SNF/NF survey tip—Get on top of these life safety code issues

By Doug Beardsley  |  March 24, 2023  |  SNF/NF providers

It appears some of our Life Safety Code requirements may have taken a back-seat during the peaks of COVID-19. Eight different K-Tags are being issued at rates above 15%, with one requirement being issued in 40% of surveys! Some are complex (for example, testing and maintenance of sprinkler systems and emergency power generators), while others are not as complex (for example, staff fire drills, and annual inspections of doors and bedside electrical receptacles). 

Nursing facility providers are encouraged to print out the chart below, and review it with your director of maintenance, facility engineer, or whoever is responsible for compliance with Life Safety Code requirements. That person can use the chart as an audit tool to see how your facility would measure on your next Minnesota Department of Health survey. The full list of K-Tags issued can be found here, without the more robust description of each requirement. 

% Surveys Issued K-Tag Abbreviated Requirement (from CMS Form 2786R) Along with Code References
40% K353 Sprinkler System – Maintenance and Testing 
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.  
a) Date sprinkler system last checked.  _____________________
b) Who provided system test.  ____________________________
c) Water system supply source.  __________________________             
31% K712 Fire Drills 
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 
18.7.1.4 through 18.7.1.7, 19.7.1.4 through 19.7.1.7
 27% K345  Fire Alarm System – Testing and Maintenance 
A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
 24% K918  Electrical Systems – Essential Electric System Maintenance and Testing 
The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches.  Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)
 19% K761  Maintenance, Inspection & Testing - Doors 
Fire doors assemblies are inspected and tested annually in accordance with NFPA 80 Standard for Fire Doors and Other Opening Protectives. Fire doors that are not located in required fire barriers, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program.  
Individuals performing the door inspection and testing have an understanding of the operating components of the doors. Written records of inspection and testing are maintained and are available for review.
18.7.6, 19.7.6, 8.3.3.1 (LSC), 5.2, 5.2.3 (NFPA 80)
 19% K920  Electrical Equipment – Power Cords and Extension Cords 
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363.  In non-patient care rooms, power strips meet other UL standards.  All power strips are used with general precautions.  Extension cords are not used as a substitute for fixed wiring of a structure.  Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5
 18%  K914 Electrical Receptacles – Maintenance and Testing 
Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data.  Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months.  Line isolation monitors (LIM), if installed, are tested at intervals of ≤ 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals ≤ 12 months.  LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 
6.3.4 (NFPA 99)
 16% K321  Hazardous Areas
Hazardous areas are protected in accordance with 18.3.2.1. The areas shall be enclosed with a 1-hour fire-rated barrier, with a ¾ hour fire-rated door without windows (in accordance with 8.7.1.1). Doors shall be self-closing or automatic-closing in accordance with 7.2.1.8. Hazardous areas are protected by a sprinkler system in accordance with 9.7, 18.3.2.1, and 8.4. 
18.3.2.1, 7.2.1.8, 8.4, 8.7, 9.7  

Doug Beardsley
Doug Beardsley  |  Vice President of Member Services  |   dbeardsl@careproviders.org  |  952-851-2489