Audit

Follow Up by Surveyor to be performed before:
Name of person conducting survey:
The hospital designs and manages the physical environment to comply with the Life Safety Code.

LS.01.01.01 EP 1. The hospital assigns an individual(s) to assess compliance with the Life Safety Code, complete the eSOC and manage the resolution of deficiencies.

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LS.01.01.01 EP2 The hospital maintains a current electronic Statement of Conditions.

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LS.01.01.01 EP3 When the hospital plans to resolve a deficiency through a Plan for Improvement (PFI), the hospital meets the time frames identified in the PFI accepted by The Joint Commission.

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LS.01.01.01 EP 4 For hospitals that use Joint Commission accreditation for deemed status purposes: The hospital maintains documentation of any inspection and approvals made by state or local fire control agencies.

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The hospital protects occupants during periods when the Life Safety Code is not met or during periods of construction. (ILSM)

LS. 01.02.01 EP 1 The hospital notifies the fire department (or other emergency response group) and initiates a fire watch when a fire alarm or sprinkler system is out of service more than 4 hours in a 24-hour period in an occupied building. Notification and fire watch times are documented (NFPA 101-2000: 9.6.1.8 and 9.7.6.1)

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LS.01.02.01 EP 2 The hospital posts signage identifying the location of alternative exits to everyone affected.

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LS.01.02.01 EP 3 The hospital has a written interim life safety measure (ILSM) policy that covers situations when Life Safety Code deficiencies cannot be immediately corrected or during periods of construction. The policy includes criteria for evaluating when and to what extent the hospital follows special measures to compensate for increased life safety risk.

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LS.01.02.01 EP4 Inspects exits in affected areas on a daily basis.

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LS.01.02.01 EP5 Provides temporary but equivalent fire alarm and detection systems for use when a fire system is impaired.

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LS.01.02.01 EP6 Provides additional firefighting equipment. The need for this equipment is based on criteria in the hospital's interim life safety measure (ILSM) policy.

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LS.01.02.01 EP7 Uses temporary construction partitions that are smoke-tight, or made of noncombustible or limited-combustible material that will not contribute to the development or spread of fire.

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LS.01.02.01 EP8 Increases surveillance of buildings, grounds, and equipment, giving special attention to construction areas and storage, excavation, and field offices.

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LS.01.02.01 EP9
Enforces storage, housekeeping, and debris-removal practices that reduce the building’s flammable and combustible fire load to the lowest feasible level.

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LS.01.02.01 EP10 Provides additional training to those who work in the hospital on the use of firefighting equipment.

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LS.01.02.01 EP11 Conducts one additional fire drill per shift per quarter.

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LS.01.02.01 EP12 Inspects and tests temporary systems monthly.

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LS.01.02.01 EP13 The hospital conducts education to promote awareness of building deficiencies, construction hazards, and temporary measures implemented to maintain fire safety.

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LS.01.02.01 EP14 The hospital trains those who work in the hospital to compensate for impaired structural or compartmental fire safety features.

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Building and fire protection features are designed and maintained to minimize the effects of fire, smoke, and heat.

LS.02.01.10 EP 5 Doors are equipped with self closing and self latching devices. Gaps between meeting edges of door pairs are no more than 1/8" wide, and undercuts are no larger than 3/4 ".

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LS.02.01.10 EP 7 Doors requiring fire rating of 3/4 hour or longer are free of coverings, decorations, or other objects applied to the door face, with the exception of information signs.

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LS.02.01.10 EP8 Ducts that penetrate a 2-hour fire-rated separation are protected by dampers that are fire-rated for 1 1/2 hours.

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The hospital provides and maintains fire alarm systems.

LS.02.01.34 EP 2 The master fire alarm control panel is located in a protected environment (an area enclosed with a 1-hour fire-rated walls and 3/4-hour fire-rated doors) that is continuously occupied or in an area with a smoke detector

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LS.02.01.34 EP 3 The remote ancillary annunciator panel is in a location approved by the local fire department or its equivalent.

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LS.02.01.34 EP 4 Pull stations are unobstructed

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The hospital provides and maintains systems for extinguishing fires.

LS.02.01.35 EP 5 Sprinkler heads are not damaged and are free from corrosion, foreign materials and paint.

LS.02.01.35 EP 6 There are 18" or more of open space maintained below the sprinkler deflector to the top of storage.

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LS.02.01.35 EP 8 The travel distance from any point to the nearest fire extinguisher is 75 ft. or less.

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LS.02.01.35 EP 9 Class K - type portable fire extinguishers are located within 30 feet of grease-producing cooking devices.

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LS.02.01.35 EP 11, 12, and 13 The automatic fire extinguishing system for grease producing devices :
EP 11 Activates the building fire alarm system
EP 12 Deactivates the fuel source
EP 13 Controls the exhaust fans as designed

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The hospital maintains fire safety equipment and fire safety building features.

EC.02.03.05 EP 1 At least quarterly, the hospital tests supervisory signal devices (except valve tamper switches).

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EC.02.03.05 EP 2 Every 3 months, the hospital tests valve tamper switches and water-flow devices.

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EC.02.03.05 EP 3 Every 12 months, the hospital tests duct detectors, electromechanical releasing devices, heat detectors, manual fire alarm boxes, and smoke detectors.

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EC.02.03.05 EP 4 Every 12 months, the hospital tests visual and audible fire alarms, including speakers.

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EC.02.03.05 EP 5 Every quarter, the hospital tests fire alarm equipment for notifying off-site fire responders.

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EC.02.03.05 EP 6 For automatic sprinkler systems: Every week, the hospital tests fire pumps under no-flow conditions.

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EC.02.03.05 EP 7 For automatic sprinkler systems: Every 6 months the hospital tests water-storage tank high-and low-water level alarms. The completion date is documented

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EC.02.03.05 EP 8 For automatic sprinkler systems: Every month during cold weather, the hospital test water - storage tank temperature alarms. The completion date of the test is documented

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EC.02.03.05 EP9 For automatic sprinkler systems: Every 12 months, the hospital tests main drains at system low point or at all system risers.

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EC.02.03.05 EP10 For automatic sprinkler systems: Every quarter, the hospital inspects all fire department water supply connections.

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EC.02.03.05 EP11 For automatic sprinkler systems: Every 12 months, the hospital tests fire pumps under flow.

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EC.02.03.05 EP12 Every 5 years, the hospital conducts water-flow tests for standpipe systems.

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EC.02.03.05 EP13 Every 6 months, the hospital inspects any automatic fire-extinguishing systems in a kitchen.

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EC.02.03.05 EP 14 Every 12 months, the hospital tests carbon dioxide and other gaseous automatic fire-extinguishing systems. The completion date of the test is documented.

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EC.02.03.05 EP15 At least monthly, the hospital inspects portable fire extinguishers.

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EC.02.03.05 EP16 Every 12 months, the hospital performs maintenance on portable fire extinguishers.

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EC.02.03.05 EP 17 The hospital conducts hydrostatic tests on standpipe occupant hoses 5 years after installation and 3 years thereafter. Completion date is documented

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EC.02.03.05 EP18 The hospital operates fire and smoke dampers 1 year after installation (commencing Jan 2010) and then at least every 6 years to verify that they fully close.

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EC.02.03.05 EP19 Every 12 months, the hospital tests automatic smoke-detection shutdown devices for air-handling equipment.

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EC.02.03.05 EP20 Every 12 months, the hospital tests sliding and rolling fire doors for proper operation and full closure. The completion date of the tests is documented.

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EC.02.03.05 EP 25:Documentation of maintenance, testing, and inspection activities for fire alarm and water-based fire protection systems includes the following:

* Name of the activity
* Date of the activity
* Required frequency of activity
* Name and contact information, including affiliation of the person who performed the activity
* NFPA Standard (s) referenced for the activity (This information must be on ALL reports reflected in the Elements of Performance for EC.02.03.05
* Results of the activity

NOTE: Additional guidance on documenting activities, see NFPA 25, 1998 edition (Section 2.13) and NFPA 72, 1999 edition (Sectin 7-5.2).

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The hospital inspects, tests, and maintains emergency power systems

EC.02.05.07 EP 1 Battery powered lights are tested monthly for 30 seconds

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EC.02.05.07 EP 2 Battery powered lights are tested annually for 90 minutes

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EC.02.05.07 EP 3 Qtrly functional test of SEPSS for 5 min/class. 60% full duration of class /annual

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EC.02.05.07 EP 4. Twelve times a year, at intervals of not less than 20 days and not more than 40 days, the hospital tests each emergency generator for at least 30 continuous minutes.

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EC.02.05.07 EP 5 monthly load test 30% or exhaust gas temp or annual load bank 20/50/75%

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EC.02.05.07 EP 6 all transfer switches 12 times per year

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EC.02.05.07 EP 7 Generator load test every 3 years for 4 hours

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EC.02.05.07 EP 8 Generator 4 hour test at least 30% of nameplate

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Medical Gas and Vacuum Systems are Inspected

EC.02.05.09 EP 1 Review maintenance program and testing documentation

* test inspect & maintain master panels: area alarms: automatic pressure switches: shut off valves: flexible connectors: outlets

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The organization establishes and maintains a safe, functional environment.

EC.02.06.01 EP 13 (CLD) The hospital maintains ventilation, temperature, and humidity levels suitable for the care, treatment, and services provided.

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Building tour deficiencies

Other:

Follow up needed

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.