Texas Health and Human Services - The 10 Most Frequently Cited Deficiencies
Nursing Homes - Life Safety Code

Welcome

The Texas Health and Human Services Commission (HHSC) designed this presentation to inform you about the 10 most frequently cited Life Safety Code deficiencies in nursing homes during fiscal year 2022.

Navigation for this Presentation

To advance to the next page, click on Next.

To return to the previous page, click on Previous.

You may also click on the page numbers that are above this text.

 

wManual pull station

a

eee

HHSC Annual Report

State law requires HHSC to compile and report survey and enforcement data every year.  HHSC publishes the data in the Long-term Care Regulation (LTCR) Annual Report. Part of this report includes the top 10 deficiencies or violations cited during the fiscal year covered by the report.

The Annual Report is available on the Internet at the following weblink: HHSC LTCR Annual Report

This training on the top 10 Life Safety Code deficiencies for nursing homes is based on the data in the LTCR Services March 2023 Annual Report. The data covers the period from 9/1/21 to 8/31/22. Nine of the top 10 deficiencies listed for fiscal year 2022 also appeared in the top 10 list for fiscal year 2021.

In this presentation, the top 10 deficiencies listed for fiscal year 2022 appear in order from the least frequently cited (#10) to the most frequently cited (#1).

 

 

Deficiencies Chart for Fiscal Year 2022 and Fiscal Year 2021

Tag Number

Tag Title

Fiscal Year 2022

Fiscal Year 2021

K741

Smoking Regulations

10

Not ranked

K363

Corridor - Doors

9

9

K222

Egress Doors

8

8

K211

Means of Egress

7

5

K324

Cooking Facilities

6

7

K321

Hazardous Areas - Enclosure

5

6

K918

Electrical Systems - Essential Electrical System Maintenance and Testing

4

3

K372

Subdivision of Building Spaces - Smoke Barrier Construction

3

4

K353

Sprinkler System - Maintenance and Testing

2

2

K521

Heating, Ventilation and Air Conditioning

1

1

 

 

#10 K741

K741 Smoking Regulations

The facility failed to comply with requirements for smoking regulations, including adopting a plan to address where smoking is permitted, or failed to provide noncombustible safety type ashtrays or receptacles in convenient locations.

This tag was not ranked in the top 10 deficiencies for fiscal year 2021.

a

No smoking sign

 

#10 K741

K741 Smoking Regulations

Examples of findings cited under K741 include:

 

 

#9 K363    

K363 Corridor - Doors

The facility failed to comply with requirements related to corridor doors, including door construction and fire rating, means for keeping doors closed, clearance beneath doors, impediments to closure of doors, use of roller latches, or construction and labeling of door frames.

This tag was ranked ninth in the top 10 deficiencies for fiscal year 2021.

a

Door frame

#9 K363    

K363 Corridor - Doors

Examples of findings cited under K363 include:

 

 

#8 K222    

K222 Egress Doors

The facility failed to comply with requirements for latches, locks, or special locking arrangements on egress doors.

This tag was ranked eighth in the top 10 deficiencies for fiscal year 2021.

a

Door handle

 

 

#8 K222    

K222 Egress Doors

Examples of findings cited under K222 include:

 

 

#7 K211

K211 Means of Egress - General

The facility failed to comply with requirements for egress, including aisles, passageways, corridors, exit discharges, or exit locations.  

This tag was ranked fifth in the top 10 deficiencies for fiscal year 2021.

j

 

Exit sign

#7 K211      

K211 Means of Egress - General

Examples of findings cited under K211 include:

 

 

#6 K324

K324 Cooking Facilities

The facility failed to comply with requirements related to cooking facilities or cooking equipment.  

This tag was ranked seventh in the top 10 deficiencies for fiscal year 2021.

a

Grease filter

 

 

#6 K324

K324 Cooking Facilities

Examples of findings cited under K324 include:

 a

 

 

 

#5 K321

K321 Hazardous Areas - Enclosure

The facility failed to comply with requirements related to the protection of hazardous areas.  

This tag was ranked sixth in the top 10 deficiencies for fiscal year 2021.

a

Paper stacks

 

#5 K321

K321 Hazardous Areas - Enclosure

Examples of findings cited under K321 include:

 

#4 K918

K918 Electrical Systems - Essential Electrical System Maintenance and Testing

The facility failed to test and maintain the generator or alternate power source as required by the Health Care Facilities Code.  

This tag was ranked third in the top 10 deficiencies for fiscal year 2021.

a

generator

 

 

 

#4 K918

K918 Electrical Systems - Essential Electrical System Maintenance and Testing

Examples of findings cited under K918 include:

 

 

#3 K372

K372 Subdivision of Building Spaces - Smoke Barrier Construction

The facility failed to construct smoke barriers in accordance with certain Life Safety Code requirements or with the required resistance ratings.  

This tag was ranked fourth in the top 10 deficiencies for fiscal year 2021.

a

Tape measure

 

#3 K372

K372 Subdivision of Building Spaces - Smoke Barrier Construction

Examples of findings cited under K372 include:

 

 

 

 

 

 

#2 K353

K353 Sprinkler System - Maintenance and Testing

The facility failed to comply with requirements for testing, maintaining, and inspecting a sprinkler system or for retaining records related to the sprinkler system.  

This tag was ranked second in the top 10 deficiencies for fiscal year 2021.

 a

Fire sprinkler system tests

 

 

 

#2 K353

K353 Sprinkler System - Maintenance and Testing

Examples of findings cited under K353 include:

 

 

 

 

#1 K521

K521 Heating, Ventilation and Air Conditioning

The facility failed to comply with Life Safety Code requirements for heating, ventilation, and air conditioning systems.  

This tag was ranked first in the top 10 deficiencies for fiscal year 2021.

a

Damper

 

#1 K521

K521 Heating, Ventilation and Air Conditioning

Examples of findings cited under K521 include:

 

 

Conclusion

This presentation has reviewed the top ten deficiencies.  

In addition to complying with the required inspections, tests and maintenance of your life safety systems (such as fire alarm systems), remember to meet all of the documentation requirements.  Document every relevant detail and save your documentation.

Contact

For questions or more information:

HHSC Long-term Care Regulation program

Policy and Rules Section

LTCRPolicy@hhs.texas.gov or (512) 438-3161

The HHSC website is at the following weblink: https://www.hhs.texas.gov/.

fggh

Keyboard