Exploring the Top 5 life safety code citations

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Josh Malbogat, Senior Living Director at TheWorxHub by Dude Solutions
Josh Malbogat, Senior Living Director at TheWorxHub by Dude Solutions

Upholding a safe environment for residents and staff is a big concern for skilled nursing facilities. However when it comes to annual facility audits, only a small percentage of providers are found to be deficiency-free. As patients can be at risk when there are deficiencies and their families are privy to the results of inspections, it is important that operators follow routine guidelines to be safe and compliant.

Most often it is the maintenance and operations staff tasked with meeting rigorous compliance requirements to ensure first-rate facility safety standards are met to pass inspections.

Surveys occur annually and although code requirements are available, nearly 20 percent of facilities receive some form of citation. With this in mind, providers need to have systems in place that both maintenance managers and administrators can use to:

  • Monitor whether required tasks are completed
  • Ensure that the correct steps are followed and documented.
  • Review historical data to identify common failure points
Studying top life safety citations can help spot check an overall plan and ensure that common citations do not become an issue. The following are some of the most frequent life safety citations being issued today and what nursing home administrators and maintenance directors can do to prevent them in their facilities.

Common life safety code violations

Electrical wiring and equipment

Electrical safety is a high priority in residential facilities and closely examined during audits. Electrical wiring should be in accordance with the National Fire Protection Association's NFPA 70, National Electrical Code. Frequent violations include power strips and power cords being used near residents, linked together or covered by a rug or furniture. It is critical that facilities make sure cords are used in the correct places and that they do not have tangled cords or exposed wiring, e.g., a missing outlet cover or a missing junction box cover plate.

Generator inspection and load testing

Quality equipment, good design and regular maintenance and inspections are key to maintaining optimal generator performance. Generators should be reviewed weekly and monthly, according to a set schedule and those reviews should be properly documented based on state requirements. In accordance with NFPA 99, generators need to be tested under a load for 30 minutes. Ensure your documentation of testing is up to date and accurate.

Door construction and exit accessibility

The proper construction of doors and being able to exit a facility safely is of utmost importance for resident and guest safety. Doors that protect corridor openings should always prevent smoke and should not include obstructions that prevent them from closing. Common problems include gaps in doors as they age, improper latches and obstructions like doorstops. Check automatic and self-closing doors with a regular review of doors.

In addition, patients, visitors and staff should always have the ability to quickly exit the building via a clear path during an emergency. Facilities staff should ensure that storage or supplies aren't blocking doors and that all exits are clearly marked. Quick visual inspections and regular reviews make all the difference.

Fire drills, emergency preparedness and testing

Routinely monitoring fire safety equipment inside a senior living facility is essential to ensuring a safe and secure environment. Review the application, installation, location, performance, inspection, testing, and maintenance of fire alarm systems thoroughly. Emergency drills should be conducted at least once per shift per quarter at random with varying scenarios and should be properly documented.

Additionally, according to NFPA 72, facilities need to ensure that their fire alarm system is testing at the correct frequencies. Providers should also test off premises transmission equipment to outside emergency service providers.

Sprinkler system maintenance / auto sprinkler system type

During an audit, automatic sprinkler systems will be reviewed to make sure that systems and sprinkler heads are in working order. All tests for gauge calibration and replacement parts should be documented so that the maintenance team can review as necessary and provide notes for auditing purposes.

Additionally, sprinklers should be installed throughout the facility in accordance with NFPA 13. It is important for facilities personnel to check to make sure sprinklers were installed in all locations during construction and that they were properly installed. Some areas where sprinklers are often forgotten include closets, storage areas, attics, etc.

Automating the process of sending maintenance and operations professionals compliance reminders and related notes about expected readings and inspection points via facility management or other software can help operations managers stay on top of these common violations. This type of solution can also help facility managers prepare for an audit. Today, many operations departments are utilizing mobile devices for sending these reminders so that staff can quickly complete mandatory documentation on-site — reducing the risk of overlooking necessary documentation.

Aiming for a zero-free citation survey can be challenging, but the payoff in terms of safety for residents and staff and a sterling reputation can be significant.

Josh Malbogat is the Senior Living Director at TheWorxHub by Dude Solutions.

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