Unit 8
Some frequently asked questions and answers from the Office of the State Fire Marshal:
Can we prop open resident room doors?
You cannot use a wooden wedge, kick down, or other items like a trash can to prop open doors. However, nonrated resident room doors may be equipped with a magnetic or friction hold-open device that would allow the door to remain open but still meet the requirement for a single-motion to close. Rated doors such as your smoke barrier, fire barrier, and hazardous room doors must remain closed. If they are equipped with a hold-open device, those devices must be tied into the fire alarm system.
Fire Drills
What is the definition of unexpected times? And why do we have to document a scenario?
KSFMO will cite providers for similar times if you hold a fire drill the first day of the month every quarter and if you do not vary your time more than 2-3 hours. Drills should be conducted throughout shifts and should not show a pattern (same time of day, same day of the month). Scenarios ensure that drills are performed under varying conditions – such as the size, type and location of the fire. NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. 2000 NFPA 101, 18/19.7.1.2
(this means that the facility does not have to pull the fire alarms and make all the noise at night like they would during the day and evening shifts)
What are the requirements for storage within 18 inches of a sprinkler head?
The 18-in. (0.46-mm) dimension is not intended to limit the height of shelving on a wall or shelving against a wall in accordance with 5-6.6. Where shelving is installed on a wall and is not directly below sprinklers, the shelves, including storage thereon, can extend above the level of a plane located 18 in. (0.46 mm) below ceiling sprinkler deflectors. Shelving, and any storage thereon, directly below the sprinklers cannot extend above a plane located 18 in. (0.46 mm) below the ceiling sprinkler deflectors.
Is there a minimum size requirement for a closet to be sprinklered?
No. A closet of any size must be sprinklered. There is a lot of confusion amongst the states and the providers about the difference between a closet and a wardrobe. A wardrobe does not have to be sprinklered. A wardrobe is anything not build into the facility. A wardrobe may be bolted or recessed into a wall. The question you must ask yourself is “Can it be removed from the facility like a piece of furniture”
Please clarify at what point will OSFM cite a sprinkler head for being corroded or dirty?
CMS and OSFM will only cite facilities if the corrosion, paint, dust, or lint is heavy and would prevent proper operation. NFPA Standard: Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. 1998 NFPA 25, 2-2.1.1
Remember that it is not just the administrator and maintenance department's jobs to ensure safety for your residents and yourselves. If you see a potential safety issue, please report it to your charge nurse, Director of Nursing, maintenance department or administrator.
