Representatives from Care Providers of Minnesota and the Minnesota Department of Health met with staff from the Centers for Medicare and Medicaid Services (CMS) Region V in Chicago on December 12 and 13, 2011. A highlight of this annual meeting is sharing updated information regarding survey deficiencies for each state located within CMS Region V.

Region V staff did an excellent job breaking down the top ten most common Life Safety Code infractions (K-Tags) in each state, including hints for being in compliance. The next ten issues of the Action newsletter will share the CMS Region V and provider hints for avoiding common K-Tag deficiencies.

Failure to comply with the requirements for fire drills is the most common Life Safety Code deficiency issued in Minnesota.

K-Tag Deficiency #1: K0050 — Fire Drills

Requirement:

Fire drills are held at unexpected times under varying conditions, 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. Where drills are conducted between 9:00 p.m. and 6:00 a.m., a coded announcement may be used instead of audible alarms.

Survey success hints:

• Fire drills must be documented. Documentation must include the date of the drill, time of the drill (including what shift), location of the drill, type of simulated fire, etc. This documentation is necessary to prove that the drills were done under varying times and conditions. CMS Region V recommends that the drills for each shift be varied enough so that no more than three of four drills per shift would fall within one hour from the others. Documentation must also include confirmation (including time) regarding the auto-dialing function to the fire station.

• Fire drills must be conducted at a frequency of one per shift per quarter.

• The Minnesota State Fire Code (MSFC) also requires that fire drills be conducted quarterly on each shift. The MSFC requires a few additional bits of documentation for each fire drill:
  • Identity of the person conducting the drill
  • Notification method used
  • Staff members on duty and participating
  • Number of occupants evacuated (when evacuation is part of the drill)
  • Special conditions simulated
  • Problems encountered
  • Time required to accomplish complete evacuation (when evacuation is part of the drill)

• View a helpful document pertaining to fire drills here — it was developed as part of the Life Safety Code Documentation Project.

• View a sample fire drill documentation form here.

The entire Life Safety Code Documentation Project resource is available for use and download at the State Fire Marshal’s website http://www.health.state.mn.us/divs/fpc/lifesafetycode.html. Care Providers of Minnesota also has printed, tabbed, and bound the entire project into an easy-to-use resource, available for only $45 to Care Providers of Minnesota members (you will need to log in to the website to get member pricing).

Fire drills are a deficiency providers should be able to avoid! Administrators should review the hints noted above and related resources with staff assigned the responsibility for conducting fire drills, and then audit for internal compliance. We should easily be able to improve in this area, and reduce the number of facilities found deficient!

Doug Beardsley
952.851.2489
dbeardsl@careproviders.org

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