Our friends from CMS Region V in Chicago continue to conduct their Life Safety Code Federal Monitoring Survey (FMS) inspections of approximately 19 of Minnesota’s nursing facilities each year (5% of our skilled nursing facilities).  Every year tends to bring with it new variations of findings, creating a stir amongst the provider community.  Administrators, Maintenance Directors, Engineers, and Directors of Environmental Services should be aware of current “trends” in Life Safety Code surveys and verify that their facility is compliant with all required codes.

Recent survey findings/trends that have resulted in deficiencies from FMS include:

• K17 – Ceilings – Holes of any size in ceiling tiles and any gaps between escutcheon plates and ceiling tiles.

• K17, K20, or K25 – Smoke Barrier Penetrations – Fire caulking cracks and penetrations in the concrete walls or floors (simple expanding foam is unacceptable).

• K38 – Sidewalks – Exterior sidewalk grades that have grade changes in excess of 1/2".

• K48 – Fire Plan – Inspectors are specifically looking for the words "smoke compartment" in the fire plan.  Regardless of what is said in the plan, if it does not say smoke compartment, it is being cited.

• K52 – Fire Alarm System – Use of the NFPA 72 form is required and the form must be filled out completely by the contracted service company (or qualified individuals).

• K62 – Sprinkler Systems – Sprinkler head corrosion in the kitchen is a hot issue, regardless of if the seat or link is affected.

• K69 – Activity Kitchens and OT Kitchens – CMS has begun to view any kitchens open to the corridor as hazardous areas.  These include the stoves used in occupational therapy, unless the room is protected as a hazardous area.  If there is any evidence of grease laden vapors in an OT area stove hood, CMS is calling for a hood extinguishing system.  We have requested clarification on this issue from the CMS Central Office and are working with AHCA on this significant issue, particularly in light of proposed NFPA codes that take into account increased “culture change” designs.

Want to see more of what CMS Region V looks for when they conduct a FMS survey?  Click here to view an excellent PowerPoint produced by CMS Region V inspectors!

Doug Beardsley
952.851.2489
dbeardsl@careproviders.org