state fire marshal whca conference

State Fire Marshal

WHCA Conference

February, 2019

Objectives• Review top 10 violations

• New code changes

• Emergency Plans

Top 10 Violations for 2018K-Tag Description

K918 Electrical System-Essential Electrical

K920 Power Cords and Extension Cords

K353 Sprinkler System Maintenance and Testing

K914 Electrical Systems-Maintenance and Testing

K363 Corridor Doors

K921 Electrical Equipment-Testing and Maintenance

K521 HVAC

K511 Utilities-Gas and Electric

K923 Gas Equipment-Cylinder Storage

K211 Means of Egress-General

Essential Electrical

• Generator must be inspected yearly and there must be no deficiencies.

• There must be weekly inspections and monthly load tests.

• Depending on your facility there are varying fuel requirements.

• Generators are required to be serviced annually. • Generators are required to be inspected by you

weekly and ran at full load for 30 minutes once a month.

• Emergency generator requirements:• Be tested monthly for 30 minutes under load• Have records maintained and available for review• Be engine driven• Automatically start within ten seconds of losing

power• Have an annual certification test to be conducted

with records kept

Generators

• Additional diesel generator requirements:

• Generators shall be tested monthly for 30 minutes under a load at not less than 30 percent of the EPS nameplate kW rating or loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer

Diesel Generators

• If the diesel generator cannot be tested monthly to meet the required KW rating or exhaust temperature conditions; the generator shall:

• Be exercised annually with supplemental loads at not less than 50 percent of the EPS nameplate kW rating for 30 continuous minutes and at not less than 75 percent of the EPS nameplate kW rating for 1 continuous hour for a total test duration of not less than 1.5 continuous hours.

Diesel Generators

• Generator Maintenance:

• A detailed log of generator operations shall be maintained on the premises.

• The system is required to run UNDER LOAD for a minimum of 30 minutes per month (Including Natural Gas Generators).

• A simple exercise run that DOES NOT activate the transfer switch does NOT meet the code requirement.

• Records will provide adequate detail to differentiate when the system was run under load.

Generators cont:

Power Cords/Extension Cords

• All extension cords are for temporary use. • All power-strips for medical equipment must be

1363A.• All power-strips within 6 feet of a patient bed

must be 1363A.• Never plug appliances into a power-strip unless

the user manual allows this.

Sprinkler Maintenance• What is required:

• All sprinkler heads are sample tested or replaced as required

• All deficiencies are corrected on sprinkler reports

• Quarterly sprinkler inspections are completed

• All sprinkler heads are clean and escutcheon rings are in place

• There is no high piled storage

Blocked sprinkler heads

15

Electrical Receptacle Testing• New requirement for all Nursing Homes• Different requirement for hospital and non-hospital grade

receptacles.

Corridor Doors

• Doors to resident rooms must close and latch.

• Other requirements depend on the room the door is protecting and the area it is in.

Electrical Patient-Centered Equipment• New requirement for all Nursing Homes• Requires a policy, testing, and continuing education

Fire Smoke Dampers• Fire and smoke dampers must be checked every four years. Six

if it is a hospital.

Fire Door Inspections• Fire and smoke dampers must be checked every four years. Six

if it is a hospital.

Code Update• Quarterly sprinkler inspections

• Fire/smoke dampers

• NICET II

• Fire Wall Annual Inspections-July 1, 2019

Oxygen Cylinder Storage

• Oxygen cylinders must be segregated full versus empty.

• All cylinders must be secured.

Emergency Preparedness

• There are new CMS requirements as of this month:– All facility types must now prepare for infectious diseases

(Ebola, Zika ect)

– There is also clarifying information on what temperatures are required for each facility to maintain.

– There is clarifying information on what happens if two emergencies occur within the facility with one year.

– There is clarifying information on generator requirements.


• There are numerous helpful websites and documents, please start at the CMS.gov website.


• This covers all provider types.

• Based on risks associated with your facility. The risks in Washington State are different than those in Florida.


• There are numerous helpful websites and documents, please start at the CMS.gov website.

Emergency PreparednessRisk assessment must be based off of an all hazards approach.

This means both natural, man-made, and internal emergencies.

Risk Assessment and Planning

Emergency Preparedness• Policies must include all items for your

provider type.

Policies and Procedures


• Communication Plan

– Must include names and contact info other facilities, hospitals, state and local officials.

Communication Plan


• Training and Testing– All staff members must be trained.

– Two drills are required yearly unless an actual emergency takes place.

Training and Testing

Emergency Planning• Make sure that people know how to respond in different scenarios.

Emergency Planning• A great way to be prepared for any emergency is to know what hazards are in your area.

– An assisted living in Seattle would have to prepare for a different set of natural disasters and potential man-made disasters than an assisted living in Walla Walla.

– Each county is required to have a HV assessment completed to sent to the state. You can look at this and you may find out hazards that you were unaware of.

– Be aware of what kind of aid will be available to your facility. If the incident is facility based or local, you can more likely count of outside assistance.

– However, if the incident is regional (The entire west coast) the possibilities of immediate help greatly wanes.

Emergency PlanningNatural disasters are just a few of the many disasters that you should prepare for. Others include, but are not limited to:

• Health emergencies: Measles, Zika, Influenza, Ebola.

• Internal emergencies: suspicious packages, refrigerator breaks, computer system held for ransom.

• Local emergencies: lockdown nearby, active shooter in facility.

• Communication emergencies: 911 is down, phone service is down, cell phone service is down.

Emergency PlanningVolunteer management-how are you going to maintain control over the volunteers that may come and the supplies that they may bring.

Emergency PlanningCommunications

Communications is essential for any good working relationship. It is essential in a disaster

Emergency Planning

Case Studies• A 2005 case study of evacuating or sheltering in place in the event of a hurricane.

ICS• ICS is a system that the federal, state, and local governments use to manage incidents.

• It is important that people understand the different roles that are played and what the different responsibilities are.

Helpful Website• ASPR TRACIE

Name Counties

Bloor, Kimberly QA, Western Washington

DeGraff, Doug Adams, Asotin, Benton, Columbia, Franklin, Garfield, Grant, Walla Walla, Whitman

Dellsite, Kenneth Clallam, Jefferson, Kitsap, Mason, Grays Harbor, Thurston and Pacific

Magee, Brendan King North , Snohomish South, Edmonds

Maier, Barbara Chelan, Douglas, Okanogan, Kittitas, Klickitat and Yakima

Montgomery, Dylan Northern Pierce, Southern King Fife, Enumclaw, Auburn and Federal Way

Ridley, David Island, San Juan, Skagit, Whatcom and Snohomish

Rogers, David Ferry, Lincoln, Pend Oreille, Spokane and Stevens

West, Donald Pierce

Wolden, Nicholas Clark, Cowlitz, Lewis, Skamania and Wahkiakum

Questions?

state fire marshal whca conference

Documents