10/16/2019
Life Safety Code Survey Tip: K761 Maintenance, Inspection & Testing of Doors
K761 was the fifth highest K-tag cited in Ohio in 2018 and has had 114 citations in 2019. This citation is related to Maintenance, Inspection & Testing of doors.
In accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives, fire doors should be inspected and tested annually. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, should be routinely inspected as part of the facility maintenance program. The person performing the door inspections and testing should be knowledgeable in this area, have received training and/or have experience that demonstrates their ability. The written records of inspection and testing are to be maintained and available for review.
Ensure that doors are audited on a routine basis and that the audit is part of your facility’s preventative maintenance program. Many factors, including weather changes, can affect the doors latching.
The individual that completes the audit of the doors must have knowledge, training or experience proving that they can complete the door inspection and testing. The Centers for Medicare & Medicaid Services (CMS) have a Life Safety Code Transition Course available to view on the Integrated Surveyor Training Website. This resource can be used for education for maintenance staff.
Life Safety Code information can be found on the Centers for Medicare & Medicaid Services Life Safety Code webpage and on the Ohio Department of Health webpage.
LeadingAge Ohio is hosting the Ohio Department of Health on October 22 at the LeadingAge Ohio office in Columbus from 10am – 12:30pm for a meeting focused on emergency preparedness. Members are encouraged to invite their staff in charge of the emergency preparedness and life safety code.
If you have questions related to life safety code, emergency preparedness or the meeting, please email Stephanie DeWees, Quality & Regulatory Specialist for Long Term Care at sdewees@leadingageohio.org.
