The Kansas Fire Marshal Releases Survey Results

 

Federal Foss Survey Results

KSFM recently received their results from CMS on the Foss Surveys in healthcare facilities. KSFM wanted to share with you the findings so you can use can these as helpful tips to ensure your centers are up to the highest standards in fire protection.

Zoned evacuation plans(K48) Make sure evacuation plans show not only total evacuations of the building(s) but also smoke zone evacuations.

Generator Testing- (K144) On maintenance records, make sure you are doing a monthly 30% of the nameplate rating for at least 30 minutes with an additional cool-down period.  Also, don't forget to document your evidence of maintaining a minimum exhaust temperate as recommended by the manufacture in lieu of the 30% monthly test. Do not forget the 30% annual load bank test documentation as well.

Doors Protecting Corridors- (K18) Make sure corridor doors are fitting tightly within the door frames and there is no sagging below the doorstop.

Emergency Plan and Fire Drills- (K48) If a fire drill is titled "responding to a minor fire" and the plan does not address the transmission of the alarm to the fire department and does not state the person discovering the fire should activate the fire alarm.  A "minor" fire is still a fire.  This would be considered a deficiency.

Air handling Systems – (K67) Air handling systems that supply cool air to resident rooms and office space. The systems are not designed as a balanced system with equal supply/exhaust from the resident rooms and an equal supply/exhaust from the corridors, which result in the corridor being used as a plenum.

Best way to determine this, is to find out how the heating and air conditioning work in the corridors and then in the resident rooms. When the heat or air comes from the resident rooms to heat/cool the corridor (or vice versa – the heat/air comes from the corridor to heat/cool the resident rooms) go out and look at the corridor/resident rooms and look for the supply and returns. If your facility is fully sprinklered, has a complete fire alarm system and the HVAC shuts down on activation of the fire alarm, you may be eligible to apply for a waiver.

If you have any questions or concerns, please contact KSFM.