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
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
deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.

K111 Building Rehabilitation
Repair, Renovation, Modification, or Reconstruction
Any building undergoing repair, renovation, modification, or reconstruction
complies with both of the following:
• Requirements of Chapter 18 and 19.
• Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6.
18.1.1.4.3, 19.1.1.4.3, 43.1.2.1
Change of Use or Change of Occupancy
Any building undergoing change of use or change of occupancy
classification complies with the requirements of Section 43.7, unless
permitted by 18.1.1.4.2 or 19.1.1.4.2.
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)
Additions
Any building undergoing an addition shall comply with the requirements of
Section 43.8. If the building has a common wall with a nonconforming
building, the common wall is a fire barrier having at least a two hour fire
resistance rating constructed of materials as required for the addition.
Communicating openings occur only in corridors and are protected by
approved self-closing fire doors with at least a 1-1/2 hour fire resistance
rating. Additions comply with the requirements of Section 43.8.
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
If a nonsprinklered smoke compartment has undergone major rehabilitation
the automatic sprinkler requirements of 18.3.5 have been applied to the
smoke compartment.
In cases where the building is not protected throughout by a sprinkler
system, the requirements of 18.4.3.2, 18.4.3.3, and 18.4.3.8 are also met.
Note: Major rehabilitation involves the modification of more than 50 percent,
or more than 4500 ft² of the area of the smoke compartment.
18.1.1.4.3.3, 19.1.1.4.3.3

K131 Multiple Occupancies – Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of
the following:
 They are not intended to serve four or more inpatients for purposes of
housing, treatment, or customary access.
• They are separated from areas of health care occupancies by construction having a minimum two hour fire resistance rating in accordance with Chapter 8.
• The entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an Ambulatory Health Care Occupancy regardless of the number of patients served.

18.1.3.3, 19.1.3.3, 42 CFR 482.41, 42 CFR 485.623

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

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

K161 Building Construction Type and Height
2012 NEW
Building construction type and stories meets Table 18.1.6.1, unless
otherwise permitted by 18.1.6.2 through 18.1.6.7
18.1.6.4, 18.1.6.5

Construction Type
1 I (442), I (332), II (222) *Not allowed non-sprinklered - Any number of stories sprinklered
2 II (111) 2 *Not allowed non-sprinklered - Maximum 3 stories sprinklered
3 II (000)
4 III (211)
6 V (111)
*Not allowed non-sprinklered - Maximum 1 story sprinklered 5 IV (2HH)
7 III (200)
8 V (000)
*Not allowed non-sprinklered

Sprinklered stories must be sprinklered throughout by an approved,
supervised automatic system in accordance with section 9.7. (See 18.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories,
including basements, floors on which patients are located, location of smoke or
fire barriers and dates of approval. Complete sketch or attach small floor
plan of the building as appropriate.

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

K163 Interior Nonbearing Wall Construction
Interior nonbearing walls in Type I or II construction are constructed of
noncombustible or limited-combustible materials.
Interior nonbearing walls required to have a minimum 2 hour fire
resistance rating are permitted to be fire-retardant-treated wood enclosed
within noncombustible or limited-combustible materials, provided they are
not used as shaft enclosures.
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
List in the REMARKS section any LSC Section 18.2 and 19.2 Means of
Egress requirements that are not addressed by the provided K-tags, but are
deficient. This information, along with the applicable Life Safety Code or
NFPA standard citation, should be included on Form CMS-2567.
18.2, 19.2

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

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

K222 Egress Doors
Doors in a required means of egress shall not be equipped with a latch or a
lock that requires the use of a tool or key from the egress side unless using
one of the following special locking arrangements:
☐ CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the
patient are used, only one locking device shall be permitted on each door
and provisions shall be made for the rapid removal of occupants by: remote
control of locks; keying of all locks or keys carried by staff at all times; or
other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
☐ SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are
used, all of the Clinical or Security Locking requirements are being met. In
addition, the locks must be electrical locks that fail safely so as to release
upon loss of power to the device; the building is protected by a supervised
automatic sprinkler system and the locked space is protected by a complete
smoke detection system (or is constantly monitored at an attended location
within the locked space); and both the sprinkler and detection systems are
arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4

☐ DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance
with 7.2.1.6.1 shall be permitted on door assemblies serving low and
ordinary hazard contents in buildings protected throughout by an approved,
supervised automatic fire detection system or an approved, supervised
automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
☐ ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with
7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
☐ ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall
be permitted on door assemblies in buildings protected throughout by an
approved, supervised automatic fire detection system and an approved,
supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4

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

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

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

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

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

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

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

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

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

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

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

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

K254 Corridor Access
All habitable rooms not within suites have a door leading directly outside to
grade or have a door leading to an exit access corridor. Patient sleeping
rooms with less than eight patient beds may have one room intervening to
reach an exit access corridor provided the intervening room is equipped
with an approved automatic smoke detection system.
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
All suites are separated from the remainder of the building (including from
other suites) by construction meeting the separation provisions for corridor
construction (18.3.6.2-18.3.6.5 or 19.3.6.2-19.3.6.5). Existing approved
barriers shall be allowed to continue to be used provided they limit the
transfer of smoke. Intervening rooms have no hazardous areas and
hazardous areas within suites comply with 18/19.2.5.7.1.3. Subdivision of
suites shall be by noncombustible or limited-combustible construction.
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
Occupants shall have exit access to a corridor or direct access to a
horizontal exit. Where ≥ 2 exits are required, one exit access door may be
to a stairway, passageway or to the exterior. Suites shall be provided with
constant staff supervision. Staff shall have direct visual supervision of
patient sleeping rooms, from a constantly attended location or the room
shall be provided with an automatic smoke detection system.
Suites more than 1,000 ft² shall have 2 or more remote exits. One means of
egress from the suite shall be to a corridor and one may be into an adjacent
suite separated in accordance with corridor requirements.
Suites shall not exceed the following size limitations:
• 5,000 square feet if the suite is not fully smoke detected or fully
sprinklered.
• 7,500 square feet if the suite is either fully smoke detected or fully
sprinklered.
• 10,000 square feet if the suite is both fully smoke detected and fully
sprinklered and the sleeping rooms have direct supervision from a
constantly attended location.
Travel distance between any point in a suite to exit access shall not exceed
100 feet and distance to an exit shall not exceed 150 feet (200 feet if
building is fully sprinklered).
18.2.5.7.2, 19.2.5.7.2

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

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

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

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

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

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

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

SECTION 3: PROTECTION

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

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

K321 2012 NEW
Hazardous areas are protected in accordance with 18.3.2.1. The areas
shall be enclosed with a 1-hour fire-rated barrier, with a ¾ hour fire-rated
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
are protected by a sprinkler system in accordance with 9.7, 18.3.2.1, and
8.4.
Describe the floor and zone locations of hazardous areas that are deficient
in REMARKS.
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
Laboratories employing quantities of flammable, combustible, or
hazardous materials that are considered a severe hazard are protected by
1-hour fire resistance-rated separation, automatic sprinkler system, and
are in accordance with 8.7 and with NFPA 99.
Laboratories not considered a severe hazard are protected as hazardous
areas (see K321).
Laboratories using chemicals are in accordance with NFPA 45, Standard
on Fire Protection for Laboratories Using Chemicals.
Gas appliances are of appropriate design and installed in accordance with
NFPA 54. Shutoff valves are marked to identify material they control.
Devices requiring medical grade oxygen from the piped distribution system
meet the requirements under 11.4.2.2 (NFPA 99).
18.3.2.2, 19.3.2.2, 8.7, 8.7.4.1 (LSC)
9.3.1.2, 11.4.3.2, 15.4 (NFPA 99)

K323 Anesthetizing Locations
Areas designated for administration of general anesthesia (i.e., inhalation
anesthetics) are in accordance with 8.7 and NFPA 99.
Zone valves are: located immediately outside each life-support, critical
care, and anesthetizing location of moderate sedation, deep sedation, or
general anesthesia for medical gas or vacuum; readily accessible in an
emergency; and arranged so shutting off any one anesthetizing location will
not affect others.
Area alarm panels are provided to monitor all medical gas, medicalsurgical vacuum, and piped WAGD systems. Panels are at locations that
provide for surveillance, indicate medical gas pressure decreases of 20
percent and vacuum decreases of 12 inch gauge HgV, and provide visual
and audible indication. Alarm sensors are installed either on the source
side of individual room zone valve box assemblies or on the patient/use
side of each of the individual zone box valve assemblies.
The EES critical branch supplies power for task illumination, fixed
equipment, select receptacles, and select power circuits, and EES
equipment system supplies power to ventilation system.
Heating, cooling, and ventilation are in accordance with ASHRAE 170.
Medical supply and equipment manufacturer’s instructions for use are
considered before reducing humidity levels to those allowed by ASHRAE,
per S&C 13-58.
18.3.2.3, 19.3.2.3 (LSC)
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
Cooking equipment is protected in accordance with NFPA 96, Standard for
Ventilation Control and Fire Protection of Commercial Cooking Operations,
unless:
• residential cooking equipment (i.e., small appliances such as
microwaves, hot plates, toasters) are used for food warming or limited
cooking in accordance with 18.3.2.5.2, 19.3.2.5.2.
• cooking facilities open to the corridor in smoke compartments with 30 or
fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3,
or
• cooking facilities in smoke compartments with 30 or fewer patients
comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required
to be enclosed as hazardous areas, but shall not be open to the corridor.

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

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

Indicate flame spread rating(s)

K332 Interior Floor Finish
2012 NEW (Indicate N/A for 2012 EXISTING)
Interior finishes shall comply with 10.2. Floor finishes in exit enclosures and
exit access corridors and spaces not separated by walls that resist the
passage of smoke shall be Class I or II.
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
A fire alarm system is installed with systems and components approved for
the purpose in accordance with NFPA 70, National Electric Code, and
NFPA 72, National Fire Alarm Code to provide effective warning of fire in
any part of the building. In areas not continuously occupied, detection is
installed at each fire alarm control unit. In new occupancy, detection is also
installed at notification appliance circuit power extenders, and supervising
station transmitting equipment. Fire alarm system wiring or other
transmission paths are monitored for integrity.
18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8

K342 Fire Alarm System – Initiation
Initiation of the fire alarm system is by manual means and by any required
sprinkler system alarm, detection device, or detection system. Manual
alarm boxes are provided in the path of egress near each required exit.
Manual alarm boxes in patient sleeping areas shall not be required at exits
if manual alarm boxes are located at all nurse’s stations or other
continuously attended staff location, provided alarm boxes are visible,
continuously accessible, and 200’ travel distance is not exceeded.
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
Positive alarm sequence in accordance with 9.6.3.4 are permitted.
Occupant notification is provided automatically in accordance with 9.6.3 by
audible and visual signals.
In critical care areas, visual alarms are sufficient. The fire alarm system
transmits the alarm automatically to notify emergency forces in the event of
a fire.
Annunciation and annunciation zoning for fire alarm and sprinklers shall be
provided by audible and visual indicators and zones shall not be larger than
22,500 square feet per zone.
18.3.4.3 through 18.3.4.3.3, 9.6.4

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

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

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

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

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

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

K353 Sprinkler System – Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and
maintained in accordance with NFPA 25, Standard for the Inspection,
Testing, and Maintaining of Water-based Fire Protection Systems. Records
of system design, maintenance, inspection and testing are maintained in a
secure location and readily available.

Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
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
Where the sprinkler system is impaired, the extent and duration of the
impairment has been determined, areas or buildings involved are inspected
and risks are determined, recommendations are submitted to management
or designated representative, and the fire department and other authorities
having jurisdiction have been notified. Where the sprinkler system is out of
service for more than 10 hours in a 24 hour period, the building or portion of
the building affected are evacuated or an approved fire watch is provided
until the sprinkler system has been returned to service.
18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25)

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

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

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

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

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

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

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

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

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

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

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

SECTION 4: SPECIAL PROVISIONS

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

K421 2012 NEW
High-rise buildings comply with section 11.8.
18.4.2

SECTION 5: BUILDING SERVICES

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

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

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

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

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

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

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

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

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

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

SECTION 6: RESERVED
SECTION 7: OPERATING FEATURES

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

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

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

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

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

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

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

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

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

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

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

K791 Construction, Repair, and Improvement Operations
Construction, repair, and improvement operations shall comply with 4.6.10.
Any means of egress in any area undergoing construction, repair, or
improvements shall be inspected daily to ensure its ability to be used
instantly in case of emergency and compliance with NFPA 241.
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
List in the REMARKS section any NFPA 99 requirements (excluding
Chapter 7, 8, 12, and 13) that are not addressed by the provided K-Tags,
but are deficient. This information, along with the applicable Health Care
Facilities Code or NFPA standard citation, should be included on Form
CMS-2567.

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

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

K903 Gas and Vacuum Piped Systems – Categories
Medical gas, medical air, surgical vacuum, WAGD, and air supply systems
are designated:
☐ Category 1. Systems in which failure is likely to cause major injury or death.
☐ Category 2. Systems in which failure is likely to cause minor injury.
☐ Category 3. Systems in which failure is not likely to cause injury, but can
cause discomfort

Deep sedation and general anesthesia are not to be administered using a
Category 3 medical gas system.
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
All master, area, and local alarm systems used for medical gas and vacuum
systems comply with appropriate Category warning system requirements,
as applicable.
5.1.9, 5.2.9, 5.3.6.2.2 (NFPA 99)

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

K906 Gas and Vacuum Piped Systems – Central Supply System Operations
Adaptors or conversion fittings are prohibited. Cylinders are handled in
accordance with 11.6.2. Only cylinders, reusable shipping containers, and
their accessories are stored in rooms containing central supply systems or
cylinders. No flammable materials are stored with cylinders. Cryogenic
liquid storage units intended to supply the facility are not used to transfill.
Cylinders are kept away from sources of heat. Valve protection caps are
secured in place, if supplied, unless cylinder is in use. Cylinders are not
stored in tightly closed spaces. Cylinders in use and storage are prevented
from exceeding 130°F, and nitrous oxide and carbon dioxide cylinders are
prevented from reaching temperatures lower than manufacture
recommendations or 20°F. Full or empty cylinders, when not connected, are
stored in locations complying with 5.1.3.3.2 through 5.1.3.3.3, and are not
stored in enclosures containing motor-driven machinery, unless for
instrument air reserve headers.
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,
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
Medical gas, vacuum, WAGD, or support gas systems have documented
maintenance programs. The program includes an inventory of all source
systems, control valves, alarms, manufactured assemblies, and outlets.
Inspection and maintenance schedules are established through risk
assessment considering manufacturer recommendations. Inspection
procedures and testing methods are established through risk assessment.
Persons maintaining systems are qualified as demonstrated by training and
certification or credentialing to the requirements of AASE 6030 or 6040.
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
The gas and vacuum systems are inspected and tested as part of a
maintenance program and include the required elements. Records of the
inspections and testing are maintained as required.
5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99)

K909 Gas and Vacuum Piped Systems – Information and Warning Signs
Piping is labeled by stencil or adhesive markers identifying the gas or
vacuum system, including the name of system or chemical symbol, color
code (Table 5.1.11), and operating pressure if other than standard. Labels
are at intervals not more than 20 feet, are in every room, at both sides of
wall penetrations, and on every story traversed by riser. Piping is not
painted. Shutoff valves are identified with the name or chemical symbol of
the gas or vacuum system, room or area served, and caution to not use the
valve except in emergency.
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
Whenever modifications are made that breach the pipeline, any necessary
installer and verification test specified in 5.1.2 is conducted on the
downstream portion of the medical gas piping system. Permanent records
of all tests required by system verification tests are maintained.
5.1.14.4.1, 5.1.14.4.6, 5.2.13, 5.3.13.4.3 (NFPA 99)

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

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

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

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

K915 Electrical Systems – Essential Electric System Categories
☐ Critical care rooms (Category 1) in which electrical system failure is likely
to cause major injury or death of patients, including all rooms where electric
life support equipment is required, are served by a Type 1 EES.
☐ General care rooms (Category 2) in which electrical system failure is
likely to cause minor injury to patients (Category 2) are served by a Type 1
or Type 2 EES.
☐ Basic care rooms (Category 3) in which electrical system failure is not
likely to cause injury to patients and rooms other than patient care rooms
are not required to be served by an EES. Type 3 EES life safety branch has
an alternate source of power that will be effective for 1 1/2 hours.
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
A remote annunciator that is storage battery powered is provided to operate
outside of the generating room in a location readily observed by operating
personnel. The annunciator is hard-wired to indicate alarm conditions of
the emergency power source. A centralized computer system (e.g.,
building information system) is not to be substituted for the alarm
annunciator.
6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99)

K917 Electrical Systems – Essential Electric System Receptacles
Electrical receptacles or cover plates supplied from the life safety and
critical branches have a distinctive color or marking.
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
Testing
The generator or other alternate power source and associated equipment is
capable of supplying service within 10 seconds. If the 10-second criterion is
not met during the monthly test, a process shall be provided to annually
confirm this capability for the life safety and critical branches. Maintenance
and testing of the generator and transfer switches are performed in
accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12
times a year in 20-40 day intervals, and exercised once every 36 months for
4 continuous hours. Scheduled test under load conditions include a
complete simulated cold start and automatic or manual transfer of all EES
loads, and are conducted by competent personnel. Maintenance and
testing of stored energy power sources (Type 3 EES) are in accordance
with NFPA 111. Main and feeder circuit breakers are inspected annually,
and a program for periodically exercising the components is established
according to manufacturer requirements. Written records of maintenance
and testing are maintained and readily available. EES electrical panels and
circuits are marked, readily identifiable, and separate from normal power
circuits. Minimizing the possibility of damage of the emergency power
source is a design consideration for new installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

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

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

K921 Electrical Equipment – Testing and Maintenance Requirements
The physical integrity, resistance, leakage current, and touch current tests
for fixed and portable patient-care related electrical equipment (PCREE) is
performed as required in 10.3. Testing intervals are established with
policies and protocols. All PCREE used in patient care rooms is tested in
accordance with 10.3.5.4 or 10.3.6 before being put into service and after
any repair or modification. Any system consisting of several electrical
appliances demonstrates compliance with NFPA 99 as a complete system.
Service manuals, instructions, and procedures provided by the
manufacturer include information as required by 10.5.3.1.1 and are
considered in the development of a program for electrical equipment
maintenance. Electrical equipment instructions and maintenance manuals
are readily available, and safety labels and condensed operating
instructions on the appliance are legible. A record of electrical equipment
tests, repairs, and modifications is maintained for a period of time to
demonstrate compliance in accordance with the facility's policy. Personnel
responsible for the testing, maintenance and use of electrical appliances
receive continuing training.
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
List in the REMARKS section any NFPA 99 Chapter 11 Gas Equipment
requirements that are not addressed by the provided K-Tags, but are
deficient. This information, along with the applicable Life Safety Code or
NFPA standard citation, should be included on Form CMS-2567.
Chapter 11 (NFPA 99)

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

K924 Gas Equipment – Testing and Maintenance Requirements
Anesthesia apparatus are tested at the final path to patient after any
adjustment, modification or repair. Before the apparatus is returned to
service, each connection is checked to verify proper gas and an oxygen
analyzer is used to verify oxygen concentration. Defective equipment is
immediately removed from service. Areas designated for servicing of
oxygen equipment are clean and free of oil, grease, or other flammables.
Manufacturer service manuals are used to maintain equipment and a
scheduled maintenance program is followed.
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
Smoking materials are removed from patients receiving respiratory therapy.
When a nasal cannula is delivering oxygen outside of a patient’s room, no
sources of ignition are within in the site of intentional expulsion (1-foot).
When other oxygen deliver equipment is used or oxygen is delivered inside
a patient’s room, no sources of ignition are within the area are of
administration (15-feet). Solid fuel-burning appliances is not in the area of
administration. Nonmedical appliances with hot surfaces or sparking
mechanisms are not within oxygen-delivery equipment or site of intentional
expulsion.
11.5.1.1, TIA 12-6 (NFPA 99)

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

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

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

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

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

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

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

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

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.