senior living case study
Maintaining Automatic Sprinklers
In Nursing Homes
By Esteban Cota
A
National Fire Protection Association (NFPA) study from 2012
showed that, despite increased attention to fire and life safety in
recent years, more fires have occurred in nursing homes than in
any other type of healthcare facility. In fact, between 2006 and 2010,
U.S. fire departments responded to an estimated 2,840 fires per year in
nursing homes. Additionally, 88% of the deaths and 65% of the fire
injuries in healthcare properties that occurred during this period were
in nursing homes.
Centers for Medicare & Medicaid Services (CMS) has mandated
that all nursing homes be fully sprinklered as of August 13, 2013, in
order to continue participating in Medicare or Medicaid. Facilities that
are not fully sprinklered on or after this date will be cited for not complying with CMS requirements at 42 CFR 483.70(a)(8).
Clinic or
doctor’s office,
11%
Nursing
home, 46%
Mental health
facility, 21%
Hospital or
hospice, 23%
Source: NFPA Fires in Health Care Facilities, by Marty Ahrens, November 2012
Federal records show that more than 1,100 nursing homes still
have only “partial” systems or no sprinklers at all. State surveyors are
inspecting nursing homes for full sprinkler coverage per NFPA 13:
Standard for the Installation of Sprinkler Systems.
But installation of the sprinkler system is just the first step. Once
installed, a documented fire protection management program consisting of visual inspections, testing, and maintenance must be in
place for all fire safety equipment including, but not limited to,
sprinklers. Fire sprinkler requirements are listed in the requirements
November/December 2014
of NFPA 25: Standards for Inspection, Testing, and Maintenance of
Water-Based Fire Protection Systems.
All healthcare facilities certified by CMS are also mandated to
comply with the NFPA 101: Life Safety Code, 2000 Edition. In addition,
all licensed care facilities must comply with federal requirements
as well as fire and building codes as specified and adopted by
individual states.
Per NFPA 101 and NFPA 25, facility owners are responsible for having all fire protection systems and equipment inspected, tested, and
maintained in accordance with nationally recognized standards and
state regulations. Facility owners must ultimately ensure that all visual
inspections, testing, and maintenance are completed by qualified
individuals. If on-site staff is not adequately trained, experienced, and
credentialed, then a third-party service provider must be brought in to
perform the inspections, testing, and maintenance.
Choosing A Service Provider
What a facility receives from its vendor can often differ from how
the vendor interprets the scope of work. A lack of clarity in proposals
and agreements can result in some of the facility’s life safety equipment being out of compliance with codes and standards.
A facility may get cited for deficiency of non-compliance during a
state health life safety survey, even if a contracted vendor performed
the work. In addition, if a fire or system failure were to occur, not
knowing what is covered under an agreement could be very costly to
the facility and put it in a litigious situation. Therefore before any work
is done, the facility should thoroughly read and understand its service
agreement and immediately address any questions or concerns with
its vendor.
Fa cil ityExecutive.com
PHOTO: SIEMENS
Structure Fires in Health Care Facilities,
By Occupancy Type: 2006-2010
The research report on Fires in Health Care Facilities published by NFPA in 2012, covering the years 2006-2010, indicates that when sprinkler systems were present and
the fire large enough, the sprinkler operated and was effective 86% of the time. For
that reason, facility managers must ensure all fire system components are effective.
Prior to entering into any agreement, the facility should ask the
vendor to demonstrate its knowledge of specific healthcare requirements, such as the Conditions of Participation, CMS State Operators’
Manual, and accreditation standards like the Joint Commission.
Facility managers might also want to ask a vendor to provide a list
of recently performed comparable healthcare related projects.
Vendors should also be willing to share information about their
ongoing training programs, to demonstrate that their technicians
are current on changing codes and requirements related to healthcare accreditation.
A facility’s Quality Assessment Committee should be part of the
interview process. Committee members can help ensure that
processes and measures are taken to provide patient safety and care
and can help develop and implement an action plan to rectify identified non-compliance issues.
Excerpt from Title 42 –
Public Health, U.S. Code of Federal Regulations
facility staff with documentation content and ensure that it is
properly maintained.
Itemizing inventory of the devices to be tested, inspected,
or maintained can help alleviate possible pitfalls in recording
results. While NFPA 25 does not require inventories, facilities that
inventory their systems are able to better manage their overall
fire safety plan.
In addition, a life safety surveyor may ask to see system inventories to determine that each individual system or component has been
checked, show the outcome of the task, and verify any system
changes since the previous survey. Each system/component should
be marked as “pass” or “fail” per every applicable task, as the surveyor
could question if components without a pass/fail mark were checked.
The life safety surveyor might also perceive an absence of inventories
as an implied area of deficiency with the facility’s fire and life safety
management plan. The surveyor may also cite a deficiency of noncompliance under the federal requirements of the Conditions of Participation for nursing facilities, Section §483.70(c)(2) of the Code of
Federal Regulations which states the facility must maintain all essential mechanical and electrical systems as well as patient care equipment in safe operating condition.
Excerpt from Title 42 –
Public Health, U.S. Code of Federal Regulations
Finally, prior to any contractual agreement, the vendor should submit a draft schedule of services to be performed, which should align
with the facility’s past inspection, testing, and maintenance activities.
The annual schedule delivery plan should include a detailed written
description of scheduling logic and should identify tasks to be performed and/or deliverables to be provided.
Inspection And Testing Documentation
After any inspection, testing, or maintenance is finished, facilities
must review the documentation for accuracy and completeness
prior to filing it for subsequent surveyor review. Any errors or
omissions should be referred back to the individual performing the
task for verification or for retest. The facility’s staff should have a
good understanding of the tests performed and feel comfortable
explaining the documentation to a life safety surveyor during a
survey. Mock documentation reviews and surveys can be simulated
using sample test reports from the vendor. Establishing regular
quality review meetings with the vendor can also help familiarize
Ensuring compliance with various local, state, and federal
codes and regulations is important. Sometimes, state licensing
requirements, specialized skill set levels, or lack of in-house
manpower make it necessary for facilities to outsource inspection,
testing, and maintenance to a third-party vendor. When selecting a
service provider, facilities should consider the vendor’s technical
and management approaches, past performance, and price/cost.
To ensure service contract specifications are met, the facility team
should be involved with the vendor before, during, and after work
is performed. ●
Cota (esteban.cota@siemens.com) is a national business manager
for automation, fire safety, and security services at Siemens Industry, Inc. (www.siemens.com). His more than 20 years of healthcare
industry experience includes hands-on testing and installation of
systems, as well as engineering, sales, and business development.
He is a member of the NFPA 72 Chapter for Testing, Inspection
and Maintenance Technical Committee, the American Society for Healthcare Engineering (ASHE), and the National Fire Protection Association (NFPA).
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Reproduced with permission from Today’s Facility Manager November/December 2014 issue. Copyright ® 2015 Group C Media, Inc. All rights reserved.
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Nove mbe r/December 2014