IMPORTANT: CMS Changes Requirements on Access-Controlled Egress Doors in Healthcare Facilities- Effective Immediately ADVOCACY UNDERWAY
For many years CMS has allowed an entire healthcare facility to have “Access-Controlled Egress Doors” if the code was posted by some means. The State office of the Fire Marshal has been informed that CMS will no longer allow this practice, based on a phone call yesterday with Katherine Achor at CMS Region VII. Effectively immediately a healthcare facility that has “Access-Controlled Egress Doors* for the entire facility will cited during their Fire Marshal inspection. The new requirement applies to healthcare facilities (and assist living ONLY if it is in the same building as the healthcare facility with no 2 hour separation between assisted living and healthcare). To be on “total lock down” (i.e. access-controlled egress doors) throughout the building a provider must justify the clinical needs or special needs (see K222 below) of all the patients/residents in the building. It may be possible, but highly unlikely according to McNorton, for CMS to exempt one finite unit in a building from the new interpretation. If you believe your organization has a clinical or special need to have select access-controlled egress, send a written request with explanatory information about where you wish to have access-controlled egress and detailed rationale to: Brenda McNorton, Chief of Inspections, Office of the State Fire Marshal, 800 SW Jackson Suite 104, Topeka, KS 66612. Or pdf your letter to Brenda.mcnorton@ks.gov.
We have communicated serious concerns about this surprise regulatory interpretation with the other LTC associations, KDADS, LeadingAge national.
K222 – Egress Doors: Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements:
CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4.
August 20212 Issue of Prevention Highlights
Prevention Highlights, a publication of the Office of the Kansas State Fire Marshal Prevention Division. Select topics:
- How to prevent being cited for fire wall penetrations
- New KSFM staff
- Important notice on propane use
- Child care center requirements
Risk Assessment on Facility systems to be Targeted in Fire Marshal Inspections
The Kansas Office of the State Fire Marshal has been directed by CMS to cite tags in healthcare facilities where they find noncompliance with K901-Building System Categories. Building Systems are designed to meet Category 1 through 4 requirements as detailed in NFPA 99. The attached sheet explains what the code requires. Categories are determined by a formal and documented risk assessment procedure performed by qualified personnel. Chapter 4 (NFPA 99)
K901 requires the facility to do a risk assessment on facility systems. Life support must be determined individually (with the exception of ventilators) and can be provided by other medical devices, such as suctioning to maintain a clear airway. Kansas inspectors will ask facilities for their documentation on these assessments. These must be kept in your fire safety note book.
Here is an example of a facility risk assessment tool.
Questions? Email Brenda McNorton, Chief of Inspections, Office of the State Fire Marshal at brenda.mcnorton@ks.gov.
