Facility Documentation & Survey History

When was the most recent CMS Survey?

Is the facility survey binder in a public area, and is updated?

How many K-Tags were received in the last survey?

Record all previous K-Tags received:

After reviewing the Plan of Correction, is the facility in substantial compliance from the last survey?

Is the facilities Safety Data Sheet book up to date, and organized for rapid access?

Life Safety Drills and Disaster Preparedness

Does the facility All Hazards disaster manual includes P.A.S.S and R.A.C.E. or R.A.C.E.R-relocate (Oregon)?

Does the facility have record of all staff participating at least once per year in fire drills and received annual refresher training in Fire and Disaster Preparedness ?

Does the facility have an updated All Hazards disaster manual, and completed their Hazard Vulnerability Assessment, NFPA 99 Patient Equipment Risk assessment, and emergency supply inventory in the last 12 months?

Have the facility staff been trained on any changes made to the Emergency Disaster manual, HVA, or supply levels?

During Staff interviews were staff familiar with Fire Life Safety procedures( P.A.S.S., R.A.C.E.R., All-Hazards materials, building security)

Is there 7 days of food supply on hand along with stand alone cooking capability? (Verify Emergency Menu and stock)

There is at least 1 gallon of water per person(staff, residents, family) calculated during peak hours for 7 days? Does the facility have a sanitary way to retrieve and treat the water?

Does the facility have an updated contact list for alternate suppliers, transportation contracts, and evacuation sites (including facility maps and directions)?

Did the facility conduct a tabletop exercise and participate in a full scale
community-based exercise, or conduct an individual facility exercise if a community-based exercise is not available?

Did the Facility perform an emergency drill testing their Electronic Medical Records during the last year and were any deficiencies corrected?

When was the last full scale or individual excoriate completed?
When was the last table-top drill completed?

Does the facility have a policy and procedure for the impairment of any life safety system? (policy must include details for implementing a fire watch when an impairment exceeds 4 hours, Approved fire watch must include the following elements: a)involves at least one person with fire watch responsibility beyond normal staffing assignment(s) b)Individuals in fire watch are trained in fire prevention and in occupant and fire department notification of fire c)Notification of state and local fire marshal of the impairment d)Notification of the nearest fire department e) log is available to document and review fire watch)

Are facility fire drills physically simulating realistic evacuations, and focus on defend in-place strategy?

Do Facility Fire Drills include documentation of alarm transmission to the monitoring station?

Are 1st Shift Fire Drills conducted at least once per quarter and are varied in time(>2hrs) and location to ensure realistic testing?

Please document any corrections needed:

Are 2nd Shift Fire Drills conducted at least once per quarter and are varied in time(>2hrs) and location to ensure realistic testing?

Please document any corrections needed:

Are 3rd Shift Fire Drills conducted at least once per quarter and are varied in time(>2hrs) and location to ensure realistic testing?

Please document any corrections needed:

Fire Alarm System

Person(s) conducting Testing have certificates of competency on file ?

Is the Fire Panel a Zone or Addressable System?

Was sensitivity done in the last two years? (deficiencies and corrections documented)?

Enter Date of last calibration:

Annual fire alarm testing documentation is complete, accurate and documents test results according to NFPA 72(indicating all devices, both initiating and receiving, and the test results)?

Is the panel installed in a supervised location?

Are Smoke detectors properly tested annually, and calibrated with documentation for each initiating device according to the NFPA 72 schedule(One year after install, calibration every two years afterwards unless system does not meet annual testing threshold)?

Smoke detectors are not placed within three (3) feet of a direct airflow supply or return air vent?

Are all Pull stations properly identified and easily accessible(no storage or obstructions)?

Is the Fire Alarm System connected to sprinkler system and tested annually? (Includes Kitchen Hood system)

Are there any gaps in ceiling and/or tiles adjacent to sprinkler heads, are all escutcheons are secured tight to ceiling?

Fire Sprinkler System

Person(s) conducting Testing have certificates of competency on file?

What type of sprinkler system is installed in the facility?

Does the sprinkler system supply exceed (>500 GPM) or if hydraulically calculated, has a great capacity (GPM) than whats listed on the nameplate of the sprinkler riser? (Check forward flow test for results)

Are a minimum of two of each type of sprinkler heads and a sprinkler wrench stored in the riser room?

Are the pressure gauges tested and calibrated or replaced in the last 5 years?

Enter Gauge Calibration or Replacement date:

Have the Quarterly Sprinkler tests been completed correctly showing pre and post pressure within 10%, and tests were completed timely?

Was the Fire Sprinkler system (including anti-freeze loops) tested and serviced in the last 12 months (NFPA 25)?

Was the Fire Sprinkler 5 year obstruction inspection completed and deficiencies were corrected(systems older than 50 years)?

All sprinkler heads are clean, dust free and clear of paint or other obstructions?

Each compartment has the same type response head(SR, QR) and temperature rating of heads in use?

High pile storage is a minimum of 18' below and away from sprinkler head fan deflector?

All cubicle curtains are installed to prevent interference with the sprinkler system?

Fire Extinguisher System

Person(s) conducting Testing have certificates of competency on file?

Does the facility have 3 years of service tags on-site and were the fire extinguishers serviced in the last 12 months showing an accurate inventory of all equipment?

Are Fire Extinguishers inventoried and checked monthly and signed off?

If a K-Class Extinguisher is used in the kitchen does dietary staff have training on the proper use documented ?

Are all Extinguishers installed not less than 4 inches off the floor? All extinguishers less than 40 lbs must not be installed higher than 60' , extinguishers over 40 lbs not above 3.5 '?

Kitchen and Hood Suppression System

Person(s) conducting Testing have certificates of competency on file?

What type of Kitchen Hood Fire Suppression system is used?

Has the kitchen hood and suppression system been inspected every 6 months by a testing company?

Most recent inspection:
Previous 6 month inspection:

Is there record of the hood and chase being cleaned no less than once per year?

Are kitchen staff cleaning drip pan and hood filters at least once per week?

Are all hood filters a baffle type construction and fit tightly with no gaps or movement when air is flowing?

Does Kitchen dish machine temps reach 180 degrees on final rinse, or reach 140 with use of bleach and routinely verified with test kit(200ppm)?

Are the facility ice machines drained, cleaned, filter checked quarterly, and scoops not stored in bins?

Are all facility fridges and medication fridges have current temperature logs and are clean with no undated open food or beverages( excluding employee fridge)?

Do all walk-in fridges or freezers have panic release hardware?

Are all Refrigeration units clean and appear maintained (coils clean, not dusty,sanitary interior)?

Does the facility have a grease trap maintenance program, is it clean and are any problems present?

Fuel and electrical sources are automatically disconnected when the extinguishing system or fire alarm is activated?

Does the Facility have a deep fryer that is kept 16' from stove or ignition source and under the suppression system?

Is there an activation for the hood suppression system in the path of egress?

Are all Dining services staff are trained in how to activate of the hood suppression system and any specialty fire suppression equipment?

Does the facility have an effective pest management plan, and is it updated?

Emergency Generator & ATS

Person(s) conducting Testing have certificates of competency on file?

Was the Generator load bank completed according to NFPA 110(2011)? (annually, 2 hours @ 80% EPS, or Every 3 years for 4 hours @ 80% EPS)?

What frequency of load bank is being completed?

Enter Date of Last Load Bank:

Was the Generator serviced in the last 12 months?

Enter Date of Last Inspection

Were the monthly facility load tests (30 minutes) , emergency lighting, and emergency outlets tested and completed on time, all deficiencies corrected or in process?

Has the automatic transfer switch been tested annually and within calibration?

Does the generator startup and transfer power to the building in under 10 seconds( ATS or Generator controlled delay is allowed, signal to fire to voltage stabilization is under 10 seconds NFPA 110 Section 6.2) ?

Is the area around the Generator, ATS, and Electrical panels clear (3ft) and clean?

Is there battery powered emergency light that illuminates the Generator?

Are there instructions Mounted at the Generator and ATS and are staff trained to manually start the Generator and transfer ATS in the event of a run failure?

Is the generator cabinet and ATS easily accessible to all staff(not locked, or staff has access to unlock) ?

Is there a fire extinguisher, no smoking sign, and Emergency Stop mounted near but not on the Generator or ATS?

How much fuel is needed to run the generator under full load for 96 hours?

Is there enough fuel on-site to need? If not does the facility have a contracted source for emergency fuel?

Fire Doors and Dampers

Person(s) conducting Testing have certificates of competency on file?

Is the monthly Fire/Smoke door inspection log (NFPA 80) updated with no outstanding repairs? (a.Proper operation checked b.Positive latch c. Gap for Smoke doors less than 1/2 inch. d. gasket material is correct type. 3. can resist the passage of smoke)

Are smoke dampers being cleaned and checked for proper closing, were the smoke dampers serviced within the required testing time frame?

Fire/Smoke dampers and roll down doors are inspected and serviced every two years to ensure no rusting or blockage, noting hinges and other moving parts.

Last Inspection Date:

Fire dampers fuse able links are changed and damper exercised every 4 years?

Last Inspection Date:

Corridors & Egress

Corridors are at least 5 feet wide and clear on one side(NFPA 101-2011), Linen carts, soiled utility carts, wheelchairs and lifts are not stored in hallways. (Isolation carts and crash carts are permissible in the corridors) Linen carts, soiled utility carts, wheelchairs and lifts are considered stored if not in use for over 30 minutes in a corridor. (When appropriate staff is around and using something, it is to be considered being in use) Provide pictures of items out of compliance.

Exit and directional signage properly provide direction for egress path, must provide continuous illumination, lighted or serviced by emergency power and appropriately tested with documentation?

Emergency battery lighting is labeled, tested for 30 seconds, and logged every month?

Emergency battery lighting is tested on battery for 1.5 hours annually (done even if battery is new)?

Exit signs in rooms that are larger than 1000 sq ft have emergency battery power for 1.5 hours installed and tested?

Exit discharges outside the building have a hard surface to the public way. Exit discharges outside the building are usable in inclement weather (snow, rain) without impediments and are illuminated along the egress path ending at least 50 ft away from the building?

Do the Smoke barrier doors, where both swing in the same direction have directional signage and are required to have a coordinator to ensure doors close properly which allows one door to close first preventing the doors from hitting(Astragal & coordinator)?

All smoke and fire Doors in exit corridors, stairwell enclosures, horizontal exits, smoke barriers and hazardous areas are only held open by a device that automatically closes the door upon activation of fire alarm and/or local smoke detector and/or automatic sprinkler system?

Doors in the egress pathway are locked with keypads with clearly marked codes, they are capable of being released by a single button, or are equipped with delayed egress functionality that allows exit after 10-30 seconds of consistent pressure?

Exit doors or exit access doors are not painted/disguised in a manner that obstructs the use of the door?

There is only one delayed egress locking arrangement in the path of egress travel?

Doors leading to areas that DO NOT provide egress to the public way are appropriately marked 'NO EXIT'?

Randomly selected staff are aware of how to bypass magnetically locked or delay egress locking arrangements?

Alcohol Hand Rub Dispensers at least 4ft apart, not install over or within 6' of any electrical switch or outlet, installed with a drip tray, the dispenser capacity is not>1.2L, and there is not more than 10 gallons in a single smoke compartment?

Smoke Barrier / Fire Walls are constructed from outside wall to outside wall or other smoke/fire barrier and from floor to roof/floor deck above?

All Penetrations in the building are sealed with rated materials for that compartment. (No expanding foam or caulk unless it is UL/FM rated)?

Line, trash, or recycle containers in hallways or other areas do not exceed a combined density of 32 gallon capacity in a 64 sq ft area?

Do all interior finishes meet or exceed Class A ratings(fully sprinkled buildings)?

Curtains have labels or tags indicating non flammability rating?

Decorations are not combustible and are flame resistant or are treated with retardant annually(must be tagged with date and MSDS #) NOTE: Combustible decorations, such as photographs and paintings, in limited quantities do not pose a fire hazard for fire development or spread?

Electrical & Mechanical Areas

Do all mechanical areas have proper signage?

Do areas in front of electrical panels have 3' of clearance?

Are breakers and circuits identified and clearly labeled, by (Panel-Sub-panel-Breaker)?

Does the facility have current records of Lock Out/ Tag Out training for all authorized individuals?

Does the facility have the appropriate Lock Out/ Tag Out materials on-site?

Does the facility have the a plug tension test log, and are all patient care areas documented?

All electrical boxes and devices have proper covers and are not broken or damaged?

Are all conduits and penetrations in mechanical areas sealed with drywall mud or fire stopping to maintain 1hr. fire separation?

There are no portable space heaters used in the facility?

Are all flammable, corrosives, and caustic substances labeled and properly stored?

Soiled linen and trash are stored in room doors have automatic closures and positively latch, if greater than 64 cu/ft of material are they protected as hazardous areas?

Oxygen Storage and Smoking (K-76, K-77, K-141, K-143)

Oxygen storage areas are secured against unauthorized entry, must have self closing hinges, positive latching, separated from combustible materials, protected by an automatic sprinkler system, the temperature of the room must not exceed 130 degrees F, and electrical switched, receptacles and fixtures are above 60 inches from the floor?

Oxygen cylinder storage area has clearly marked full and empty areas, all cylinders are secured properly in a cart or cylinder stand?

Smoking, open flames, electrical heating elements and other sources of ignition do not occur within 20 feet of an outside storage location?

Oxygen storage areas are properly identified (CAUTION - OXIDIZING GAS(ES) STORED WITHIN - NO SMOKING)?

NO SMOKING signage is posted on all exterior doors where Oxygen is used in the facility, Facilities that are smoking campuses, residents that are smokers and on oxygen must have signage on the lintel of their room?

No cigarette butts visible on the ground or in areas where smoking is prohibited. Metal containers with self closing cover devices which ashtrays should be emptied as needed?

Facility enforces its smoking policy, has an updated smokers roster identifying dependent and independent smokers, and a facility smoking schedule.

Smoking materials are properly secured for all smokers according to state and CMS regulations?

Resident Rooms & Care Areas

Are the facilities resident hot water temperatures documented and within the state's requirement for safe bathing temperatures 105-115F UT/MW, 105-120 OR, 105-120 CA (Section 613.5, 2013 CPC)?

Do all resident and public accessible doors have ADA lever handles installed?

Do all resident bathroom doors have ADA lever privacy handles?

Do all resident and public bathrooms have scald protection installed?

Does facility signage meet ADA specifications?

Do resident door knobs meet ADA specifications?

Do resident lavatories and plumbing fixtures meet ADA specifications?

Environmental Observations:

Room #

Does the room present clean, safe, and without offensive odor?

Describe and deficiencies or environmental concerns:

Nurse Call and Patient Monitoring Systems

Is the nurse call, and bath pull stations being tested quarterly?

Does the facility have a patient monitoring system (Wanderguard, Roam Alert ect.)?

Does the facility have a log that checks each protected door and patient device (in use) at least weekly?

Has there been any recent history of patient elopement?

What steps has the facility implemented to mitigate that risk(QAPI)?

HVAC (K-67, K-68, K-104)

Are HVAC units generally in good condition and a failure of any one piece of equipment would not jeopardize the facilities ability to heat or cool patient areas?

Isolation room has a separate HVAC system and its own outside air supply and exhaust?

Are all HVAC discharges and returns properly balanced and clean so air pressure to critical areas do not effect doors closing?

Does the facility have equipment, materials, (Air purifer, plastic, duct tape ect.)and a plan to provide filtered air in the case of excess smoke or hazardous material release?

Elevator

Does the Facility have an Elevator?

Was the elevator serviced in the last 12 months, the permit current, operating normally, and the elevator pump shaft and sump clean?

Date of Last service:

Roof

Does the facility have a fall protection plan,required equipment and ladder are in good condition?

Do facility skylights have fall protection cages or have portable barriers to use if needed?

LAUNDRY / TRASH (K-29, K-75)

Laundry water temps reach 180 degrees, or reach 160 with use of bleach for white loads?

Lint trap dryer screens have no holes, and are cleaned once per shift?

Are fire boxes cleaned, bearings lubricated, and roof traps emptied at least weekly?

Is there 3' of clearance around the washers and dryers?

Is the dryer exhaust cleaned from machine to the roof quarterly, and does it appear clean?

Are mop heads are being tumbled in the dryer?

Building Security

Are all facility exterior doors capable of being locked down?

Describe locations and needed changes to meet the requirement.

Has there been recent security concerns or issues?

Issue #

Describe each issue in detail:

Have those issues been addressed?

Outline any issues that are not being addressed.

Facility Construction & Equipment

Does the facility have an up to date construction binder with permits and project details for review?

Has their been any construction since the last survey that could effect the fire alarm, sprinkler system , generator, patient monitoring, nurse call, or any safety features protecting patients and staff?

Describe any recent construction that has taken place, specifically if it has effected the fire alarm, sprinkler system, generator, patient monitoring, or nurse call system, reference any permit numbers as appropriate and inspect work to make sure building protection features are not degraded.

Waivers (FSES, CMS exemption)

Does the facility have any Federal or State Life Safety Waivers in place?

Detail what waivers are in place, time frame, and survey impact.

SIGNATURES

Signature of Surveyor
Signature of Facility Representative
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.