Ask Proactive – It has been 3 years since our facility’s last annual survey. What are the top Life Safety K tags that are being cited?

It has been 3 years since our facility’s last annual survey. What are the top Life Safety K tags that are being cited?

A:

The top 5 Life Safety K tags have been fairly consistent over the last few years and have primarily just changed in their ranking number. These include:

1. K035 – Sprinkler Maintenance and Testing: The facility automatic sprinkler and standpipe systems must be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems.
2. K0918 – Electrical Systems – Essential Electric System Maintenance and Testing: The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches.  Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours.
3. K0321 – Hazardous Areas – Enclosure: Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with ¾ hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
4. K0712 – Fire Drills: Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and 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. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
5. K0345 – Fire Alarm Testing and Maintenance: A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available.

You can find all of the Life Safety K Tags at: https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms2786R.pdf

Janine Lehman, RN, RAC-CT, CLNC
Director of Legal Nurse Consulting

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