Life Safety Informational Release
of DQA 08-001 (PDF, 58
Life Safety Informational Release
The purpose of this memorandum is to notify the health care provider
community of common Life Safety Code NFPA 101 (LSC) items that have been
cited in recent Medicare or Medicaid surveys.
The following list is based on the Centers for Medicare and Medicaid's
(CMS) Federal Monitoring Surveys (FMS) for long term care (LTC) facilities.
CMS has concluded fiscal year 2007 FMS activities, and has shared their
common findings with the state agencies of Illinois, Indiana, Michigan,
Minnesota, Ohio, and Wisconsin. Overall, the federal surveys resulted in a
significant increase in deficiencies compared to the state agency survey
findings. Most of the deficiencies are being corrected by the facilities,
and this has created a new baseline for compliance.
The Wisconsin Department of Health and Family Services (DHFS) is
attempting to address the disparity between the federal and state survey
findings by proactively notifying all providers subject to the Life Safety
Code of conditions that will prompt CMS to cite. Department surveyors will
look at these conditions/concerns based on current CMS
If these conditions are found out of compliance with the LSC, based upon
CMS interpretations, they will be cited. Facility staff may presently be
aware of these conditions, or may seek professional consultation to identify
them, so that they can proactively address them prior to their next LSC
survey. Correcting all of the items identified in this memorandum does not
guarantee a deficiency free survey; because each facility is designed,
operated, and maintained differently. Surveyors will continue to survey for
all applicable regulations.
Copies of the Life Safety Code NFPA 101 are available from the National
Fire Protection Association (NFPA) at http://www.nfpa.org
(exit DHFS), or by contacting
NFPA at 1-800-344-3555. The following tags are paraphrased to aid in
comprehension, but the code sections referenced should be reviewed in their
entirety to ensure a thorough understanding. The LSC survey tags at issue
K14: Interior finish for corridors and exitways, including exposed
interior surfaces of buildings such as fixed moveable walls, partitions,
columns, and ceilings has a flame spread rating of Class A or Class B. LSC
references 184.108.40.206 and 220.127.116.11
Scenario: Facility lacks flame-spread documentation or uses
field-applied products that are not listed for the intended application.
K18: Doors protecting corridor openings in other than required
enclosures of vertical openings, exits, or hazardous areas are substantial
doors, such as those constructed of 1-¾ inch solid-bonded core wood, or
capable of resisting fire for at least 20 minutes. Doors in sprinklered
buildings are only required to resist the passage of smoke. LSC reference:
Scenario: Double-leaf corridor doors to normally occupied rooms
lack an astragal, rabbet, or bevel when the gap between the doors exceeds
1/8-inch. Inactive leafs within a pair of double doors for a normally
occupied room lack a reliable latching mechanism; e.g., automatic flush
bolting hardware. Concerns are also related to improper operation to full
closure due to conflicting coordinator or latch mechanism operation. Refer
to CMS Memo S&C 07-18 for additional information.
K25: Smoke barriers are constructed to provide at least a one-half
hour fire resistance rating for existing facilities, and one hour for new
construction plans approved after 9/11/2003. Pipes, conduits, bus ducts,
cables, wires, air ducts, pneumatic tubes, and similar building service
equipment that pass through smoke barriers shall be protected. LSC
references: 18.104.22.168, 22.214.171.124, 126.96.36.199, and 188.8.131.52
Scenario: Penetrations through a smoke barrier are not protected
with a fire-stopping compound, or the existing compound has deteriorated.
Fire-stopping compounds ensure the integrity of the barrier is continuous;
and in the event of a fire, will reasonably ensure that health care staff
and residents have some form of safe refuge on one side or the other of the
smoke barrier. Typical penetrations arise from new utilities, such as
electrical conduit or communication cables, among others.
K27: Smoke barrier door openings have at least a 20-minute fire
protection rating or are at least 1 ¾ inch thick solid bonded core wood.
Doors shall be self-closing or automatic-closing. LSC references 184.108.40.206,
220.127.116.11 and 18.104.22.168.
Scenario: The smoke barrier door gaps exceed 1/8 inch in clearance
or do not have an astragal, bevel, or rabbet.
K29: Hazardous areas shall be enclosed with one-hour fire-rated
construction (with ¾-hour fire-rated doors) or an approved automatic fire
extinguishing system. When the approved automatic fire extinguishing system
option is used, the areas are separated from other spaces by smoke-resisting
partitions and doors. Doors are self-closing and non-rated. LSC reference:
Scenario: Existing combustible storage rooms, greater than 50
square feet, shall be deemed a hazardous room. Typically, the facility is
fully sprinkler protected, and these storage rooms require a door closer.
Additionally, penetrations within a hazardous room enclosure require the
opening to be protected or sealed, depending upon the wall construction.
Lastly, the fire rated doors exceed the 1/8-inch door gap restriction. Note:
The period of construction for a facility, e.g., 1973 New, 1981 New, 1985
New, and 1991 New, could require both automatic sprinkler protection and
one-hour fire rated enclosure, depending on the size of the hazardous room.
K38: Exit access is so arranged that exits are readily accessible
at all times. LSC references: 7.1, 19.2.1, and 22.214.171.124.4.
126.96.36.199.1 Delayed-Egress Locks. Approved, listed, delayed-egress locks
shall be permitted to be installed on doors serving low and ordinary hazard
contents in buildings protected throughout by an approved, supervised
automatic sprinkler system or an approved, supervised fire detection system;
provided that the following criteria are met:
(a) The doors shall unlock upon actuation of any
approved, supervised automatic sprinkler
upon the actuation of any heat
activation of not more than two
smoke detectors of an approved,
automatic fire detection system.
(b) The doors shall unlock upon loss of power
controlling the lock or locking mechanism.
(c) An irreversible process shall release the lock
within 15 seconds upon application of a force
release device that shall not exceed
15 pounds of force,
or be required to be
continuously applied for more than 3
The initiation of the release process shall
activate an audible signal in the vicinity of
the door. Once
the door lock has been
released by the application of force
releasing device, relocking shall be by manual
(d) On the door adjacent to the release device,
there shall be a readily visible, durable sign
letters not less than 1 inch high and not
less than 1/8 inch
in stroke width on a
contrasting background that reads as
PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS
Scenario: The devices are not working per the requirements found
in section 188.8.131.52.1, or two devices are installed within a primary egress
path in conflict with the requirements found in section 184.108.40.206.4.
Typically, the doors will not release and open within 15 seconds, or the
doors will lack the proper signage, or the doors will require more than 15
pounds to initiate and open the doors.
These unique locking devices are allowed in health care facilities
without significant clinical or admission restrictions and provide a needed
form of elopement deterrence, but the system must operate in compliance with
all of the prescriptive requirements to provide such flexibility. Note that
these locking devices shall not be coupled with doors artistically disguised
to look like a bookcase or outside environment. Lastly, the exit-discharge
path has grade changes in excess of ½", which provides a trip hazard
for occupants and emergency responders.
K45: Illumination of means of egress, including exit discharge, is
arranged so that failure of any single lighting fixture (bulb) will not
leave the area in darkness. (This does not refer to emergency lighting in
accordance with 7.9) LSC reference: 18.2.8 and 19.2.8.
Scenario: Exit discharge normal lighting lacks, at minimum,
duplicate light bulbs in fixtures or overlapping light patterns.
K46: Emergency lighting of at least 1 ½-hour duration is provided
in accordance with 7.9. LSC reference: 220.127.116.11
Scenario: Battery emergency lighting is not tested and documented
to substantiate a monthly test for 30 seconds and an annual test for 90
minutes. Emergency lighting is not provided at each exit discharge, or the
facility can not substantiate that the emergency lighting is provided.
Proper emergency lighting is commonly provided in egress corridors and at
exit doors, but exterior exit paths also require illumination to a
reasonable distance (40 ft.) from the structure.
K48: There is a written plan for the protection of all residents
and for their evacuation in the event of an emergency. LSC references:
18.104.22.168 and 22.214.171.124
126.96.36.199 A written health care occupancy fire safety plan shall provide
for the following:
(1) Use of alarms;
(2) Transmission of alarm to fire department;
(3) Response to alarms;
(4) Isolation of fire;
(5) Evacuation of immediate area;
(6) Evacuation of smoke compartment;
(7) Preparation of floors and building for evacuation; and
(8) Extinguishment of fire
Scenario: The written facility evacuation plan does not include
all of the items required by 188.8.131.52.; typically missing the smoke
compartment evacuation component and how it relates to the specific facility
layout or configuration. Additionally, some fire emergency plans do not
identify manual initiation of the building's fire alarm system by staff.
K50: Fire drills are held at unexpected times, under varying
conditions, and at least quarterly on each shift. The staff is familiar with
procedures and is aware that drills are part of established routine.
Responsibility for planning and conducting drills is assigned only to
competent persons who are qualified to exercise leadership. LSC reference:
Scenario: The facility fails to conduct a quarterly fire drill;
or, the facility may conduct all of its required drills, but the drills for
a given shift occur at approximately the same time (within a 1-hour window).
The goal of this regulation is to ensure staff is properly trained on all
shifts for the unexpected occurrence of a fire.
K51: A fire alarm system with approved devices or equipment is
installed in accordance with the National Fire Alarm Code NFPA 72 to provide
effective warning of fire in any part of the building. Activation of the
complete fire alarm system shall be by manual fire alarm initiation,
automatic detection, or extinguishing system operation. Electronic or
written records of tests shall be available.
Fire alarm systems shall be maintained periodically and records of
maintenance kept readily available. The fire alarm system must provide
automatic notification to the local fire department through one of the
approved methods found in NFPA 72.
Scenario: The buildings fire alarm system is not connected per
NFPA 72. Typical deficiencies result when a fire alarm signal is initiated
by the facility, the signal is sent off site to a remote or central
monitoring station, and the monitoring station calls the facility back to
confirm a fire prior to dispatching emergency forces. CMS emphasized this
point in the January 10, 2003 Federal Register adoption of the 2000 edition
of NFPA 101. Emergency services are to be notified automatically without
K52: A fire alarm system required for life safety is installed,
tested, and maintained in accordance with NFPA 70, the National Electrical
Code and NFPA 72, the National Fire Alarm Code. The system has an approved
maintenance and testing program complying with the applicable requirements
of NFPA 70 and NFPA 72. LSC reference: 184.108.40.206
Scenario: The facility lacks documentation of conducting quarterly
fire alarm signal transmission testing to an offsite location. Additionally,
the facility may lack smoke detector sensitivity and functional testing.
Detectors are located within 36" of ventilation supply or exhaust
diffusers. Not all devices on the system are reflected on the testing
records. Initiating devices are not visually inspected semi-annually. These
systems can only provide their intended safety if properly tested and
maintained per NFPA 72.
K56: If there is an automatic sprinkler system, it is installed in
accordance with NFPA 13, Standard for the Installation of Sprinkler Systems,
to provide complete coverage for all portions of the building. The system is
properly maintained in accordance with NFPA 25, Standard for the Inspection,
Testing, and Maintenance of Water-Based Fire Protection Systems. It is fully
supervised. There is a reliable, adequate water supply for the system.
Required sprinkler systems are equipped with water flow and tamper switches,
which are electrically connected to the building fire alarm system. LSC
Scenario: The facility lacks documentation of conducting quarterly
sprinkler testing/inspections; or if completed, a report will often contain
problems and the facility failed to correct the problems.
systems have unsupervised control valves, have painted or obstructed
sprinkler heads, do not have an adequate supply of spare sprinkler heads, or
do not have a sprinkler wrench readily available. Compromised ceiling
systems are a major contributor to building safety concerns. Some trade-offs
in the code have been allowed, but only if the system is properly installed,
maintained, and inspected.
K61: Required automatic sprinkler systems shall have valves
supervised so that at least a local alarm will sound when the valves are
closed. LSC reference: 220.127.116.11, NFPA 72, NFPA 25 § 9-2.8.2.
Scenario: Sprinkler system water supplies have valves
unsupervised, or the required pressure gauges are not recalibrated or
replaced every five years.
K66: Smoking regulations shall be adopted and shall include not
less than the following provisions:
(1) Smoking shall be prohibited in any room,
ward, or compartment where flammable
combustible gases, or oxygen is
used or stored, or in
any other hazardous
location; and such area shall be
signs that read NO SMOKING, or shall be
posted with the international symbol for no
(2) Smoking by patients/residents classified as
not responsible shall be prohibited, except
when under direct supervision.
(3) Ashtrays of noncombustible material and
safe design shall be provided in all areas
smoking is permitted.
(4) Metal containers with self-closing cover
devices into which ashtrays can be emptied
readily available to all areas where
smoking is permitted.
LSC Reference 18.7.4
Scenario: Outdoor areas lack a noncombustible ashtray or
self-closing metal container.
K67: Heating, ventilating, and air conditioning shall comply with
9.2, and shall be installed in accordance with the manufacturer's
specifications. LSC references 18.104.22.168, 22.214.171.124, and NFPA 90A
Scenario: All fire dampers are not tested at least every four
years; which includes operating damper to full closure, and lubricating
moving parts as necessary.
K69: Cooking facilities are protected in accordance with NFPA 96,
Standard for Ventilation Control and Fire Protection of Commercial Cooking
Operations. LSC reference: 126.96.36.199
Scenario: The facility lacks substantiation that the kitchen hood
assembly is cleaned periodically per NFPA 96 section 8-3.1. Typical
hospital/nursing homes fall into the "moderate-volume" cooking
category and lack semi-annual inspections that check for contaminate levels
and the subsequent cleaning once contaminates are found.
The kitchen hood cleaning includes the hood, grease removal devices,
fans, ducts, and other apparatus to bare metal. Additionally, some
facilities have an outdated dry chemical hood extinguishment system. An
outdated system has been defined by CMS as one requiring replacement by a
UL300 wet chemical if any of the following events occur: (1) The dry
chemical has been discharged; (2) the dry chemical has been hydrostatically
retested; or (3) new cooking appliances have been installed.
Lastly, some new UL300 systems have been installed; yet the new
extinguishment system is not connected to the building's fire alarm system,
the existing hood has mesh filters, or the existing hood construction has
seams that are not liquid-tight.
K76: Compressed gas storage and administration areas shall be
protected in accordance with NFPA 99 Standard for Health Care Facilities
(a) Oxygen storage locations of greater than
3,000 cu. ft. are enclosed by a one-hour fire
(b) Oxygen storage locations less than 3,000 cu.
1. A minimum distance of 20 feet from
combustibles or incompatible
materials in a non-sprinkler
oxygen storage room, or
2. A minimum distance of 5 feet. from
combustible or incompatible
materials in a fully sprinkler
protected oxygen storage room.
Scenario: Oxygen storage exceeding the 300 cubic feet incidental
amounts specified in CMS Memo S&C 07-10 in a fully sprinkler building is
found within five feet of non-respiratory therapy combustibles.
Additionally, oxygen bottles are not secured or full, and empty bottles are
not adequately separated.
K143: Liquid oxygen transferring shall be:
(a) separated from any portion of a facility
wherein residents are housed, examined,
or treated by a
separation of a fire barrier
of 1-hour fire-resistance
the fire rated door to this room shall be in
closed position while transferring, so
residents are not
exposed to this hazard; and
(b) the area or room formed by the fire barrier
is served by functioning mechanical
(c) the area or room formed by the fire barrier is
fully sprinkler protected, and
(d) the area or room formed by the fire barrier
has a ceramic or concrete floor, and
(e) the area or room formed by the fire barrier
is posted with signs indicating that
transferring is occurring,
and that smoking in
the immediate area is not permitted,
(f) combustible or incompatible materials are a
minimum of 5 feet distance from the
(g) ignition sources are a minimum of 5 feet
distance from the transferring operation.
Source: Health Care Facilities standard NFPA 99 section 8-188.8.131.52
and Compressed Gas Association (CGA) Pamphlet P-2.6 and P-2.7.
Scenario: The door and frame assembly is not a 45-minute
fire-rated assembly, staff transfer liquid oxygen with the rated door open
to patients/residents, or disposable oxygen supplies in excess of a one-week
supply are stored in the oxygen supply room.
K144: Generators are tested monthly and exercised under load for
30 minutes per month in accordance with NFPA 110 section 6-4.2, or the
generators are tested annually under a two-hour load bank test in accordance
with NFPA 110 section 6-4.2.2. The emergency power system, including all
appurtenant components, shall be inspected weekly in accordance with NFPA
110 section 6-4.1.
Scenario: The emergency generator lacks substantiation that it is
tested under 30% nameplate loading, or lacks testing for continuous testing
for 30 minutes under load. The system lacks substantiation that it and all
components are inspected weekly. Additionally, an emergency generator
located in a building does not have task lighting to illuminate the work
area around the generator in the event of a normal power outage. Lastly, for
systems permitted to use natural or synthetic gas, the facility lacks
substantiation that the utility supply is reliable, e.g., on a
K154/K155: Where a required sprinkler system or fire alarm system
is out of service for more than 4 hours in a 24-hour period, the authority
having jurisdiction shall be notified, and the building shall be evacuated,
or an approved fire watch system shall be provided for all parties left
unprotected by the shutdown until the sprinkler/fire alarm system has been
returned to service. 184.108.40.206, 220.127.116.11
Scenario: The facility has a sprinkler or fire alarm system, but
it does not have a fire watch policy in how to address one or both systems
being out of service for more than 4 hours in a 24-hour period.
K211: Where Alcohol Based Hand Rub (ABHR) dispensers are installed
in a corridor:
The corridor is at least 6 feet wide;
The maximum individual fluid dispenser capacity
shall be 1.2 liters;
The dispensers shall have a minimum spacing of
4 feet from each other;
Not more than 10 gallons are used in a single
smoke compartment outside
a storage cabinet;
Dispensers are not installed over or adjacent to
an ignition source;
If the floor is carpeted, the building is fully
LSC reference 18.104.22.168
Scenario: The ABHR dispenser center is located within 6 inches or over
an ignition source.
As stated above, compliance with the above listed K-tags does not
constitute a deficiency-free survey. This memorandum is motivated by the
mutual concern of the Department and facilities for compliance with the
requirements, and to maximize safety for all residents. All LSC tags are
subject to review at each survey. If you have any questions, the following
resources are available:
Long Term Care Facilities:
- Eau Claire Region (WRO): Joe Bronner
- Green Bay Region (NERO): Joanne Powell
- Madison Region (SRO): Juan Flores
- Milwaukee Region (SERO): Katherine Friend
- Rhinelander Region (NRO): Joe Bronner
Non-Long Term Care Facilities:
- Northern Region (WRO, NRO, NERO):
Jan Heimbruch (608) 266-0371
- Southern Region (SERO, SRO): Mark Andrews
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