Helpful Hints: Top 10 Life Safety Compliance Deficiencies of 2011 - Part 5

By Steve Swedish, Windmill Software

The next K Tag that we have on the Top Ten Life Safety Code citations of 2011 is #5: K38 Exit Access and Means of Egress. 

I think that this is one of the more important K Tags to watch for because it pertains to the physical evacuation in case of a fire or some other type of emergency. The tag helps you ensure that there's a way to exit the building for staff and residents and that when you reach that exit, there's a clear path to safety.  I had the great opportunity to attend both the AHCA Annual Conference and the Leading Age Annual Meeting over the last 4 weeks and this tag has come up pretty frequently. It appears as though a number of you are currently dealing with K38 or have in the past. 

As always, I encourage you to share your experiences relevant to K38 at the bottom of the blog.  Your real-life stories help us all interpret the code - or at least how your surveyor interpreted it!

K38 Means of Egress and Exit Access

• Exit access is so arranged that exits are readily accessible at all times in accordance with section 7.1.18.2.1 and 19.2.1
• Access to all required exits shall be in accordance with 7.3. 32.3.2.5.1 and 33.3.2.5.1

Walking surface must be level, clear, and unobstructed at all times and useable under all weather conditions:

• Storage not permitted in corridors
• Abrupt changes in elevations shall not exceed ¼". Under ½" can be beveled. Over ½" must be corrected by other means
• Snow, ice, water, soft ground are examples of impediments that can obstruct egress by individuals that use walkers, wheelchairs or require other forms of assistance

Means of Egress (Painted Doors)

• Exit doors or exit access doors cannot be painted/disguised in a manner that obscures their use as a door
• A door that contains a window and has a compliant exit sign above the door can be painted if a cognitively aware individual can still tell it's an exit door
• The window cannot be painted. This may also be cited at K72

Means of Egress (Locked Doors)

• Special locking arrangements are permitted under certain circumstances in health care facilities
• Locks are permitted on doors in a means of egress if residents have a clinical need for the extra security measures
• Door lock regulations also pertain to gates in the means of egress
• Magnetic locks must release upon activation of fire alarm or loss of power
• Doors can be locked from the outside to prevent unauthorized entry without obstructing egress

All staff members that work in that unit must have the knowledge and ability to unlock doors:

• All staff must have keys (A single key at a nurses station is not acceptable) or all staff must know code and know how to use keypad
• Mixed Population -Not all residents have clinical needs

Doors can be locked, but staff, visitors, and residents without clinical needs must have ability to use doors

• Delayed-egress locks

Delay of 15 seconds permitted after pressure applied to door for no more than 3 seconds (30 sec delay exception)

Doors must have signs that read:

• PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS

There must be no more than one delayed-egress lock in means of egress:

• Including gates

Locks are permitted if the building has either:

• A complete fire detection system in accordance with LSC Section 9.7
• A complete automatic sprinkler system in accordance with LSC Section 9.6
• Sensor-controlled locks must meet delayed-egress lock requirements if they lock in that manner
• Deadbolt locks are not permitted unless the deadbolt releases with the same action of the door handle

Helpful Hints to Avoid a K38 Citation

• The floor level on each side of the door must be level (In existing buildings, there can be a grade change if the change is equal to that of one step).
• Delayed-egress devices can only be installed in a building that has either a complete sprinkler system or a completed fire detection system.  Also, there must be an instruction sign on a door with a delayed-egress device. Delayed-egress devices must release upon activation of the fire alarm or within 15 seconds of an acceptable amount of force being applied to the door for no more than 3 seconds. Also, there can be only one delayed-egress device in means of egress.
• Doors must open with only one releasing operation
• Means of egress must be clear and unobstructed at all times and useable in all weather conditions

Common Citation Scenarios

The devices are not working per the requirements found in section 7.2.1.6.1. 

Two devices are installed within a primary egress path in conflict with the requirements found in section 19.2.2.2.4. Typically, the doors will:

• not release and open within 15 seconds or
• the doors will lack the proper signage or
• the doors will require more than 15 pounds to initiate and open the doors.

These unique locking devices are allowed in health care facilities without significant clinical or admission restrictions and provide a needed form of elopement deterrence but the system must operate in compliance with all of the prescriptive requirements to provide such flexibility. Note that these locking devices shall not be coupled with doors artistically disguised to look like a bookcase or outside environment.

Lastly, the exit-discharge path has grade changes in excess of ½" which provides a trip hazard for occupants and emergency responders.

I hope that you have found this helpful and I look forward to talking with you again next week when I cover #6 on the Top Ten Life Safety Code Deficiencies of 2011 -- K25 Smoke Barriers.

Sources:

Top 10 Deficiencies and How to Avoid Them, Indiana State Department of Health

Preventative Maintenance Manual, Ohio Department of Health

So That's What They Look For, CMS

 

This entry was written by Steve Swedish, posted on Tuesday, October 30, 2012 Bookmark the permalink. Follow any comments here with the RSS feed for this post. You can post a comment.