Life Safety Code Checklist for Nursing Homes: What to Expect When Surveyors Come Knocking. Learn more about the relationship between nursing homes and the Life Safety Code.
On May 4, 2016 the Centers for Medicare and Medicaid Services (CMS) adopted the 2012 edition of the NFPA’s Life Safety Code (LSC), effective July 5, 2016. From then on, nursing homes certified by CMS have been subject to both the LSC and NFPA 99 Health Care Facilities Code (HCFC).
In order to gain and renew CMS certification, facilities must undergo LSC/HCFC surveys. Among others, these facilities include
- Skilled Nursing Facilities
- Nursing Facilities
- Inpatient Hospice Facilities
- Program for All-inclusive Care for the Elderly Facilities
Surveys are conducted by CMS in conjunction with state agencies and accreditation organizations.
What to expect from LSC surveys
Surveys are conducted according to Appendix I of CMS’s State Operations Manual, entitled “Survey Procedures for Life Safety Code Surveys.” Surveys are unscheduled and unannounced, so having a Life Safety Code checklist for nursing homes helps facilities be ready at all times.
The surveying process has six parts:
- Offsite survey preparation on the part of the surveyors
- Entrance conference and onsite preparation
- Orientation tour to introduce surveyors to staff and provide a facility overview
- Gathering information
- Analyze information and make a decision
- Exit conference
For the sake of this article, we will mainly explore steps 2 and 4.
Once surveyors have come to your facility and identified themselves as such, the administration must provide
- A list of key facility personnel
- A copy of the facility’s building layout
- Fire safety documents, including those covering the facility’s
- Disaster plan
- Evacuation plan
- Fire alarm tests
- Fire drills
- Fire extinguisher maintenance and tests
- Flame spread ratings of interior finishes
- Generator tests
- Kitchen range hood maintenance
- Smoke-stopping, fire-stopping, and fire-proofing specifications
- Smoking policy
- Sprinkler maintenance
After the orientation tour has been given, surveyors will gather information via various inspections.
| What will be checked | What will be checked for |
|---|---|
| Corridors | Any obstructions Construction of walls and ceilings |
| Exit pathways | Distance to exits Doors and door hardware Exit lighting and signage Exit stairs Exterior walkways |
| Fire alarm control panel | Connection to fire department or remote station outside of facility Inspection tags and labels Operational lights |
| Fire protection system | Fire alarm pull stations and general systems Fire extinguishers Smoke detectors |
| Hazardous areas | Fire separation constructions Proper door type Sprinkler installation |
| Laboratories | Door type Emergency eyewash equipment Fire separation constructions Flammable liquids and gases storage Fume hood ventilation Sprinkler systems |
| Medical gas storage areas | Alarms for gas systems Proper construction and restraint of cylinders Ventilation |
| Resident rooms (not all, but a representative sample) | Construction and penetrations of walls and ceilings Flammability of cubicle curtains, drapes, and wastebaskets Interior hazards, such as outlets, extension cords, and portable space heaters Latching, operation, fit, and fire-rating of corridor doors |
| Smoke and fire barriers | Any penetrations Completeness from wall-to-wall and floor-to-floor Construction materials Locations and continuity |
| Sprinkler systems | Connection to fire systems Coverage provided Testing and maintenance records Operational status of tamper switches and waterflow detection devices |
Additionally, surveyors will check
- Access doors
- Emergency lighting systems
- Emergency power systems
- Kitchen range hood fire suppression systems
How to be prepared for LSC surveys
As you saw in the previous section, surveyors are checking a lot when they come through. The following Life Safety Code checklist for nursing homes is broken down by how frequently each task should be performed.
| Frequency | What to inspect and test |
|---|---|
| Weekly | Door alarms Emergency generators Eye wash stations Fire doors (ability to latch and release) Sprinkler systems (water pressure and valves) Water temperature in kitchens, residents’ rooms, laundry rooms |
| Monthly | Emergency generators (30 minute load test) Emergency lights (30 second test) Exit signs (bulbs) Fire extinguishers Kitchen range hood fire suppression systems (grease buildup on nozzles and ductwork) Single station smoke detectors |
| Quarterly (every 3 months) | Residents’ beds (particularly rails) Sprinkler systems (tamper and flow switches) |
| Semiannually (twice a year) | Fire alarm systems Generators Kitchen range hood fire suppression systems (done by a professional company) |
| Annually | Backflow prevention Emergency generators Emergency lights (1.5 hour test) Fire alarm systems Fire extinguishers Fire doors Generators (fuel test) Kitchen range hood fire suppression systems Sprinkler systems |
| Biennially (every 2 years) | Boiler and pressure vessel Electrical wiring system Generator (load) |
| Every 5 years | Sprinkler system (internal pipes) |
Additional preparedness tips
The Life Safety Code checklist for nursing home documentation includes catalogs of inspections, maintenance procedures, and tests done on
- Battery-powered smoke detectors
- Electrical wiring systems
- Elevators
- Emergency generators
- Emergency power systems
- Fire extinguishers
- Fusible link dampers
- Kitchen range hood suppression systems
- Sprinkler systems
Also be able to provide records of
- Building Inspection Program
- Building Maintenance Program
- Facility layout
- Fire plan
- Including records of fire drills (which must be conducted quarterly) over the last 12 months
- Fire safety and emergency preparedness plans
- Fire watch policies
- Flame resistance of any new blinds, curtains, or drapes
- Smoking prohibitions and use areas
- Water outages affecting sprinkler systems
And finally, be sure to check that
- Corridors and exit pathways are clear
- Doors are self-closing, latch automatically, and can open easily
- Each alcohol-based hand rub dispenser is at least 4 feet away from any others
- Generators switch to emergency power within 10 seconds of normal power being lost
- Non-storage rooms are not being used as storage spaces
- Penetrations in walls and ceilings are sealed with fire-rated caulking
- Penetrations for ductwork should have fire dampers installed in them
- Rooms are separated by 1-hour fire-rated constructions
- Smoking and non-smoking areas are clearly marked
- Sprinkler heads are free of obstruction and corrosion
InspectNTrack and LSC Surveys
As is evident from the Life Safety Code checklist for nursing homes above, there’s a lot to do and keep track of in order to be LSC survey ready. Even if you have been taking all of the necessary steps as outlined above, it will not matter unless you can prove compliance when it counts. Using paper forms to document inspections, maintenance, and tests is a risky bet, as not just single sheets, but entire documentation systems can be misplaced, lost, or destroyed.
InspectNTrack’s software holds all of your records in one place and is equipped to inspect fire safety systems, medical equipment, and more! Already being used in a variety of settings oriented specifically toward healthcare, its automated scheduling system makes sure you never miss a single inspection or test.
InspectNTrack’s software holds all of your records in one place and is equipped to inspect fire safety systems, medical equipment, and more! Already being used in a variety of settings oriented specifically toward healthcare, its automated scheduling system makes sure you never miss a single inspection or test.
