Incorrect written fire safety plans are a common source of deficiencies during Life Safety Code (LSC) surveys. K48, K154, and K155 are the K tags that correspond to the LSC requirements for written fire safety plans.
K48 requires compliance with LSC Sections 188.8.131.52 or 184.108.40.206, which state that a written fire safety plan must cover the eight listed items in those code sections. The following are a few examples of issues that result in deficiencies being cited at K48:
- The written fire safety plan fails to address the evacuation of the smoke compartment, which was a new requirement to the 2000 Edition of the LSC. Related to this are issues when a plan states residents will be evacuated to another area of the building. Using an undefined term, such as “another area”, does not cover the requirement for evacuation of the smoke compartment, because “another area” may be in the same smoke compartment as the fire.
- The written fire safety plan instructs staff to determine the size of a fire and act accordingly. Fire plans have been reviewed where staff are instructed to extinguish the fire and not remove residents or activate the fire alarm if, in the staff member’s opinion, the fire is small. A fire plan should not have different actions based on a staff member’s determination of the size of a fire. Upon discovering a fire, a staff member’s first action should be to rescue anyone in immediate danger. While doing so, they should call out a code word alerting other staff members of the fire so they can activate the fire alarm.
These examples do not address all possible reasons for a citation at K48.
K154 & K155
K154 requires compliance with LSC Section 220.127.116.11, which states that a facility must be evacuated or an approved fire watch must be conducted when the sprinkler system is out of service for more than four hours in a twenty-four hour period.
K155 requires compliance with LSC Section 18.104.22.168, which states that a facility must be evacuated or an approved fire watch must be conducted when the fire alarm system is out of service for more than four hours in a twenty-four hour period. Most facilities adopt policies, often called fire watch policies, to meet the requirements of LSC Sections 22.214.171.124 and 126.96.36.199. The following are a few examples of issues that result in deficiencies being cited at these K tags:
- The fire watch policy incorrectly addresses the time criteria for instituting the fire watch. The LSC states the fire watch must be conducted if the fire alarm or sprinkler system is out of service for more than four hours in a twenty-four hour period. Errors occur when the policy erroneously states the systems must be out of service for more than four hours, which implies four consecutive hours. However, the requirements do not require the outage to last for four consecutive hours. A fire watch must be conducted when the sum of all outages in a twenty-four hour period totals more than four hours.
- The fire watch policy fails to address contacting all authorities having jurisdiction (AHJ). The Centers for Medicare & Medicaid Services (CMS) is one of the AHJs for the LSC for certified facilities. State agencies (SA) act on behalf of CMS for certification purposes. Therefore, contacting a SA should be addressed in a facility’s fire watch policy.
- The fire watch policy states staff members will be assigned the fire watch in addition to their normal duties. Staff members must be dedicated to the fire watch and cannot conduct a fire watch in addition to their normal duties. A staff member’s normal duties would most likely keep them from conducting the fire watch, which must be conducted continuously during the outage, for extended periods of time.
These examples do not address all possible reasons for citations at K154 or K155.