The document that has blanket waivers was updated today and now includes provisions for fire drills and a few other items in the LSC. Please review and utilize the information provided by the Kansas Office of the State Fire Marshal
A message from KHCA Life Safety Consultant Stan Spzytek
Additional Clarification on 1135 Blanket Waiver- Life Safety Code Requirements
CMS has provided additional clarification on Life Safety code compliance. See details below. Of particular note, your SNFs can now do training instead of conducting actual fire drills during the declared emergency. Your facilities should conduct a training session on each shift during each quarter of the declared emergency and make sure that it is properly documented including a sign-in sheet. The training sessions can documented with the facilities existing fire drill forms. It will be important to include comments on the form indicating that it was a training session as allowed by CMS under the waiver instead of an actual fire drill.
In a revised communication on the 1135 waivers issued May 8, 2020, CMS is modifying (and clarifying) the following requirements:
- Alcohol-based Hand-Rub (ABHR) Dispensers: We are waiving the prescriptive requirements for the placement of alcohol based hand rub (ABHR) dispensers for use by staff and others due to the need for the increased use of ABHR in infection control. However, ABHRs contain ethyl alcohol, which is considered a flammable liquid, and there are restrictions on the storage and location of the containers. This includes restricting access by certain patient/resident population to prevent accidental ingestion. Due to the increased fire risk for bulk containers (over five gallons) those will still need to be stored in a protected hazardous materials area. Refer to: 2012 LSC, sections 18/184.108.40.206. In addition, facilities should continue to protect ABHR dispensers against inappropriate use as required by 42 CFR §482.41(b)(7) for hospitals; §485.623(c)(5) for CAHs; §418.110(d)(4) for inpatient hospice; §483.470(j)(5)(ii) for ICF/IIDs and §483.90(a)(4) for SNF/NFs.
- Fire Drills: Due to the inadvisability of quarterly fire drills that move and mass staff together, we will instead permit a documented orientation training program related to the current fire plan, which considers current facility conditions. The training will instruct employees, including existing, new or temporary employees, on their current duties, life safety procedures and the fire protection devices in their assigned area. Refer to: 2012 LSC, sections 18/220.127.116.11.
- Temporary Construction: CMS is waiving requirements that would otherwise not permit temporary walls and barriers between patients. Refer to: 2012 LSC, sections 18/18.104.22.168.
You may contact our Life Safety Consultant who is on a temporary engagement with KHCA for additional clarification or to answer and specific questions.
Stan Szpytek | President - Fire and Life Safety, Inc.