Life Safety Documentation for Healthcare Facilities

1. MHCEA CONFERENCE May 3, 2019

2. LIFE SAFETY DOCUMENTATION LIST Deputy State Fire Marshal Healthcare Team

3. 1. Current Life Safety building floor plan Plan should start with an A.000

4. 2. Emergency Fire Evacuation plan

5. 3. SMOKING REGULATIONS/ POLICY • Facility policies must describe the methods by which residents are deemed safe to smoke without supervision. These methods may include assessment of a resident’s cognitive ability, judgment, manual dexterity and mobility. Frequency of reassessment to determine if any change has occurred should also be documented. Surveyors may request to see documentation of the assessment that resulted in a resident being permitted to smoke without supervision. Facilities should err on the side of caution and provide staff, family or volunteer supervision when unsure of whether or not the resident is safe to smoke unsupervised. • Oxygen use is prohibited in smoking areas for the safety of residents (NFPA 101, 2012 ed., 19.7.4). An oxygen-enriched environment facilitates ignition and combustion of any material, especially smoking products such as matches and cigarettes. Facilities should ensure resident safety by such efforts as informing visitors of smoking policies and hazards to prevent smoking related incidents and/or injuries. • Additional guidance about resident smoking can be found at 42 CFR, Part 483.15(b), F242 Self- Determination and Participation. Surveyors are reminded that according to the Interpretive Guidelines at F242, a change in the facility’s policy to prohibit smoking does not affect current residents who smoke. Current residents are allowed to continue smoking in a designated area that may be outside, weather permitting. Residents admitted after the policy change must be informed, during the admission process, of the policy prohibiting smoking. • The facility is obligated to ensure the safety of designated smoking areas which includes protection of residents from weather conditions and non-smoking residents from second hand smoke. The facility is also required to provide portable fire extinguishers in all facilities (NFPA 101, 2012 ed., 18/19.3.5.6). The Life Safety Code (NFPA 101, 2012 ed., 19.7.4) requires each smoking area be provided with ashtrays made of noncombustible material and safe design. Metal containers with self closing covers into which ashtrays can be emptied must be readily available. • A new issue concerns the use of electronic cigarettes (e-cigarettes). These products are designed to deliver nicotine or other substances to the user in the form of a vapor. They are composed of a rechargeable, battery-operated heating element, a replaceable cartridge that may contain nicotine or other chemicals, and an atomizer that, when heated, converts the contents of the cartridge into a vapor. The vapor has a light odor that dissipates quickly. These e-cigarettes are not considered smoking devices, and their heating element does not pose the same dangers of ignition as regular cigarettes.

6. 4. Fire Drills Records

7. 5. OUT OF SERVICE POICIES • Fire Alarm out of service is 4 hours in a 24 hour period • Fire sprinkler system is 10 hours in a 24 hour period • Verify correct contact information

8. 6. FIRE ALARM SYSTEM REPORTSShowing monthly D.A.C.T testing and the NFPA 72 form

9. 7. SMOKE DETECTOR SENSITIVITY TESTING • This must show the sensitivity range, and the actual tested sensitivity for each smoke detector and date tested. • To ensure that each smoke detector or smoke • alarm is within its listed and marked sensitivity range, it shall • be tested using any of the following methods: • (1) Calibrated test method • (2) Manufacturer’s calibrated sensitivity test instrument • (3) Listed control equipment arranged for the purpose • (4) Smoke detector/fire alarm control unit arrangement • whereby the detector causes a signal at the fire alarm control • unit where its sensitivity is outside its listed sensitivity range • (5) Other calibrated sensitivity test methods approved by the • authority having jurisdiction

10. 8. RESIDENT ROOM SMOKE DETECTORS • Tested weekly/ monthly per manufacturer recommendations

11. 9. FIRE SPRINKLER SYSTEM • Quarterly testing done by in house. • Annual vendor test report. Make sure maintain staff is on the e-mail report. • NFPA 25 forms should be used. • Date of last 5 year inspection completed. Pipes/ gauges/ valves • Fire pumps are inspected weekly and ran monthly

12. 10. RANGE HOOD SYSTEM INSPECTION • Semi-annual inspection dates • System activate of the fire alarm system • Cleaning of hood (s) annual LSC 9.2.3 refer to NFPA 96 • Hydrostatic test date

13. 11. FIRE EXTINGUISHER • Monthly in-house inspection dates • Annual vendor service date • 6 year & 12 year maintenance date per fire extinguisher • Inventory log

14. 12. Generator • Weekly visual log • Monthly 30 minute load test • Exercised once every 36 months for 4 hours. • Annual load bank test on Diesel models only • Letter of Reliability on Natural or Propane models.

15. 13. BATTERY EMERGENCY LIGHT TESTING • Monthly 30 second test • Annual 90 minute test • Record all lighting tested by month.

16. 14. SMOKE DAMPER TESTING • Inspected and tested every 4 years in Nursing home • Inspected and test every 6 years in Hospital only • Maintain an record of test dates.

17. 15. FLAME SPREAD DOCUMENTATION • Provide documentation for all wall, ceiling & floor finishes • Provide documentation on all curtains and draperies per 10.3.1 • Excluding curtains and draperies at showers and bath’s, on windows in patient sleeping room located in a fire sprinkler compartments. • In non-patient sleeping rooms in a fire sprinkler compartments where panels do not exceed 48 sq. Ft or total area does not exceed 20 percent of the wall. • Upholstered furniture and mattresses belonging to nursing home residents do not have to meet these requirements as all nursing homes are required to be fully sprinklered. Newly introduced upholstered furniture and mattresses means purchased on or after the LSC final rule effective date. 18.7.5.2, 18.7.5.4, 19.7.5.2, 19.7.5.4

18. 16. UPHOLSTERED FURNITURE FLAMMABILITY • California Tech bulletin 133 or 117 & NFPA 266, upholstered furniture documentation for numbers 15 & 16 must be kept on file for the life of the items or material.

19. 17. DOOR INSPECTIONS • Doors must meet the 11 point inspection documented on all Fire doors. • 5.2 Inspections: Fire door assemblies shall be inspected and tested not less than annually, and • written record of the inspection shall be signed and kept for inspection by the AHJ. • 5.2.4 Swinging Doors with Builders Hardware or Fire Door Hardware. • 5.2.4.1 Fire door assemblies shall be visually inspected from both sides to assess the overall condition • of door assembly.

20. 18.MED GAS TRAINING • 11.5.2.1 Qualification and Training of Personnel. • 11.5.2.1.1* Personnel concerned with the application and • maintenance of medical gases and others who handle medical • gases and the cylinders that contain the medical gases shall be • trained on the risks associated with their handling and use. • 11.5.2.1.2 Health care facilities shall provide programs of continuing • education for their personnel. • 11.5.2.1.3 Continuing education programs shall include periodic • review of safety guidelines and usage requirements for • medical gases and their cylinders. • 11.5.2.1.4 Equipment shall be serviced only by personnel • trained in the maintenance and operation of the equipment. • 11.5.2.1.5 If a bulk cryogenic system is present, the supplier • shall provide annual training on its operation.

21. 19.RISK ASSESSMENT DOCUMENTATION • Risk Assessment. Categories shall be determined by following • and documenting a defined risk assessment procedure. • The Minnesota Department of Health uses health risk assessment to better understand the adverse effects of exposures to hazardous chemicals and other substances on people.

22. 20. SPACE HEATER POLICY • Portable electric heaters. A problem for nearly every hospital and Nursing homes. • Staff gets cold and Facilities Management cannot adjust the HVAC system to keep everyone happy. Family’s members also do not understand the requirements so portable electric heaters brought from home start showing up. • You need to do frequent rounding of suspicious trouble spots (you know where they are) to make sure staff does not bring in portable heaters.

23. 21. LAB PROCEDURES/ INCIDENTS • Laboratories employing quantities of flammable, combustible, or hazardous materials that are considered as a severe hazard shall be in accordance with Section 8.7 and the provisions of NFPA 99, Health Care Facilities Code, applicable to administration, maintenance, and testing.

24. 22. ELECTRICAL OUTLET TEST REPORT • Receptacles in patient care areas (normal & emergency powered) must be testing after initial installation, replacement, or service, per • NFPA 99-1999 ed, 3-3.3 and 3-3.4 and at intervals defended by the facility based on documented performance data (with non-hospital grade • tested at least annually, per NFPA 99-1999 ed, 3-3.4.2.3 • Hospital Grade VS standard outlet