RE: K Citation and Locking of Doors Fire Marshal/CMS Requirements

July 8, 2009 (Revised 2/25/14)

RE: K Citation and Locking of Doors – Fire Marshal/CMS Requirements

Dear Nursing Home Members:

One of our members recently received notification during a Fire Marshal visit/inspection about door locking requirements, specifically with regard to a potential K citation. The link below is the reference document which was given to our member:

Life Safety Code - Key Pads - Egress - 2009.pdf In speaking with our State Fire Marshal’s office, they indicate that they are waiting to hear a more current update from CMS since discussing this issue internally recently. Evidently they have not seen anything newer from CMS on this yet, and at least some have the understanding that there would possibly be an I J if an area is locked up so as to trap or prevent of people of average cognitive ability from exiting an area of a facility.

Note that this is contrary to CMS’ information below. Until we do receive anything new from CMS or the Fire Marshal, we recommend you consider following the guidelines below:

We also consulted with LeadingAge (formerly AAHSA) for clarification and confirmation. LeadingAge contracts with Tom Jaeger for their Life Safety Consulting work; his analysis is below:

From: [email protected] [mailto:[email protected]] Sent: Sunday, June 29, 2008 1:39 PM Subject: Re: FW: Healthcare presentation

Please see summary of what we are telling members as to what to do relative to locking of doors, based on recent policies of CMS. If we are contradicting CMS policy, which I do not believe we are and I am positive we are not in violation of the Life Safety Code, providers would only be allowed to use delayed egress locks. In slide #6 where it says "if the surveyor can not get out of the door, it's a violation." You have two choices, use a delayed egress lock which requires no special knowledge or you provide the surveyor with the information on how to unlock the door before the surveyor goes into a locked unit.

Please note that CMS policy says "K 038 will be cited if------all cognitively aware residents, staff and visitors do not have access to the method of opening the doors." The key words are "method to opening the doors." Our policy does require that, when non delayed egress locks are used, that the method to unlock the doors be given to cognitively aware residents, staff and visitors, to include the surveyor. Page 1 of 2

An Association of Not-For-Profit and Mission Focused Senior Living & Care Providers 1495 Wilmington Drive, Suite 340 | DuPont, WA 98327 | 253-964-8870 | 253-964-8876 Fax | www.LeadingAgeWA.org (LeadingAge – further attachment below:)

CMS has made locking of doors in means of egress a resident rights issue 1. Delayed Egress Locks • Nothing has to be done 2. All other locks • Cognitively aware residents • Give info on how to unlock door and document when and who • Visitor ( to include surveyors ) • If going into locked unit • Sign in and give information on unlocking door • All staff assigned to locked unit or required to report to locked unit during an emergency must be given information on unlocking doors 3. All of the above should be included in facilities emergency plans and operational plans

(And, LeadingAge Washington – further attachment below:)

CMS June 23, 2007 Memo on locking of doors in means of egress

• CMS requires a comprehensive and individualized assessment of each resident’s needs to determine if the resident requires the information • • K38 will be cited if egress doors on a floor are locked and there is evidence that all cognitively aware residents, staff and visitors do not have access to the method of opening the doors • • If staff can not unlock the doors, it will most likely be considered an immediate jeopardy situation.

As always, contact LeadingAge Washington if we can be of any assistance. We will continue to be in contact with the Fire Marshal’s office on this matter.

253-964-8870 [email protected]

An Association of Not-For-Profit and Mission Focused Senior Living & Care Providers 1495 Wilmington Drive, Suite 340 | DuPont, WA 98327 | 253-964-8870 | 253-964-8876 Fax | www.LeadingAgeWA.org