must unlatch the door.
A two-step release, such as a knob and an independent
slide bolt, is not acceptable.
#1 K067
K067 Air conditioning/ventilating equipment
42 CFR §483.70(a)
The facility failed to meet requirements for air conditioning
and ventilating equipment. For example, each air
distribution system must have at least one manual means
for stopping the supply, return and exhaust fans in an
emergency.
This tag was ranked 1st in FY14 and 1st in FY13.
#1 K067
K067 Air conditioning/ventilating equipment
Examples of findings cited under K067:
• The exit corridor in Wing A is part of the return air system
that serves the adjoining area. (Note: Regulatory
Services routinely grants a waiver for corridors used as
return air plenums.)
• The air duct adjacent to the smoke damper in Hall B does
not have a service opening.
• The facility did not test all automatic shutdown devices at
least annually.
#1 K067
K067 Air conditioning/ventilating equipment
Observations on 6/10/14 at 1 p.m., revealed that, during a
test of the fire alarm system, a smoke damper did not close
automatically. The smoke damper was above the Wing A
ceiling on the beauty parlor side of the smoke barrier doors.
In an interview on 6/10/14 at 1 p.m., the maintenance
director said he did not know that the smoke damper failed
to close.
Activity: Multiple Choice
Directions: Read the statement and click the best option.
Each air distribution system must have at least one manual
means for stopping the:
A. supply fans in an emergency
B. return fans in an emergency
C. supply and return fans in an emergency
D. supply, return and exhaust fans in an emergency
Activity: Multiple Choice
The correct answer is D.
Each air distribution system must have at least one manual
means for stopping the supply, return and exhaust fans in
an emergency.
The means of manual operation must be at an approved
location.
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 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