DQA Quarterly Regional Office/Provider Forum Meetings

Over the last two weeks, the 4 regional offices held quarterly forums with providers.
In addition to data on regional citations, the meetings included a presentation from David Soems on the statewide Top 10 K Tags for Life Safety.
For those who were unable to attend here is the Top 10 List with comments from David.
- K353 – Sprinkler Testing – Testing sprinkler systems, attaching/hanging items from sprinkler pipes or fitting is not allowed and is a major source of violations.
- K712 – Fire Drills – Making sure that staff participate and they are performed at unexpected times.
- K345 – Fire Alarm Testing – Testing fire alarm systems.
- K321 – Hazardous Areas – Primarily areas converted to storage.
- K211 – Means of Egress – Issues with Delayed Egress systems, field modifications to the system.
- K914 – Receptacle testing – Lack of testing on receptacles, ensuring use of medical grade outlets with medical grade equipment
- K363 – Corridor Doors – Reliability of door, closing and latching.
- K372 – Subdivision of Building Spaces- Smoke Barrier Construction – Firestop around protrusions in walls/ceilings.
- K324 – Cooking Facilities – Looking for grease build up and suppression system testing every 6 months.
- K918 – Electrical Systems- Essential Electric System Maintenance and Testing – Monthly testing of generators and 4 hour test every three years.
David also recommended three key references that building and maintenance staff should have on hand:
- NFPA 101: Life Safety Code;
- NFPA 99: Code pertaining to Health Care Facilities;
These codes can be purchased from the National Fire Protection Association.
- CMS 2786 R: Crosswalk: K tags to Life Safety Code.
Finally and very importantly: We remind you that on a nursing facility recertification survey, a facility must clear any clinical and life safety code deficiencies by the final compliance date. We have had to address with DQA two instances where the member did not technically clear their life safety code deficiencies by the final compliance date putting the facility at risk for denial of payment for new admissions. Fortunately, DQA was very understanding and we were able to rectify the situations.
Questions? Please do not hesitate to contact Eric, ekoch@whcawical.org or Rick, rick@whcawical.org and we would be happy to assist you.