Title Page

  • 1. (A) PROVIDER NUMBER

  • 1. (B) MEDICAID I.D. NO.

  • 2. NAME OF FACILITY

  • 2. (B) ADDRESS OF FACILITY (STREET, CITY, STATE, ZIP CODE)
  • 3. SURVEYOR FOR

  • 4. DATE OF SURVEY

  • SURVEYOR

GENERAL INFORMATION

OTHER DETAILS

  • DATE OF PLAN APPROVAL

  • SURVEY UNDER

  • 5. SURVEY FOR CERTIFICATION OF

  • CHECK APPROPRIATE ITEM(S)

  • Specify

  • IS HOSPITAL ACCREDITED?

6. BED COMPOSITION

  • a. TOTAL NO. OF BEDS IN THE FACILITY

  • b. NUMBER OF HOSPITAL BEDS CERTIFIED FOR MEDICARE

  • c. NUMBER OF SKILLED BEDS CERTIFIED FOR MEDICARE

  • d. NUMBER OF SKILLED BEDS CERTIFIED FOR MEDICAID

  • e. NUMBER OF NF or ICF/IID BEDS CERTIFIED FOR MEDICAID

  • 7. A. DOES THE FACILITY MEETS THE STANDARD?

  • THE FACILITY MEETS THE STANDARD, BASED UPON (CHECK ALL APPROPRIATE BOXES)

PART I : NFPA 101 LSC REQUIREMENTS

SECTION 1: GENERAL REQUIREMENTS

  • K100 General Requirements – Other<br>List in the REMARKS section any LSC Section 18.1 and 19.1 General Requirements that are not addressed by the provided K-tags, but are<br>deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.

  • K111 Building Rehabilitation<br>Repair, Renovation, Modification, or Reconstruction<br>Any building undergoing repair, renovation, modification, or reconstruction<br>complies with both of the following:<br>• Requirements of Chapter 18 and 19.<br>• Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6.<br>18.1.1.4.3, 19.1.1.4.3, 43.1.2.1<br>Change of Use or Change of Occupancy<br>Any building undergoing change of use or change of occupancy<br>classification complies with the requirements of Section 43.7, unless<br>permitted by 18.1.1.4.2 or 19.1.1.4.2.<br>18.1.1.4.2 (4.6.7 and 4.6.11), 19.1.1.4.2 (4.6.7 and 4.6.11), 43.1.2.2 (43.7)<br>Additions<br>Any building undergoing an addition shall comply with the requirements of<br>Section 43.8. If the building has a common wall with a nonconforming<br>building, the common wall is a fire barrier having at least a two hour fire<br>resistance rating constructed of materials as required for the addition.<br>Communicating openings occur only in corridors and are protected by<br>approved self-closing fire doors with at least a 1-1/2 hour fire resistance<br>rating. Additions comply with the requirements of Section 43.8.<br>18.1.1.4.1 (4.6.7 and 4.6.11), 18.1.1.4.1.1 (8.3), 18.1.1.4.1.2, 18.1.1.4.1.3, 19.1.1.4.1 (4.6.7 and 4.6.11), 19.1.1.4.1.1 (8.3), 19.1.1.4.1.2, 19.1.1.4.1.3, 43.1.2.3(43.8)

  • K112 Sprinkler Requirements for Major Rehabilitation<br>If a nonsprinklered smoke compartment has undergone major rehabilitation<br>the automatic sprinkler requirements of 18.3.5 have been applied to the<br>smoke compartment.<br>In cases where the building is not protected throughout by a sprinkler<br>system, the requirements of 18.4.3.2, 18.4.3.3, and 18.4.3.8 are also met.<br>Note: Major rehabilitation involves the modification of more than 50 percent,<br>or more than 4500 ft² of the area of the smoke compartment.<br>18.1.1.4.3.3, 19.1.1.4.3.3

  • K131 Multiple Occupancies – Sections of Health Care Facilities<br>Sections of health care facilities classified as other occupancies meet all of<br>the following:<br> They are not intended to serve four or more inpatients for purposes of<br>housing, treatment, or customary access.<br>• They are separated from areas of health care occupancies by construction having a minimum two hour fire resistance rating in accordance with Chapter 8.<br>• The entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.<br><br>Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.<br><br>18.1.3.3, 19.1.3.3, 42 CFR 482.41, 42 CFR 485.623

  • K132 Multiple Occupancies – Contiguous Non-Health Care Occupancies<br>Non-health care occupancies that are located immediately next to a Health<br>Care Occupancy, but are primarily intended to provide outpatient services<br>are permitted to be classified as Business or Ambulatory Health Care<br>Occupancies, provided the facilities are separated by construction having<br>not less than two hour fire resistance-rated construction, and are not<br>intended to provide services simultaneously for four or more inpatients.<br>Outpatient surgical departments must be classified as Ambulatory Health<br>Care Occupancy regardless of the number of patients served.<br>18.1.3.4.1, 19.1.3.4.1

  • K133 Multiple Occupancies – Construction Type<br>Where separated occupancies are in accordance with 18/19.1.3.2 or<br>18/19.1.3.4, the most stringent construction type is provided throughout the<br>building, unless a two hour separation is provided in accordance with<br>8.2.1.3, in which case the construction type is determined as follows:<br>• The construction type and supporting construction of the health care<br>occupancy is based on the story in which it is located in the building in<br>accordance with 18/19.1.6 and Tables 18/19.1.6.1.<br>• The construction type of the areas of the building enclosing the other<br>occupancies shall be based on the applicable occupancy chapters.<br>18.1.3.5, 19.1.3.5, 8.2.1.3

  • K161 Building Construction Type and Height <br>2012 NEW<br>Building construction type and stories meets Table 18.1.6.1, unless<br>otherwise permitted by 18.1.6.2 through 18.1.6.7<br>18.1.6.4, 18.1.6.5 <br><br>Construction Type <br>1 I (442), I (332), II (222) *Not allowed non-sprinklered - Any number of stories sprinklered <br>2 II (111) 2 *Not allowed non-sprinklered - Maximum 3 stories sprinklered <br>3 II (000)<br>4 III (211) <br>6 V (111) <br>*Not allowed non-sprinklered - Maximum 1 story sprinklered 5 IV (2HH)<br>7 III (200) <br>8 V (000) <br>*Not allowed non-sprinklered <br><br>Sprinklered stories must be sprinklered throughout by an approved,<br>supervised automatic system in accordance with section 9.7. (See 18.3.5)<br>Give a brief description, in REMARKS, of the construction, the number of stories,<br>including basements, floors on which patients are located, location of smoke or<br>fire barriers and dates of approval. Complete sketch or attach small floor<br>plan of the building as appropriate.

  • K162 2012 NEW<br>Buildings of Type I (442), Type I (332), Type II (222), Type II (111) having<br>roof systems employing combustible roofing supports, decking or roofing<br>meet the following:<br>1. roof covering meets Class A requirements.<br>2. roof is separated from occupied building portions with 2 hour fire<br>resistive noncombustible floor assembly using not less than 2½ inches<br>concrete or gypsum fill.<br>3. the structural elements supporting the rated floor assembly meet the<br>required fire resistance rating of the building.<br>18.1.6.2, ASTM E108, ANSI/UL 790

  • K163 Interior Nonbearing Wall Construction<br>Interior nonbearing walls in Type I or II construction are constructed of<br>noncombustible or limited-combustible materials.<br>Interior nonbearing walls required to have a minimum 2 hour fire<br>resistance rating are permitted to be fire-retardant-treated wood enclosed<br>within noncombustible or limited-combustible materials, provided they are<br>not used as shaft enclosures.<br>18.1.6.4, 18.1.6.5, 19.1.6.4, 19.1.6.5

SECTION 2: MEANS OF EGRESS REQUIREMENTS

  • K200 Means of Egress Requirements – Other<br>List in the REMARKS section any LSC Section 18.2 and 19.2 Means of<br>Egress requirements that are not addressed by the provided K-tags, but are<br>deficient. This information, along with the applicable Life Safety Code or<br>NFPA standard citation, should be included on Form CMS-2567.<br>18.2, 19.2

  • K211 Means of Egress – General<br>Aisles, passageways, corridors, exit discharges, exit locations, and<br>accesses are in accordance with Chapter 7, and the means of egress is<br>continuously maintained free of all obstructions to full use in case of<br>emergency, unless modified by 18/19.2.2 through 18/19.2.11.<br>18.2.1, 19.2.1, 7.1.10.1

  • K221 Patient Sleeping Room Doors<br>Locks on patient sleeping room doors are not permitted unless the keylocking device that restricts access from the corridor does not restrict<br>egress from the patient room, or the locking arrangement is permitted for<br>patient clinical, security or safety needs in accordance with 18.2.2.2.5 or<br>19.2.2.2.5.<br>18.2.2.2, 19.2.2.2, TIA 12-4

  • K222 Egress Doors<br>Doors in a required means of egress shall not be equipped with a latch or a<br>lock that requires the use of a tool or key from the egress side unless using<br>one of the following special locking arrangements:<br>☐ CLINICAL NEEDS OR SECURITY THREAT LOCKING<br>Where special locking arrangements for the clinical security needs of the<br>patient are used, only one locking device shall be permitted on each door<br>and provisions shall be made for the rapid removal of occupants by: remote<br>control of locks; keying of all locks or keys carried by staff at all times; or<br>other such reliable means available to the staff at all times.<br>18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6<br>☐ SPECIAL NEEDS LOCKING ARRANGEMENTS<br>Where special locking arrangements for the safety needs of the patient are<br>used, all of the Clinical or Security Locking requirements are being met. In<br>addition, the locks must be electrical locks that fail safely so as to release<br>upon loss of power to the device; the building is protected by a supervised<br>automatic sprinkler system and the locked space is protected by a complete<br>smoke detection system (or is constantly monitored at an attended location<br>within the locked space); and both the sprinkler and detection systems are<br>arranged to unlock the doors upon activation.<br>18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 <br><br>☐ DELAYED-EGRESS LOCKING ARRANGEMENTS<br>Approved, listed delayed-egress locking systems installed in accordance<br>with 7.2.1.6.1 shall be permitted on door assemblies serving low and<br>ordinary hazard contents in buildings protected throughout by an approved,<br>supervised automatic fire detection system or an approved, supervised<br>automatic sprinkler system.<br>18.2.2.2.4, 19.2.2.2.4<br>☐ ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS<br>Access-Controlled Egress Door assemblies installed in accordance with<br>7.2.1.6.2 shall be permitted.<br>18.2.2.2.4, 19.2.2.2.4<br>☐ ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS<br>Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall<br>be permitted on door assemblies in buildings protected throughout by an<br>approved, supervised automatic fire detection system and an approved,<br>supervised automatic sprinkler system.<br>18.2.2.2.4, 19.2.2.2.4

  • K223 Doors with Self-Closing Devices<br>Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke<br>barrier, or hazardous area enclosure are self-closing and kept in the closed<br>position, unless held open by a release device complying with 7.2.1.8.2 that<br>automatically closes all such doors throughout the smoke compartment or<br>entire facility upon activation of:<br>• Required manual fire alarm system; and<br>• Local smoke detectors designed to detect smoke passing through the<br>opening or a required smoke detection system; and<br>• Automatic sprinkler system, if installed; and<br>• Loss of power.<br>18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

  • K224 Horizontal-Sliding Doors<br>Horizontal-sliding doors permitted by 7.2.1.14 that are not automatic-closing<br>are limited to a single leaf and shall have a latch or other mechanism to<br>ensure the door will not rebound.<br>Horizontal-sliding doors serving an occupant load fewer than 10 shall be<br>permitted, providing all of the following criteria are met:<br>• Area served by the door has no high hazard contents.<br>• Door is operable from either side without special knowledge or effort.<br>• Force required to operate the door in the direction of travel is ≤ 30 lbf to<br>set the door in motion and ≤ 15 lbf to close or open to the required<br>width.<br>• Assembly is appropriately fire rated, and where rated, is self-or<br>automatic-closing by smoke detection per 7.2.1.8, and installed per<br>NFPA 80.<br>• Where required to latch, the door has a latch or other mechanism to<br>ensure the door will not rebound.<br>18.2.2.2.10, 19.2.2.2.10

  • K225 Stairways and Smokeproof Enclosures<br>Stairways and Smokeproof enclosures used as exits are in accordance with<br>7.2.<br>18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

  • K226 Horizontal Exits<br>Horizontal exits, if used, are in accordance with 7.2.4 and the provisions of<br>18.2.2.5.1 through 18.2.2.5.7, or 19.2.2.5.1 through 19.2.2.5.4.<br>18.2.2.5, 19.2.2.5

  • K227 Ramps and Other Exits<br>Ramps, exit passageways, fire and slide escapes, alternating tread devices,<br>and areas of refuge are in accordance with the provisions 7.2.5 through<br>7.2.12.<br>18.2.2.6 to 18.2.2.10 or 19.2.2.6 to 19.2.2.10

  • K231 Means of Egress Capacity<br>The capacity of required means of egress is in accordance with 7.3.<br>18.2.3.1, 19.2.3.1

  • K232 Aisle, Corridor or Ramp Width<br>2012 NEW<br>The width of aisles or corridors (clear and unobstructed) serving as exit<br>access in hospitals and nursing homes shall be at least 8 feet. In limited<br>care facility and psychiatric hospitals, width of aisles or corridors shall be at<br>least 6 feet, except as modified by the 18.2.3.4 or 18.2.3.5 exceptions.<br>18.2.3.4, 18.2.3.5

  • K233 Clear Width of Exit and Exit Access Doors<br>2012 NEW<br>Exit access doors and exit doors are of the swinging type and are at least<br>41.5 inches in clear width. In psychiatric hospitals or limited care facilities,<br>doors are at least 32 inches wide. Doors not subject to patient use, in exit<br>stairway enclosures, or serving newborn nurseries shall be no less than 32<br>inches in clear width. If using a pair of doors, the doors shall be provided<br>with a rabbet, bevel, or astragal at the meeting edge, at least one of the<br>doors shall provide 32 inches in clear width, and the inactive leaf of the pair<br>shall be secured with automatic flush bolts.<br>18.2.3.6, 18.2.3.7

  • K241 Number of Exits – Story and Compartment<br>Not less than two exits, remote from each other, and accessible from every<br>part of every story are provided for each story. Each smoke compartment<br>shall likewise be provided with two distinct egress paths to exits that do not<br>require the entry into the same adjacent smoke compartment.<br>18.2.4.1-18.2.4.4, 19.2.4.1-19.2.4.4

  • K251 2012 NEW<br>Dead-end corridors shall not exceed 30 feet. Common path of travel shall<br>not exceed 100 feet.<br>18.2.5.2, 18.2.5.3

  • K252 Number of Exits – Corridors<br>Every corridor shall provide access to not less than two approved exits in<br>accordance with Sections 7.4 and 7.5 without passing through any<br>intervening rooms or spaces other than corridors or lobbies.<br>18.2.5.4, 19.2.5.4

  • K253 Number of Exits – Patient Sleeping and Non-Sleeping Rooms<br>Patient sleeping rooms of more than 1,000 square feet or nonsleeping<br>rooms of more than 2,500 square feet have at least two exit access doors<br>remotely located from each other.<br>18.2.5.5.1, 18.2.5.5.2, 19.2.5.5.1, 19.2.5.5.2

  • K254 Corridor Access<br>All habitable rooms not within suites have a door leading directly outside to<br>grade or have a door leading to an exit access corridor. Patient sleeping<br>rooms with less than eight patient beds may have one room intervening to<br>reach an exit access corridor provided the intervening room is equipped<br>with an approved automatic smoke detection system.<br>18.2.5.6.1 through 18.2.5.6.4, 19.2.5.6.1 through 19.2.5.6.4

  • K255 Suite Separation, Hazardous Content, and Subdivision<br>All suites are separated from the remainder of the building (including from<br>other suites) by construction meeting the separation provisions for corridor<br>construction (18.3.6.2-18.3.6.5 or 19.3.6.2-19.3.6.5). Existing approved<br>barriers shall be allowed to continue to be used provided they limit the<br>transfer of smoke. Intervening rooms have no hazardous areas and<br>hazardous areas within suites comply with 18/19.2.5.7.1.3. Subdivision of<br>suites shall be by noncombustible or limited-combustible construction.<br>18.2.5.7.1.2 through 18.2.5.7.1.4, 19.2.5.7.1.2, 19.2.5.7.1.3, 19.2.5.7.1.4

  • K256 Sleeping Suites<br>Occupants shall have exit access to a corridor or direct access to a<br>horizontal exit. Where ≥ 2 exits are required, one exit access door may be<br>to a stairway, passageway or to the exterior. Suites shall be provided with<br>constant staff supervision. Staff shall have direct visual supervision of<br>patient sleeping rooms, from a constantly attended location or the room<br>shall be provided with an automatic smoke detection system.<br>Suites more than 1,000 ft² shall have 2 or more remote exits. One means of<br>egress from the suite shall be to a corridor and one may be into an adjacent<br>suite separated in accordance with corridor requirements.<br>Suites shall not exceed the following size limitations:<br>• 5,000 square feet if the suite is not fully smoke detected or fully<br>sprinklered.<br>• 7,500 square feet if the suite is either fully smoke detected or fully<br>sprinklered.<br>• 10,000 square feet if the suite is both fully smoke detected and fully<br>sprinklered and the sleeping rooms have direct supervision from a<br>constantly attended location.<br>Travel distance between any point in a suite to exit access shall not exceed<br>100 feet and distance to an exit shall not exceed 150 feet (200 feet if<br>building is fully sprinklered).<br>18.2.5.7.2, 19.2.5.7.2

  • K257 Non-Sleeping Suites<br>Occupants shall have exit access to a corridor or direct access to a<br>horizontal exit. Where ≥ 2 exits are required, one exit access door may be<br>to a stairway, passageway or to the exterior.<br>Suites more than 2,500 ft² shall have 2 or more remote exits. One means of<br>egress from the suite shall be to a corridor and one may be into an adjacent<br>suite separated in accordance with corridor requirements.<br>Suites shall not exceed 10,000 ft².<br>Travel distance between any point in a suite to exit access shall not exceed<br>100 feet and distance to an exit shall not exceed 150 feet (200 feet if<br>building is fully sprinklered).<br>18.2.5.7.3, 19.2.5.7.3

  • K261 Travel Distance to Exits<br>Travel distance (excluding suites) to exits are measured in accordance with<br>7.6.<br>• From any point in the room or suite to exit less than or equal to 150<br>feet (less than or equal to 200 feet if the building is fully<br>sprinklered).<br>• Point in a room to room door less than or equal to 50 feet.<br>18.2.6, 19.2.6

  • K271 Discharge from Exits<br>Exit discharge is arranged in accordance with 7.7, provides a level walking<br>surface meeting the provisions of 7.1.7 with respect to changes in elevation<br>and shall be maintained free of obstructions. Additionally, the exit<br>discharge shall be a hard packed all-weather travel surface.<br>18.2.7, 19.2.7

  • K281 Illumination of Means of Egress<br>Illumination of means of egress, including exit discharge, is arranged in<br>accordance with 7.8 and shall be either continuously in operation or<br>capable of automatic operation without manual intervention.<br>18.2.8, 19.2.8

  • K291 Emergency Lighting<br>Emergency lighting of at least 1-1/2 hour duration is provided automatically<br>in accordance with 7.9.<br>18.2.9.1, 19.2.9.1 <br>

  • K292 Life Support Means of Egress<br>2012 NEW (INDICATE N/A FOR EXISTING)<br>Buildings equipped with or requiring the use of life support systems (electromechanical or inhalation anesthetics) have illumination of means of egress,<br>emergency lighting equipment, exit, and directional signs supplied by the<br>life safety branch of the electrical system described in NFPA 99.<br>(Indicate N/A if life support equipment is for emergency purposes only.)<br>18.2.9.2, 18.2.10.5

  • K293 2012 NEW<br>Exit and directional signs are displayed in accordance with 7.10 with<br>continuous illumination also served by the emergency lighting system.<br>18.2.10.1

SECTION 3: PROTECTION

  • K300 Protection – Other<br>List in the REMARKS section any LSC Section 18.3 and 19.3 Protection<br>requirements that are not addressed by the provided K-tags, but are<br>deficient. This information, along with the applicable Life Safety Code or<br>NFPA standard citation, should be included on Form CMS-2567.

  • K311 2012 NEW<br>Stairways, elevator shafts, light and ventilation shafts, chutes, and other<br>vertical openings between floors are enclosed with construction having a<br>fire resistance rating of at least 2 hours connecting four or more stories. (1-<br>hour for single story building and buildings up to three stories in height.) An<br>atrium may be used in accordance with 8.6.7.<br>18.3.1 through 18.3.1.5

  • K321 2012 NEW<br>Hazardous areas are protected in accordance with 18.3.2.1. The areas<br>shall be enclosed with a 1-hour fire-rated barrier, with a ¾ hour fire-rated<br>door without windows (in accordance with 8.7.1.1). Doors shall be selfclosing or automatic-closing in accordance with 7.2.1.8. Hazardous areas<br>are protected by a sprinkler system in accordance with 9.7, 18.3.2.1, and<br>8.4.<br>Describe the floor and zone locations of hazardous areas that are deficient<br>in REMARKS.<br>18.3.2.1, 7.2.1.8, 8.4, 8.7, 9.7

Area

  • a. Boiler and Fuel-Fired Heater Rooms

  • b. Laundries (larger than 100 sq. ft.)

  • c. Repair, Maintenance, and Paint Shops

  • d. Soiled Linen Rooms (exceeding 64 gal.)

  • e. Trash Collection Rooms (exceeding 64 gal.)

  • f. Combustible Storage Rooms/Spaces (over 50 and less than 100 sq. ft.)

  • g. Combustible Storage Rooms/Spaces (over 100 sq. ft.)

  • h. Laboratories (if classified as Severe Hazard - see K322)

  • K322 Laboratories<br>Laboratories employing quantities of flammable, combustible, or<br>hazardous materials that are considered a severe hazard are protected by<br>1-hour fire resistance-rated separation, automatic sprinkler system, and<br>are in accordance with 8.7 and with NFPA 99.<br>Laboratories not considered a severe hazard are protected as hazardous<br>areas (see K321).<br>Laboratories using chemicals are in accordance with NFPA 45, Standard<br>on Fire Protection for Laboratories Using Chemicals.<br>Gas appliances are of appropriate design and installed in accordance with<br>NFPA 54. Shutoff valves are marked to identify material they control.<br>Devices requiring medical grade oxygen from the piped distribution system<br>meet the requirements under 11.4.2.2 (NFPA 99).<br>18.3.2.2, 19.3.2.2, 8.7, 8.7.4.1 (LSC)<br>9.3.1.2, 11.4.3.2, 15.4 (NFPA 99)

  • K323 Anesthetizing Locations<br>Areas designated for administration of general anesthesia (i.e., inhalation<br>anesthetics) are in accordance with 8.7 and NFPA 99.<br>Zone valves are: located immediately outside each life-support, critical<br>care, and anesthetizing location of moderate sedation, deep sedation, or<br>general anesthesia for medical gas or vacuum; readily accessible in an<br>emergency; and arranged so shutting off any one anesthetizing location will<br>not affect others.<br>Area alarm panels are provided to monitor all medical gas, medicalsurgical vacuum, and piped WAGD systems. Panels are at locations that<br>provide for surveillance, indicate medical gas pressure decreases of 20<br>percent and vacuum decreases of 12 inch gauge HgV, and provide visual<br>and audible indication. Alarm sensors are installed either on the source<br>side of individual room zone valve box assemblies or on the patient/use<br>side of each of the individual zone box valve assemblies.<br>The EES critical branch supplies power for task illumination, fixed<br>equipment, select receptacles, and select power circuits, and EES<br>equipment system supplies power to ventilation system.<br>Heating, cooling, and ventilation are in accordance with ASHRAE 170.<br>Medical supply and equipment manufacturer’s instructions for use are<br>considered before reducing humidity levels to those allowed by ASHRAE,<br>per S&C 13-58.<br>18.3.2.3, 19.3.2.3 (LSC)<br>5.1.4.8.7, 5.1.4.8.7.2, 5.1.9.3, 5.1.9.3.4, 6.4.2.2.4.2 (NFPA 99)

  • K324 Cooking Facilities<br>Cooking equipment is protected in accordance with NFPA 96, Standard for<br>Ventilation Control and Fire Protection of Commercial Cooking Operations,<br>unless:<br>• residential cooking equipment (i.e., small appliances such as<br>microwaves, hot plates, toasters) are used for food warming or limited<br>cooking in accordance with 18.3.2.5.2, 19.3.2.5.2.<br>• cooking facilities open to the corridor in smoke compartments with 30 or<br>fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3,<br>or<br>• cooking facilities in smoke compartments with 30 or fewer patients<br>comply with conditions under 18.3.2.5.4, 19.3.2.5.4.<br>Cooking facilities protected according to NFPA 96 per 9.2.3 are not required<br>to be enclosed as hazardous areas, but shall not be open to the corridor.<br><br>18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

  • K325 Alcohol Based Hand Rub Dispenser (ABHR)<br>ABHRs are protected in accordance with 8.7.3.1, unless all conditions are<br>met:<br>• Corridor is at least 6 feet wide.<br>• Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in<br>suites) of fluid and 18 ounces of Level 1 aerosols.<br>• Dispensers shall have a minimum of four foot horizontal spacing.<br>• Not more than an aggregate of 10 gallons of fluid or 1135 ounces of<br>aerosol are used in a single smoke compartment outside a storage<br>cabinet, excluding one individual dispenser per room.<br>• Storage in a single smoke compartment greater than 5 gallons complies<br>with NFPA 30.<br>• Dispensers are not installed within 1 inch of an ignition source.<br>• Dispensers over carpeted floors are in sprinklered smoke<br>compartments.<br>• ABHR does not exceed 95 percent alcohol.<br>• Operation of the dispenser shall comply with Section 18.3.2.6(11) or<br>19.3.2.6(11).<br>• ABHR is protected against inappropriate access.<br>18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485

  • K331 2012 NEW<br>Interior wall and ceiling finishes, including exposed interior surfaces of<br>buildings such as fixed or movable walls, partitions and columns have a<br>flame spread rating of Class A. The reduction in class of interior finish for a<br>sprinkler system as prescribed in 10.2.8.1 is permitted.<br>Individual rooms not exceeding four persons may have a Class A or B<br>finish.<br>Lower half of corridor walls, not exceeding 4 feet in height, may have a<br>Class A or B flame spread rating.<br>10.2, 18.3.3.1, 18.3.3.2

  • Indicate flame spread rating(s)

  • K332 Interior Floor Finish<br>2012 NEW (Indicate N/A for 2012 EXISTING)<br>Interior finishes shall comply with 10.2. Floor finishes in exit enclosures and<br>exit access corridors and spaces not separated by walls that resist the<br>passage of smoke shall be Class I or II.<br>18.3.3.3.1, 18.3.3.3.2, 18.3.3.3.3, 10.2, 10.2.7.1, 10.2.7.2

  • K341 Fire Alarm System – Installation<br>A fire alarm system is installed with systems and components approved for<br>the purpose in accordance with NFPA 70, National Electric Code, and<br>NFPA 72, National Fire Alarm Code to provide effective warning of fire in<br>any part of the building. In areas not continuously occupied, detection is<br>installed at each fire alarm control unit. In new occupancy, detection is also<br>installed at notification appliance circuit power extenders, and supervising<br>station transmitting equipment. Fire alarm system wiring or other<br>transmission paths are monitored for integrity.<br>18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8

  • K342 Fire Alarm System – Initiation<br>Initiation of the fire alarm system is by manual means and by any required<br>sprinkler system alarm, detection device, or detection system. Manual<br>alarm boxes are provided in the path of egress near each required exit.<br>Manual alarm boxes in patient sleeping areas shall not be required at exits<br>if manual alarm boxes are located at all nurse’s stations or other<br>continuously attended staff location, provided alarm boxes are visible,<br>continuously accessible, and 200’ travel distance is not exceeded.<br>18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5

  • K343 2012 NEW<br>Positive alarm sequence in accordance with 9.6.3.4 are permitted.<br>Occupant notification is provided automatically in accordance with 9.6.3 by<br>audible and visual signals.<br>In critical care areas, visual alarms are sufficient. The fire alarm system<br>transmits the alarm automatically to notify emergency forces in the event of<br>a fire.<br>Annunciation and annunciation zoning for fire alarm and sprinklers shall be<br>provided by audible and visual indicators and zones shall not be larger than<br>22,500 square feet per zone.<br>18.3.4.3 through 18.3.4.3.3, 9.6.4

  • K344 Fire Alarm – Control Functions<br>The fire alarm automatically activates required control functions and is<br>provided with an alternative power supply in accordance with NFPA 72.<br>18.3.4.4, 19.3.4.4, 9.6.1, 9.6.5, NFPA 72

  • K345 Fire Alarm System – Testing and Maintenance<br>A fire alarm system is tested and maintained in accordance with an<br>approved program complying with the requirements of NFPA 70, National<br>Electric Code, and NFPA 72, National Fire Alarm and Signaling Code.<br>Records of system acceptance, maintenance and testing are readily<br>available.<br>9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

  • K346 Fire Alarm – Out of Service<br>Where required fire alarm system is out of services for more than 4 hours in<br>a 24 hour period, the authority having jurisdiction shall be notified, and the<br>building shall be evacuated or an approved fire watch shall be provided for<br>all parties left unprotected by the shutdown until the fire alarm system has<br>been returned to service.<br>9.6.1.6

  • K347 2012 NEW<br>Smoke detection systems are provided in spaces open to corridors as<br>required by 18.3.6.1<br>In nursing homes, an automatic smoke detection system is installed in the<br>corridors of all smoke compartments containing resident sleeping rooms,<br>unless the resident sleeping rooms have:<br>• smoke detection, or<br>• automatic door closing devices with integral smoke detectors on the<br>room side that provide occupant notification.<br>Such detectors are electrically interconnected to the fire alarm system.<br>18.3.4.5.2, 18.3.4.5.3

  • K351 2012 NEW<br>Buildings are to be protected throughout by an approved automatic<br>sprinkler system in accordance with NFPA 13, Standard for the Installation<br>of Sprinkler Systems.<br>In Type I and II construction, alternative protection measures are permitted<br>to be substituted for sprinkler protection in specific areas where State and<br>local regulations prohibit sprinklers.<br>Listed quick-response or listed residential sprinklers are used throughout<br>smoke compartments with patient sleeping rooms.<br>In hospitals, sprinklers are not required in clothes closets of patient sleeping<br>rooms where the area of the closet does not exceed 6 ft² and sprinkler<br>coverage covers the closet footprint as required by NFPA 13, Standard for<br>Installation of Sprinkler Systems.<br>18.3.5.1, 18.3.5.4, 18.3.5.5, 18.3.5.6, 9.7, 9.7.1.1(1), 18.3.5.10 <br>

  • K352 Sprinkler System – Supervisory Signals<br>Automatic sprinkler system supervisory attachments are installed and<br>monitored for integrity in accordance with NFPA 72, National Fire Alarm<br>and Signaling Code, and provide a signal that sounds and is displayed at a<br>continuously attended location or approved remote facility when sprinkler<br>operation is impaired.<br>9.7.2.1, NFPA 72

  • K353 Sprinkler System – Maintenance and Testing<br>Automatic sprinkler and standpipe systems are inspected, tested, and<br>maintained in accordance with NFPA 25, Standard for the Inspection,<br>Testing, and Maintaining of Water-based Fire Protection Systems. Records<br>of system design, maintenance, inspection and testing are maintained in a<br>secure location and readily available. <br><br>Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.<br>9.7.5, 9.7.7, 9.7.8, and NFPA 25

  • a) Date sprinkler system last checked.

  • b) Who provided system test

  • c) Water system supply source.

  • K354 Sprinkler System – Out of Service<br>Where the sprinkler system is impaired, the extent and duration of the<br>impairment has been determined, areas or buildings involved are inspected<br>and risks are determined, recommendations are submitted to management<br>or designated representative, and the fire department and other authorities<br>having jurisdiction have been notified. Where the sprinkler system is out of<br>service for more than 10 hours in a 24 hour period, the building or portion of<br>the building affected are evacuated or an approved fire watch is provided<br>until the sprinkler system has been returned to service.<br>18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25) <br>

  • K355 Portable Fire Extinguishers<br>Portable fire extinguishers are selected, installed, inspected, and<br>maintained in accordance with NFPA 10, Standard for Portable Fire<br>Extinguishers.<br>18.3.5.12, 19.3.5.12, NFPA 10

  • K361 Corridors – Areas Open to Corridor<br>Spaces (other than patient sleeping rooms, treatment rooms and hazardous<br>areas), waiting areas, nurse’s stations, gift shops, and cooking facilities,<br>open to the corridor are in accordance with the criteria under 18.3.6.1 and<br>19.3.6.1.<br>18.3.6.1, 19.3.6.1

  • K362 2012 NEW<br>Corridor walls shall form a barrier to limit the transfer of smoke. Such walls<br>shall be permitted to terminate at the ceiling where the ceiling is constructed<br>to limit the transfer of smoke. No fire resistance rating is required for the<br>corridor walls.<br>18.3.6.2

  • K363 2012 NEW<br>Doors protecting corridor openings shall be constructed to resist the<br>passage of smoke. Corridor doors and doors to rooms containing<br>flammable or combustible materials have self-latching and positive latching<br>hardware. Roller latches are prohibited by CMS regulation. These<br>requirements do not apply to auxiliary spaces that do not contain<br>flammable or combustible material.<br>Powered doors complying with 7.2.1.9 are permissible if provided with a<br>device capable of keeping the door closed when a force of 5lbf is applied,<br>whether or not power is applied.<br>Clearance between bottom of door and floor covering is not exceeding 1<br>inch. There is no impediment to the closing of the doors. Hold open<br>devices that release when the door is pushed or pulled are permitted.<br>Nonrated protective plates of unlimited height are permitted. Dutch doors<br>meeting 18.3.6.3.6 are permitted.<br>18.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485<br>Show in REMARKS details of doors such as fire protection ratings,<br>automatic closing devices, etc.

  • K364 Corridor – Openings<br>Transfer grilles are not used in corridor walls or doors. Auxiliary spaces<br>that do not contain flammable or combustible materials are permitted to<br>have louvers or be undercut.<br>In other than smoke compartments containing patient sleeping rooms,<br>miscellaneous openings are permitted in vision panels or doors, provided<br>the openings per room do not exceed 20 in² and are at or below half the<br>distance from floor to ceiling. In sprinklered rooms, the openings per room<br>do not exceed 80 in².<br>Vision panels in corridor walls or doors shall be fixed window assemblies in<br>approved frames. (In fully sprinklered smoke compartments, there are no<br>restrictions in the area and fire resistance of glass and frames.)<br>18.3.6.5.1, 19.3.6.5.2, 8.3

  • K371 2012 NEW<br>Smoke barriers shall be provided to form at least two smoke compartments<br>on every floor used by inpatients for sleeping or treatment, and on every<br>floor with an occupant load of 50 or more persons, regardless of use.<br>Size of compartments cannot exceed 22,500 square feet or a 200-foot<br>travel distance from any point in the compartment to a door in the smoke<br>barrier.<br>Smoke subdivision requirements do not apply to any of the stories or areas<br>described in 18.3.7.2.<br>18.3.7.1, 18.3.7.2<br>Detail in REMARKS zone dimensions including length of zones and deadend corridors.

  • K372 2012 NEW<br>Smoke barriers shall be constructed to provide at least a 1-hour fire<br>resistance rating and constructed in accordance with 8.5. Smoke barriers<br>shall be permitted to terminate at an atrium wall. Smoke dampers are not<br>required in duct penetrations of fully ducted HVAC systems.<br>18.3.7.3, 18.3.7.4, 18.3.7.5, 8.3<br>Describe any mechanical smoke control system in REMARKS.

  • K373 Subdivision of Building Spaces – Accumulation Space<br>Space shall be provided on each side of smoke barriers to adequately<br>accommodate the total number of occupants in adjoining compartments.<br>18.3.7.5.1, 18.3.7.5.2, 19.3.7.5.1, 19.3.7.5.2

  • K374 2012 NEW<br>Doors in smoke barriers have at least a 20-minute fire protection rating or<br>are at least 1¾-inch thick solid bonded core wood.<br>Required clear widths are provided per 18.3.7.6(4) and (5).<br>Nonrated protective plates of unlimited height are permitted. Horizontalsliding doors comply with 7.2.1.14. Swinging doors shall be arranged so<br>that each door swings in an opposite direction.<br>Doors shall be self-closing and rabbets, bevels, or astragals are required at<br>the meeting edges. Positive latching is not required.<br>18.3.7.6, 18.3.7.7, 18.3.7.8

  • K379 2012 NEW<br>Windows in smoke barrier doors shall be installed in each cross corridor<br>swinging or horizontal-sliding door protected by fire-rated glazing or by<br>wired glass panels in approved frames.<br>18.3.7.9

  • K381 Sleeping Room Outside Windows and Doors<br>Every patient sleeping room has an outside window or outside door. In new<br>occupancies, sill height does not exceed 36 inches above the<br>floor. Windows in atrium walls are considered outside windows. Newborn<br>nurseries and rooms intended for occupancy less than 24 hours have no<br>outside window or door requirements. Window sills in special nursing care<br>areas (e.g., ICU, CCU, hemodialysis, neonatal) do not exceed 60 inches<br>above the floor.<br>42 CFR 403, 418, 460, 482, 483, and 485

SECTION 4: SPECIAL PROVISIONS

  • K400 Special Provisions – Other<br>List in the REMARKS section any LSC Section 18.4 and 19.4 Special<br>Provisions requirements that are not addressed by the provided K-tags, but<br>are deficient. This information, along with the applicable Life Safety Code or<br>NFPA standard citation, should be included on Form CMS-2567.

  • K421 2012 NEW<br>High-rise buildings comply with section 11.8.<br>18.4.2

SECTION 5: BUILDING SERVICES

  • K500 Building Services – Other<br>List in the REMARKS section any LSC Section 18.5 and 19.5 Building<br>Services requirements that are not addressed by the provided K-tags, but<br>are deficient. This information, along with the applicable Life Safety Code or<br>NFPA standard citation, should be included on Form CMS-2567.

  • K511 Utilities – Gas and Electric<br>Equipment using gas or related gas piping complies with NFPA 54, National<br>Fuel Gas Code, electrical wiring and equipment complies with NFPA 70,<br>National Electric Code. Existing installations can continue in service<br>provided no hazard to life.<br>18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2

  • K521 HVAC<br>Heating, ventilation, and air conditioning shall comply with 9.2 and shall be<br>installed in accordance with the manufacturer’s specifications.<br>18.5.2.1, 19.5.2.1, 9.2

  • K522<br>18.5.2.2, 19.5.2.2<br>HVAC – Any Heating Device<br>Any heating device, other than a central heating plant, is designed and<br>installed so combustible materials cannot be ignited by device, and has a<br>safety feature to stop fuel and shut down equipment if there is excessive<br>temperature or ignition failure. If fuel fired, the device also:<br>• is chimney or vent connected.<br>• takes air for combustion from outside.<br>• provides for a combustion system separate from occupied area<br>atmosphere.

  • K523 HVAC – Suspended Unit Heaters<br>Suspended unit heaters are permitted provided the following are met:<br>• Not located in means of egress or in patient rooms.<br>• Located high enough to be out of reach of people in the area.<br>• Has a safety feature to stop fuel and shut down equipment if there is<br>excessive temperature or ignition failure.<br>18.5.2.3(1), 19.5.2.3(1)

  • K524 HVAC – Direct-Vent Gas Fireplaces<br>Direct-vent gas fireplaces, as defined in NFPA 54, inside of all smoke<br>compartments containing patient sleeping areas comply with the<br>requirements of 18.5.2.3(2), 19.5.2.3(2).<br>18.5.2.3(2), 19.5.2.3(2), NFPA 54

  • K525 HVAC – Solid Fuel-Burning Fireplaces<br>Solid fuel-burning fireplaces are permitted in other than patient sleeping<br>areas provided:<br>• Areas are separated by 1-hour fire resistance construction.<br>• Fireplace complies with 9.2.2.<br>• Fireplace enclosure resists breakage up to 650°F and has heattempered glass.<br>• Room has supervised CO detection per 9.8.<br>18.5.2.3(3) and 19.5.2.3(3)

  • K531 Elevators<br> 2012 NEW<br>Elevators comply with the provision of 9.4. Elevators are inspected and<br>tested as specified in ASME A17.1, Safety Code for Elevators and<br>Escalators. Firefighter’s Service is operated monthly with a written record.<br>New elevators conform to ASME/ANSI A17.1, Safety Code for Elevators<br>and Escalators, including Firefighter’s Service Requirements. (Includes<br>firefighter’s Phase I key recall and smoke detector automatic recall,<br>firefighter’s service Phase II emergency in-car key operation, machine room<br>smoke detectors, and elevator lobby smoke detectors.)<br>18.5.3, 9.4.2, 9.4.3

  • K532 Escalators, dumbwaiters, and moving walks<br>2012 NEW<br>Escalators, dumbwaiters, and moving walks comply with the provisions of<br>9.4.<br>18.5.3, 9.4.2.2

  • K541 2012 NEW<br>Rubbish chutes, incinerators, and laundry chutes shall comply with the<br>provisions of Section 9.5, unless otherwise specified in 18.5.4.2.<br>• The fire resistance rating of chute charging room shall not be required<br>to exceed 1-hour.<br>• Any rubbish chute or linen chute shall be provided with automatic<br>extinguishing protection in accordance with Section 9.7.<br>• Chutes shall discharge into a trash collection room used for no other<br>purpose and shall be protected in accordance with 8.7.<br>18.5.4.2, 8.7, 9.5, 9.7, NFPA 82

SECTION 6: RESERVED

SECTION 7: OPERATING FEATURES

  • K700 Operating Features – Other<br>List in the REMARKS section any LSC Section 18.7 and 19.7 Operating<br>Features requirements that are not addressed by the provided K-tags, but<br>are deficient. This information, along with the applicable Life Safety Code or<br>NFPA standard citation, should be included in Form CMS-2567.

  • K711 Evacuation and Relocation Plan<br>There is a written plan for the protection of all patients and for their<br>evacuation in the event of an emergency.<br>Employees are periodically instructed and kept informed with their duties<br>under the plan, and a copy of the plan is readily available with telephone<br>operator or with security. The plan addresses the basic response required<br>of staff per 18/19.7.2.1.2 and provides for all of the fire safety plan<br>components per 18/19.7.2.2.<br>18.7.1.1 through 18.7.1.3, 18.7.2.1.2, 18.7.2.2, 18.7.2.3, 19.7.1.1 through<br>19.7.1.3, 19.7.2.1.2, 19.7.2.2, 19.7.2.3

  • K712 Fire Drills<br>Fire drills include the transmission of a fire alarm signal and simulation of<br>emergency fire conditions. Fire drills are held at expected and unexpected<br>times under varying conditions, at least quarterly on each shift. The staff is<br>familiar with procedures and is aware that drills are part of established<br>routine. Where drills are conducted between 9:00 PM and 6:00 AM, a<br>coded announcement may be used instead of audible alarms.<br>18.7.1.4 through 18.7.1.7, 19.7.1.4 through 19.7.1.7

  • K741 Smoking Regulations<br>Smoking regulations shall be adopted and shall include not less than the<br>following provisions:<br>(1) Smoking shall be prohibited in any room, ward, or compartment where<br>flammable liquids, combustible gases, or oxygen is used or stored and<br>in any other hazardous location, and such area shall be posted with<br>signs that read NO SMOKING or shall be posted with the international<br>symbol for no smoking.<br>(2) In health care occupancies where smoking is prohibited and signs are<br>prominently placed at all major entrances, secondary signs with<br>language that prohibits smoking shall not be required.<br>(3) Smoking by patients classified as not responsible shall be prohibited.<br>(4) The requirement of 18.7.4(3) shall not apply where the patient is under<br>direct supervision.<br>(5) Ashtrays of noncombustible material and safe design shall be provided<br>in all areas where smoking is permitted.<br>(6) Metal containers with self-closing cover devices into which ashtrays can<br>be emptied shall be readily available to all areas where smoking is<br>permitted.<br>18.7.4, 19.7.4

  • K751 Draperies, Curtains, and Loosely Hanging Fabrics<br>Draperies, curtains including cubicle curtains and loosely hanging fabric or<br>films shall be in accordance with 10.3.1. Excluding curtains and draperies:<br>at showers and baths; on windows in patient sleeping room located in<br>sprinklered compartments; and in non-patient sleeping rooms in sprinklered<br>compartments where individual drapery or curtain panels do not exceed 48<br>square feet or total area does not exceed 20 percent of the wall.<br>18.7.5.1, 18.3.5.11, 19.7.5.1, 19.3.5.11, 10.3.1 <br>

  • K752 Upholstered Furniture and Mattresses<br>Newly introduced upholstered furniture meets Class I or char length, and<br>heat release criteria in accordance with 10.3.2.1 and 10.3.3, unless the<br>building is fully sprinklered.<br>Newly introduced mattresses shall meet char length and heat release<br>criteria in accordance with 10.3.2.2 and 10.3.4, unless the building is fully<br>sprinklered.<br>Upholstered furniture and mattresses belonging to nursing home<br>residents do not have to meet these requirements as all nursing homes<br>are required to be fully sprinklered.<br>Newly introduced upholstered furniture and mattresses means purchased<br>on or after the LSC final rule effective date.<br>18.7.5.2, 18.7.5.4, 19.7.5.2, 19.7.5.4

  • K753 Combustible Decorations<br>Combustible decorations shall be prohibited unless one of the following is met:<br>• Flame retardant or treated with approved fire-retardant coating that is<br>listed and labeled for product.<br>• Decorations meet NFPA 701.<br>• Decorations exhibit heat release less than 100 kilowatts in accordance<br>with NFPA 289.<br>• Decorations, such as photographs, paintings and other art are attached<br>to the walls, ceilings and non-fire-rated doors in accordance with<br>18.7.5.6(4) or 19.7.5.6(4).<br>• The decorations in existing occupancies are in such limited quantities<br>that a hazard of fire development or spread is not present.<br>18.7.5.6, 19.7.5.6

  • K761 Maintenance, Inspection & Testing - Doors<br>Fire doors assemblies are inspected and tested annually in accordance<br>with NFPA 80 Standard for Fire Doors and Other Opening Protectives.<br>Fire doors that are not located in required fire barriers, including corridor<br>doors to patient rooms and smoke barrier doors, are routinely inspected as<br>part of the facility maintenance program.<br>Individuals performing the door inspection and testing have an<br>understanding of the operating components of the doors. Written records of<br>inspection and testing are maintained and are available for review.<br>18.7.6, 19.7.6, 8.3.3.1 (LSC), 5.2, 5.2.3 (NFPA 80)

  • K754 Soiled Linen and Trash Containers<br>Soiled linen or trash collection receptacles shall not exceed 32 gallons in<br>capacity. The average density of container capacity in a room or space<br>shall not exceed 0.5 gallons/square feet. A total container capacity of 32<br>gallons shall not be exceeded within any 64 square feet area. Mobile soiled<br>linen or trash collection receptacles with capacities greater than 32 gallons<br>shall be located in a room protected as a hazardous area when not<br>attended.<br>Containers used solely for recycling are permitted to be excluded from the<br>above requirements where each container is ≤ 96 gal. unless attended, and<br>containers for combustibles are labeled and listed as meeting FM Approval<br>Standard 6921 or equivalent.<br>18.7.5.7, 19.7.5.7 <br>

  • K771 Engineer Smoke Control Systems<br>2012 NEW<br>When installed, engineered smoke control systems are tested in<br>accordance with NFPA 92, Standard for Smoke Control Systems. Test<br>documentation is maintained on the premises.<br>18.7.7 <br>

  • K781 Portable Space Heaters<br>Portable space heating devices shall be prohibited in all health care<br>occupancies. Unless used in nonsleeping staff and employee areas where<br>the heating elements do not exceed 212 degrees Fahrenheit (100 degrees<br>Celsius).<br>18.7.8, 19.7.8

  • K791 Construction, Repair, and Improvement Operations<br>Construction, repair, and improvement operations shall comply with 4.6.10.<br>Any means of egress in any area undergoing construction, repair, or<br>improvements shall be inspected daily to ensure its ability to be used<br>instantly in case of emergency and compliance with NFPA 241.<br>18.7.9, 19.7.9, 4.6.10, 7.1.10.1

PART II - HEALTH CARE FACILITIES CODE REQUIREMENTS

PART II

  • K900 Health Care Facilities Code - Other<br>List in the REMARKS section any NFPA 99 requirements (excluding<br>Chapter 7, 8, 12, and 13) that are not addressed by the provided K-Tags,<br>but are deficient. This information, along with the applicable Health Care<br>Facilities Code or NFPA standard citation, should be included on Form<br>CMS-2567.

  • K901 Fundamentals – Building System Categories<br>Building systems are designed to meet Category 1 through 4 requirements<br>as detailed in NFPA 99. Categories are determined by a formal and<br>documented risk assessment procedure performed by qualified personnel.<br>Chapter 4 (NFPA 99)

  • K902 Gas and Vacuum Piped Systems – Other<br>List in the REMARKS section any NFPA 99 Chapter 5 Gas and Vacuum<br>Systems requirements that are not addressed by the provided K-Tags, but<br>are deficient. This information, along with the applicable Life Safety Code or<br>NFPA standard citation, should be included on Form CMS-2567.<br>Chapter 5 (NFPA 99)

  • K903 Gas and Vacuum Piped Systems – Categories<br>Medical gas, medical air, surgical vacuum, WAGD, and air supply systems<br>are designated:<br>☐ Category 1. Systems in which failure is likely to cause major injury or death.<br>☐ Category 2. Systems in which failure is likely to cause minor injury.<br>☐ Category 3. Systems in which failure is not likely to cause injury, but can<br>cause discomfort<br><br>Deep sedation and general anesthesia are not to be administered using a<br>Category 3 medical gas system.<br>5.1.1.1, 5.2.1, 5.3.1.1, 5.3.1.5 (NFPA 99)

  • K904 Gas and Vacuum Piped Systems – Warning Systems<br>All master, area, and local alarm systems used for medical gas and vacuum<br>systems comply with appropriate Category warning system requirements,<br>as applicable.<br>5.1.9, 5.2.9, 5.3.6.2.2 (NFPA 99)

  • K905 Gas and Vacuum Piped Systems – Central Supply System<br>Identification and Labeling<br>Containers, cylinders and tanks are designed, fabricated, tested, and<br>marked in accordance with 5.1.3.1.1 through 5.1.3.1.7. Locations<br>containing only oxygen or medical air have doors labeled with "Medical<br>Gases, NO Smoking or Open Flame". Locations containing other gases<br>have doors labeled "Positive Pressure Gases, NO Smoking or Open Flame,<br>Room May Have Insufficient Oxygen, Open Door and Allow Room to<br>Ventilate Before Opening.”<br>5.1.3.1, 5.2.3.1, 5.3.10 (NFPA 99)

  • K906 Gas and Vacuum Piped Systems – Central Supply System Operations<br>Adaptors or conversion fittings are prohibited. Cylinders are handled in<br>accordance with 11.6.2. Only cylinders, reusable shipping containers, and<br>their accessories are stored in rooms containing central supply systems or<br>cylinders. No flammable materials are stored with cylinders. Cryogenic<br>liquid storage units intended to supply the facility are not used to transfill.<br>Cylinders are kept away from sources of heat. Valve protection caps are<br>secured in place, if supplied, unless cylinder is in use. Cylinders are not<br>stored in tightly closed spaces. Cylinders in use and storage are prevented<br>from exceeding 130°F, and nitrous oxide and carbon dioxide cylinders are<br>prevented from reaching temperatures lower than manufacture<br>recommendations or 20°F. Full or empty cylinders, when not connected, are<br>stored in locations complying with 5.1.3.3.2 through 5.1.3.3.3, and are not<br>stored in enclosures containing motor-driven machinery, unless for<br>instrument air reserve headers.<br>5.1.3.2, 5.1.3.3.17, 5.1.3.3.1.8, 5.1.3.3.4, 5.2.3.2, 5.2.3.3, 5.3.6.20.4,<br>5.6.20.5, 5.3.6.20.7, 5.3.6.20.8, 5.3.6.20.9 (NFPA 99)

  • K907 Gas and Vacuum Piped Systems – Maintenance Program<br>Medical gas, vacuum, WAGD, or support gas systems have documented<br>maintenance programs. The program includes an inventory of all source<br>systems, control valves, alarms, manufactured assemblies, and outlets.<br>Inspection and maintenance schedules are established through risk<br>assessment considering manufacturer recommendations. Inspection<br>procedures and testing methods are established through risk assessment.<br>Persons maintaining systems are qualified as demonstrated by training and<br>certification or credentialing to the requirements of AASE 6030 or 6040.<br>5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99)

  • K908 Gas and Vacuum Piped Systems – Inspection and Testing Operations<br>The gas and vacuum systems are inspected and tested as part of a<br>maintenance program and include the required elements. Records of the<br>inspections and testing are maintained as required.<br>5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99) <br>

  • K909 Gas and Vacuum Piped Systems – Information and Warning Signs<br>Piping is labeled by stencil or adhesive markers identifying the gas or<br>vacuum system, including the name of system or chemical symbol, color<br>code (Table 5.1.11), and operating pressure if other than standard. Labels<br>are at intervals not more than 20 feet, are in every room, at both sides of<br>wall penetrations, and on every story traversed by riser. Piping is not<br>painted. Shutoff valves are identified with the name or chemical symbol of<br>the gas or vacuum system, room or area served, and caution to not use the<br>valve except in emergency.<br>5.1.14.3, 5.1.11.1, 5.1.11.2, 5.2.11, 5.3.13.3, 5.3.11 (NFPA 99)

  • K910 Gas and Vacuum Piped Systems – Modifications<br>Whenever modifications are made that breach the pipeline, any necessary<br>installer and verification test specified in 5.1.2 is conducted on the<br>downstream portion of the medical gas piping system. Permanent records<br>of all tests required by system verification tests are maintained.<br>5.1.14.4.1, 5.1.14.4.6, 5.2.13, 5.3.13.4.3 (NFPA 99)

  • K911 Electrical Systems – Other<br>List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems<br>requirements that are not addressed by the provided K-Tags, but are<br>deficient. This information, along with the applicable Life Safety Code or<br>NFPA standard citation, should be included on Form CMS-2567.<br>Chapter 6 (NFPA 99)

  • K912 Electrical Systems – Receptacles<br>Power receptacles have at least one, separate, highly dependable<br>grounding pole capable of maintaining low-contact resistance with its<br>mating plug. In pediatric locations, receptacles in patient rooms,<br>bathrooms, play rooms, and activity rooms, other than nurseries, are listed<br>tamper-resistant or employ a listed cover.<br>If used in patient care room, ground-fault circuit interrupters (GFCI) are<br>listed.<br>6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)

  • K913 Electrical Systems – Wet Procedure Locations<br>Operating rooms are considered wet procedure locations, unless otherwise<br>determined by a risk assessment conducted by the facility governing body.<br>Operating rooms defined as wet locations are protected by either isolated<br>power or ground-fault circuit interrupters. A written record of the risk<br>assessment is maintained and available for inspection.<br>6.3.2.2.8.4, 6.3.2.2.8.7, 6.4.4.2

  • K914 Electrical Systems – Maintenance and Testing<br>Hospital-grade receptacles at patient bed locations and where deep<br>sedation or general anesthesia is administered, are tested after initial<br>installation, replacement or servicing. Additional testing is performed at<br>intervals defined by documented performance data. Receptacles not listed<br>as hospital-grade at these locations are tested at intervals not exceeding 12<br>months. Line isolation monitors (LIM), if installed, are tested at intervals of<br>≤ 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates<br>both visual and audible alarm. For LIM circuits with automated self-testing,<br>this manual test is performed at intervals ≤ 12 months. LIM circuits are<br>tested per 6.3.3.3.2 after any repair or renovation to the electric distribution<br>system. Records are maintained of required tests and associated repairs or<br>modifications, containing date, room or area tested, and results.<br>6.3.4 (NFPA 99)

  • K915 Electrical Systems – Essential Electric System Categories<br>☐ Critical care rooms (Category 1) in which electrical system failure is likely<br>to cause major injury or death of patients, including all rooms where electric<br>life support equipment is required, are served by a Type 1 EES.<br>☐ General care rooms (Category 2) in which electrical system failure is<br>likely to cause minor injury to patients (Category 2) are served by a Type 1<br>or Type 2 EES.<br>☐ Basic care rooms (Category 3) in which electrical system failure is not<br>likely to cause injury to patients and rooms other than patient care rooms<br>are not required to be served by an EES. Type 3 EES life safety branch has<br>an alternate source of power that will be effective for 1 1/2 hours.<br>3.3.138, 6.3.2.2.10, 6.6.2.2.2, 6.6.3.1.1 (NFPA 99), TIA 12-3

  • K916 Electrical Systems – Essential Electric System Alarm Annunciator<br>A remote annunciator that is storage battery powered is provided to operate<br>outside of the generating room in a location readily observed by operating<br>personnel. The annunciator is hard-wired to indicate alarm conditions of<br>the emergency power source. A centralized computer system (e.g.,<br>building information system) is not to be substituted for the alarm<br>annunciator.<br>6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99)

  • K917 Electrical Systems – Essential Electric System Receptacles<br>Electrical receptacles or cover plates supplied from the life safety and<br>critical branches have a distinctive color or marking.<br>6.4.2.2.6, 6.5.2.2.4.2, 6.6.2.2.3.2 (NFPA 99)

  • K918 Electrical Systems – Essential Electric System Maintenance and<br>Testing<br>The generator or other alternate power source and associated equipment is<br>capable of supplying service within 10 seconds. If the 10-second criterion is<br>not met during the monthly test, a process shall be provided to annually<br>confirm this capability for the life safety and critical branches. Maintenance<br>and testing of the generator and transfer switches are performed in<br>accordance with NFPA 110.<br>Generator sets are inspected weekly, exercised under load 30 minutes 12<br>times a year in 20-40 day intervals, and exercised once every 36 months for<br>4 continuous hours. Scheduled test under load conditions include a<br>complete simulated cold start and automatic or manual transfer of all EES<br>loads, and are conducted by competent personnel. Maintenance and<br>testing of stored energy power sources (Type 3 EES) are in accordance<br>with NFPA 111. Main and feeder circuit breakers are inspected annually,<br>and a program for periodically exercising the components is established<br>according to manufacturer requirements. Written records of maintenance<br>and testing are maintained and readily available. EES electrical panels and<br>circuits are marked, readily identifiable, and separate from normal power<br>circuits. Minimizing the possibility of damage of the emergency power<br>source is a design consideration for new installations.<br>6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

  • K919 Electrical Equipment – Other<br>List in the REMARKS section any NFPA 99 Chapter 10, Electrical<br>Equipment, requirements that are not addressed by the provided K-Tags,<br>but are deficient. This information, along with the applicable Life Safety<br>Code or NFPA standard citation, should be included on Form CMS-2567.<br>Chapter 10 (NFPA 99)

  • K920 Electrical Equipment – Power Cords and Extension Cords<br>Power strips in a patient care vicinity are only used for components of<br>movable patient-care-related electrical equipment (PCREE) assembles that<br>have been assembled by qualified personnel and meet the conditions of<br>10.2.3.6. Power strips in the patient care vicinity may not be used for nonPCREE (e.g., personal electronics), except in long-term care resident<br>rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or<br>UL 60601-1. Power strips for non-PCREE in the patient care rooms<br>(outside of vicinity) meet UL 1363. In non-patient care rooms, power strips<br>meet other UL standards. All power strips are used with general<br>precautions. Extension cords are not used as a substitute for fixed wiring of<br>a structure. Extension cords used temporarily are removed immediately<br>upon completion of the purpose for which it was installed and meets the<br>conditions of 10.2.4.<br>10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA<br>70), TIA 12-5

  • K921 Electrical Equipment – Testing and Maintenance Requirements<br>The physical integrity, resistance, leakage current, and touch current tests<br>for fixed and portable patient-care related electrical equipment (PCREE) is<br>performed as required in 10.3. Testing intervals are established with<br>policies and protocols. All PCREE used in patient care rooms is tested in<br>accordance with 10.3.5.4 or 10.3.6 before being put into service and after<br>any repair or modification. Any system consisting of several electrical<br>appliances demonstrates compliance with NFPA 99 as a complete system.<br>Service manuals, instructions, and procedures provided by the<br>manufacturer include information as required by 10.5.3.1.1 and are<br>considered in the development of a program for electrical equipment<br>maintenance. Electrical equipment instructions and maintenance manuals<br>are readily available, and safety labels and condensed operating<br>instructions on the appliance are legible. A record of electrical equipment<br>tests, repairs, and modifications is maintained for a period of time to<br>demonstrate compliance in accordance with the facility's policy. Personnel<br>responsible for the testing, maintenance and use of electrical appliances<br>receive continuing training.<br>10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8

  • K922 Gas Equipment – Other<br>List in the REMARKS section any NFPA 99 Chapter 11 Gas Equipment<br>requirements that are not addressed by the provided K-Tags, but are<br>deficient. This information, along with the applicable Life Safety Code or<br>NFPA standard citation, should be included on Form CMS-2567.<br>Chapter 11 (NFPA 99)

  • K923 Gas Equipment – Cylinder and Container Storage<br>≥ 3,000 cubic feet<br>Storage locations are designed, constructed, and ventilated in accordance<br>with 5.1.3.3.2 and 5.1.3.3.3.<br>> 300 but <3,000 cubic feet<br>Storage locations are outdoors in an enclosure or within an enclosed<br>interior space of non- or limited- combustible construction, with door (or<br>gates outdoors) that can be secured. Oxidizing gases are not stored with<br>flammables, and are separated from combustibles by 20 feet (5 feet if<br>sprinklered) or enclosed in a cabinet of noncombustible construction having<br>a minimum 1/2 hr. fire protection rating.<br>≤ 300 cubic feet<br>In a single smoke compartment, individual cylinders available for immediate<br>use in patient care areas with an aggregate volume of ≤ 300 cubic feet are<br>not required to be stored in an enclosure. Cylinders must be handled with<br>precautions as specified in 11.6.2.<br>A precautionary sign readable from 5 feet is on each door or gate of a<br>cylinder storage room, where the sign includes the wording as a minimum<br>"CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING".<br>Storage is planned so cylinders are used in order of which they are<br>received from the supplier. Empty cylinders are segregated from full<br>cylinders. When facility employs cylinders with integral pressure gauge, a<br>threshold pressure considered empty is established. Empty cylinders are<br>marked to avoid confusion. Cylinders stored in the open are protected from<br>weather.<br>11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

  • K924 Gas Equipment – Testing and Maintenance Requirements<br>Anesthesia apparatus are tested at the final path to patient after any<br>adjustment, modification or repair. Before the apparatus is returned to<br>service, each connection is checked to verify proper gas and an oxygen<br>analyzer is used to verify oxygen concentration. Defective equipment is<br>immediately removed from service. Areas designated for servicing of<br>oxygen equipment are clean and free of oil, grease, or other flammables.<br>Manufacturer service manuals are used to maintain equipment and a<br>scheduled maintenance program is followed.<br>11.4.1.3, 11.5.1.3, 11.6.2.5, 11.6.2.6 (NFPA 99)

  • K925 Gas Equipment – Respiratory Therapy Sources of Ignition<br>Smoking materials are removed from patients receiving respiratory therapy.<br>When a nasal cannula is delivering oxygen outside of a patient’s room, no<br>sources of ignition are within in the site of intentional expulsion (1-foot).<br>When other oxygen deliver equipment is used or oxygen is delivered inside<br>a patient’s room, no sources of ignition are within the area are of<br>administration (15-feet). Solid fuel-burning appliances is not in the area of<br>administration. Nonmedical appliances with hot surfaces or sparking<br>mechanisms are not within oxygen-delivery equipment or site of intentional<br>expulsion.<br>11.5.1.1, TIA 12-6 (NFPA 99)

  • K926 Gas Equipment – Qualifications and Training of Personnel<br>Personnel concerned with the application, maintenance and handling of<br>medical gases and cylinders are trained on the risk. Facilities provide<br>continuing education, including safety guidelines and usage requirements.<br>Equipment is serviced only by personnel trained in the maintenance and<br>operation of equipment.<br>11.5.2.1 (NFPA 99)

  • K927 Gas Equipment – Transfilling Cylinders<br>Transfilling of oxygen from one cylinder to another is in accordance with<br>CGA P-2.5, Transfilling of High Pressure Gaseous Oxygen Used for<br>Respiration. Transfilling of any gas from one cylinder to another is<br>prohibited in patient care rooms. Transfilling to liquid oxygen containers or<br>to portable containers over 50 psi comply with conditions under 11.5.2.3.1<br>(NFPA 99). Transfilling to liquid oxygen containers or to portable containers<br>under 50 psi comply with conditions under 11.5.2.3.2 (NFPA 99).<br>11.5.2.2 (NFPA 99)

  • K928 Gas Equipment – Labeling Equipment and Cylinders<br>Equipment listed for use in oxygen-enriched atmospheres are so labeled.<br>Oxygen metering equipment and pressure reducing regulators are labeled<br>"OXYGEN-USE NO OIL". Flowmeters, pressure reducing regulators, and<br>oxygen-dispensing apparatus are clearly and permanently labeled<br>designating the gases for which they are intended. Oxygen-metering<br>equipment, pressure reducing regulators, humidifiers, and nebulizers are<br>labeled with name of manufacturer or supplier. Cylinders and containers<br>are labeled in accordance with CGA C-7. Color coding is not utilized as the<br>primary method of determining cylinder or container contents. All labeling is<br>durable and withstands cleaning or disinfecting.<br>11.5.3.1 (NFPA 99)

  • K929 Gas Equipment – Precautions for Handling Oxygen Cylinders and<br>Manifolds<br>Handling of oxygen cylinders and manifolds is based on CGA G-4, Oxygen.<br>Oxygen cylinders, containers, and associated equipment are protected from<br>contact with oil and grease, from contamination, protected from damage,<br>and handled with care in accordance with precautions provided under<br>11.6.2.1 through 11.6.2.4 (NFPA 99).<br>11.6.2 (NFPA 99)

  • K930 Gas Equipment – Liquid Oxygen Equipment<br>The storage and use of liquid oxygen in base reservoir containers and<br>portable containers comply with sections 11.7.2 through 11.7.4 (NFPA 99).<br>11.7 (NFPA 99)

  • K931 Hyperbaric Facilities<br>All occupancies containing hyperbaric facilities comply with construction,<br>equipment, administration, and maintenance requirements of NFPA 99.<br>Chapter 14 (NFPA 99

  • K932 Features of Fire Protection – Other<br>List in the REMARKS section any NFPA 99 Chapter 15 Features of Fire<br>Protection requirements that are not addressed by the provided K-Tags, but<br>are deficient. This information, along with the applicable Life Safety Code or<br>NFPA standard citation, should be included on Form CMS-2567.<br>Chapter 15 (NFPA 99)

  • K933 Features of Fire Protection – Fire Loss Prevention in Operating Rooms<br>Periodic evaluations are made of hazards that could be encountered during<br>surgical procedures, and fire prevention procedures are established. When<br>flammable germicides or antiseptics are employed during surgeries utilizing<br>electrosurgery, cautery or lasers:<br> packaging is non-flammable.<br> applicators are in unit doses.<br> Preoperative "time-out" is conducted prior the initiation of any surgical<br>procedure to verify:<br>o application site is dry prior to draping and use of surgical<br>equipment.<br>o pooling of solution has not occurred or has been corrected.<br>o solution-soaked materials have been removed from the OR prior to<br>draping and use of surgical devices.<br>o policies and procedures are established outlining safety precautions<br>related to the use of flammable germicide or antiseptic use.<br>Procedures are established for operating room emergencies including<br>alarm activation, evacuation, equipment shutdown, and control operations.<br>Emergency procedures include the control of chemical spills, and<br>extinguishment of drapery, clothing and equipment fires. Training is<br>provided to new OR personnel (including surgeons), continuing education is<br>provided, incidents are reviewed monthly, and procedures are reviewed<br>annually.<br>15.13 (NFPA 99)

PART III – RECOMMENDATION FOR WAIVER OF SPECIFIC LIFE SAFETY CODE PROVISIONS

  • For each item of the Life Safety Code recommended for waiver, list the survey report form item number and state the reason for the conclusion that:
    (a) the specific provisions of the code, if rigidly applied, would result in unreasonable hardship on the facility, and (b) the waiver of such unmet
    provisions will not adversely affect the health and safety of the patients. If additional space is required, attach additional sheet(s).

  • PROVISION NUMBER(S)

  • JUSTIFICATION

  • K400

SURVEYOR SIGNOFF

  • Surveyor's Name & Signature

  • Title

  • Office

FIRE SAFETY AUTHORITY OFFICAL SIGNOFF

  • Official's Name & Signature

  • Title

  • Office

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