Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

ALCOHOL BASED HAND RUB ABHR (K-211)

  • Corridors are at least 6 feet wide

  • Dispensers are installed at least 4 feet apart

  • Dispensers are not installed over or adjacent to an ignition source such as electrical switches and/or outlets

  • Dispensers do not exceed a capacity of 1.2 liters

  • Not more than 10 gallons in a single smoke compartment

CONSTRUCTION / RENOVATIONS

  • Has any modification of more than 50% or 4,500 sq ft of the smoke compartment been done

  • Has any modification of less than 50% or 4,500 sq ft of the smoke compartment been done

  • Have any major LSC systems been replaced in the last 5 years (fire alarm, sprinkler system, generator, etc)

CORRIDOR WALLS / FIRE WALLS / SMOKE WALLS K-11, K-17, K-21, K-25, K-27, K-39

  • Corridors are separated from use areas by walls that form a barrier to limit the transfer of smoke and, for existing construction, required to have a fire resistance rating of 30 minutes.

  • 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

  • Penetrations are sealed with rated materials. (No expanding foam unless fire rated)

  • Only products rated by UL and FM are used for penetrations

  • Fire rated ceiling tiles are replaced with fire rated ceiling tiles.

CORRIDOR WIDTH / MEANS OF EGRESS K-39, K-72, K-73

  • MONITOR CORRIDORS SERVING AS EXIT ACCESS TO ENSURE THAT THEY ARE CLEAR AND UNOBSTRUCTED

  • Linen carts, soiled utility carts, wheelchairs and lifts are not stored in hallways. (Isolation carts and crash carts are permissible in the corridors)

  • Furniture and plants are not placed in the hallway that may impede evacuation.

  • Decorations are not combustable and are flame resistant (review interior finish documents for flame spread documentation) <br>NOTE: Combustible decorations, such as photographs and paintings, in limited quantities that do not pose a fire hazard of fire development or spread is not present)

  • Linen carts, soiled utility carts, wheelchairs and lifts are considered stored if not in use for over 30 minutes in a corridor. <br>(When appropriate staff is around and using something, it is to be considered being in use)

  • "Stop Signs" attached to exit doors do not obstruct egress or cover door hardware.

DOORS K-18, K-21, K-25, K-27, K-28, K-29, K-38

  • INSPECT DOORS TO ENSURE THAT:

  • Self Closing and Automatic devices are installed properly and are functioning

  • Smoke Doors and Doors opening into the corridor close properly and resist the passage of smoke

  • Gasket material used to correct door gaps is of a rated material (weather stripping is not allowed or rated)

  • Doors in corridors close freely, unobstructed and latch positively in the door frame. Doors open freely with door hardware

  • Door latches open with one motion

  • Doors protecting a hazardous area are self closing and latch positively in the door frame

  • Smoke barrier doors that swing in the same direction 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)

  • Magnetically locked or delay egress locking arrangements

  • Doors release appropriately

  • No more than one delayed egress locked door in the path of egress travel

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

  • Doors do not reactivate if the fire alarm system is placed in silent mode. (Fire alarm must be reset for doors to relock)

  • Doors with magnetic locking devices without the delayed egress function shall unlock upon activation of the complete fire alarm system.

  • Self closing door hold opens

  • 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

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

ELECTRICAL (K-106, K-145, K-146, K-147)

  • Power strips are not in use in resident rooms

  • GFI outlets installed within six feet of wet areas.

  • Medical equipment including the residet bed are not plugged in a power strip

  • Includes iv, tube feeding pumps, oxygen concentrators, etc...

  • Power strips are not used in typically wet locations

  • Hair dryers, refridgerators are not plugged into power strips

  • Heat producing appliances are not plugged into power strips

  • Appliances used for cooling are not plugged in to power strips

  • Maintain 3 foot clearance around all electrical panels

  • All electrical equipment is in good repair

  • Electrical cords and plugs do not have frayed or exposed wires

  • Electrical outlets have appropriate cover plates

  • Light switches have appropriate cover plates

  • Junction boxes have appropriate cover plates

EMERGENCY LIGHTING (K-45, K-46)

  • Emergency battery lighting is tested for 30 seconds every month

  • Monthly testing information is maintained on a log

  • Emergency battery lighting is tested for 1.5 hours annually

  • Annual testing information is maintained on a log or in TELS

  • Exterior emergency lighting is either battery powered or generator supplied

  • Exterior emergency lights have either two lamps in one fixture or two fixtures

  • Exit discharge emergency lighting functions for a minimum of 1.5 hours

  • Rooms that exceed 1,000 sq ft in area have illuminated exit signs

  • Exit signs in rooms that exceed 1,000 sq ft in area provided emergency power for 1.5 hours

EXITS (K-38, K-47, K-72)

  • Exit and directional signage properly provide direction for egress path

  • Exit signs provide continuious illumination

  • Exit signs area serviced by emergency power and appropriately tested with documentation

  • Exit access are readily accessable at all times and the means of egress is free of obstructions or impedments to full instant use

  • 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

  • Exit discharges outside of the building are illuminated along the path or egress to the public way

  • Doors leading to courtyards that DO NOT provide egress to the public way are appropriately marked "NO EXIT"

FIRE ALARM SYSTEM (K-51, K-52, K-54, K-60, K-107)

  • Fire alarm system is maintained in accordance with NFPA 72, National Fire Alarm Code

  • Fire alarm testing and maintenance records are available for inspection

  • Fire alarm panel is installed in a supervised location

  • Annual fire alarm testing documentation is complete, accurate and documents test results for all initiating devices

  • Annual fire alarm testing documentation is complete, accurate and documents test results for all supervisory devices

  • Verify that the fire alarm system is connected to the sprinkler system

  • There is documentation that indicated that the fire alarm activates if the sprinkler system is activated

  • Date fire alarm last checked and necessary maintenance provided

  • Name of licensed contractor providing inspection / service

FIRE DRILLS (K-50)

  • There is a plan in place for the protection of all persons in the event of fire

  • Fire drills are conducted, One drill, per shift, per quarter (drills at shift change count as ONE drill)

  • Fire drill records include documentation that transmission of an alarm was sent to the monitoring station

  • Third shift fire drills

  • QUARTER 1

  • QUARTER 2

  • QUARTER 3

  • QUARTER 4

  • First shift fire drills

  • QUARTER 1

  • QUARTER 2

  • QUARTER 3

  • QUARTER 4

  • Second shift fire drills

  • QUARTER 1

  • QUARTER 2

  • QUARTER 3

  • QUARTER 4

  • Fire drill records contain the following information

  • Differing times for drills on each shift (at least 1 hour variation)

  • Varying conditions of drills (a drill conducted at meal time is a varying condition)

  • Differing days of the week, including weekends

  • Involvment of all departments

  • Documented observations of staff responses

  • Documentation of equipment function (release of locked or delayed egress doors, magnetic hold opens, etc…)

  • Documentation of the time the monitoring agency received the alarm notification

  • Fire drills are compliant (Held quarterly, per shift, at unexpected times and under varying conditions

FIRE EXTINGUISHERS (K-64)

  • Portable fire extinguishers are inspected monthly

  • By facility staff

  • By outside vendor

  • Portable fire extinguishers are maintained annually

  • Dry chemical extinguishers have the chemicals changed every six (6) years

  • Hydrostatic testing of vessels every twelve (12) years

  • Hydrostatic testing of CO2 vessels every five (5) years

  • Extinguishers do not exceed a gross weight of 40 lbs

  • Extinguishers exceed a gross weight of 40 lbs are not mounted more than five (5) feet above the floor at the top of the extinguisher

  • Extinguishers having a gross weight of more than 40 lbs are installed so that the top of the extinguisher does not exceed 3.5 feet above the floor

  • No extinguisher shall be mounted more than 4 inches from the bottom of the extinguisher to the floor

FIRE SAFETY PLAN (K-48)

  • Last date reviewed

  • The fire safety plan includes the following items:

  • Use of alarms

  • Transmission of alarms to forces (fire department)

  • Response to alarms

  • Isolation of fire

  • Evacuation of the immediate area

  • Evacuation of the smoke compartment

  • Preperation of floors and building for evacuation

  • Extinguishment of fire

FIRE WATCH AND SYSTEMS IMPAIRMENT

  • The community has a policy for impairment of the automatic sprinkler system and/or fire alarm system if it is unavailable more than 4 hours in any continuious 24 hour period

  • The community has a policy on approved fire watch

  • Approved fire watch must include the following elements:

  • Involves at least one person with fire watch responsibility beyond normal staffing assignment(s)

  • Individuals in fire watch are trained in fire prevention and in occupant and fire department notification of fire

  • Notification of local forces of the impariment

  • Notification of the AHJ (Authority having jurisdiction) of the community

  • Notification of any other licensing authority having jurisdiction

  • Addresses separate situations in which the sprinkler system and/or fire alarm system is out of service for more that 4 hours in any 24 hours

  • A log is available to document and review fire watch

GENERATORS (K-105, K-108, K-144)

  • Generator(s) are inspected weekly

  • Generator(s) are exercised under load for 30 minute per month (Startup and cool down time are not part of the 30 minutes)

  • Under operating temperature conditions at least 30% of the EPS nameplate rating

  • Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer

  • DIESEL GENERATORS, that do not meet the above requirments are exercised monthly with the available EPS load

  • DIESEL GENERATORS, that do not meet the above requirments are load banked tested annually

  • Inspection records include all of the following:

  • Date of inspection

  • Time of inspection

  • Generators general condition (leaks, hoses, fuel supply, oil, belts, battery, cooling system transfer switch)

  • Start and End times of the load test including start-up time and cool down time

  • Generator output readings during load test

  • Signature of individual conducting the inspection, testing and/or repairs

  • Battery powered emergency lighting is available at generator set location inside building

  • Verify battery powered emergency lighting is check monthly for 30 seconds and annually for 1.5 hours

  • Is there at least a 48 hours fuel supply on site.

  • Contingency plan in place and written agreement for the resupplying of fuel in an emergency situation

  • Remote generator annunciator panel is attended in a area staffed 24/7, 7 days per week

  • EPS transer switch activates and provides power within 10 seconds to critical branch circuits

  • Natural Gas generators must comply with the following:

  • There is a letter of reliability on file in the community from their natural gas provider that contains the following:

  • Description supporting the reasonable reliability assertion

  • Statement that the fuel source is reliable

  • Statement of the low likelihood of an interruption

  • Description supporting the low interruption assertion

  • Signature from technical personnel

HAZARDOUS AREAS (K-29)

  • Hazardous areas have a solid wood core door with automatic self closing device

  • hazardous areas doors latch positively

  • Mechanical rooms are clean and orderly

  • Mechanical rooms are not used for combustable storage

  • Combustibles are stored in authorized metal cabinet

  • Clearance of 3 feet is maintained around all heat producing equipment such as a gas furnace

HEATING, VENTILATION, AIR CONDITIONING and COOLING. (HVAC) (K-67, K-68, K-104)

  • Fire dampers are inspected every two years to ensure no rusting or blockage, noting hinges and other moving parts

  • Fire dampers fuseable links are changed and damper exercised every 4 years

  • Fire dampers are cleaned and lubricated as necessary and documentated

HOOD SUPPRESSION SYSTEM (K-69)

  • Hood is inspected and documentation that the hood, ducts and suppression system nozzles are free of grease and dirt buildup

  • Hood suppression system is maintained and inspected in accordance with NFPA 96

  • Fuel sources are automatically disconnected when the extinguishing system is activated

  • Hood suppression system activator is located in the path of egress

  • Activation of the hood suppression system initiates the communitys alarm system

  • The hood suppression system is UL 300 compliant

  • Dining services staff are versed in activation of the hood suppression system

  • Is deep fryer at least 16 inches from stove

  • If fryer is less that 16" away from stove, then a eight (8) inch shield is installed on the tallest appliance

INTERIOR FINISH, FURNISHINGS & DECORATIONS (K-14, K-15, K-16, K-72, K-73, K-74, K-130)

  • Finishes meet Class A, B or C ratings in sprinklered buildings

  • The community has documentation of flame spread and smoke ratings of all their interior finishes

  • Curtains have labels or tags indicating non flammability rating

  • Records are maintained of any community treated fire resistance materials

  • Combustable decorations are flame retardant (Photographs, paintings, etc…)

  • Decorations are not hung from fire sprinker heads and/or pipes

  • Highly flammable decorations are not used in the community (Hay bales, straw, fine tinsel, live christmas trees, etc…)

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

  • Soiled linen and trash are stored in rooms protected as hazardous areas

  • Soiled linen and trash are stored in room doors have automatic closers and positively latch

  • Linen containers in hallways or other areas do not exceed a combined 32 gallon capacity in a 64 sq ft area. Approx 8' x 8'

OXYGEN STORAGE (K-76, K-77, K-141, K-143)

  • Storage areas are secured against unauthorized entry

  • Storage area doors are equipped with self closing devices

  • Storage area doors are positive latching

  • Oxygen cylinders are seperated from combustible materials by a minimum distance of five (5) feet of the storage area is protected by an automatic sprinkler system

  • Cylinder and container storage locations meet temperature limitations (Cylinders are protected from reaching temperatures that could exceed 130 degrees ferinheit)

  • Storage area electrical wall fixtures are installed in fixed locations not less than 5 feet above the floor to protect from physical damage

  • Cylinders are protected to prevent damage to cylinders, valve, regulators or safety devices

  • Cylinders are not stored near elevators or locations where heavy objects could strike or fall on the cylinder

  • Freestanding cylinders are properly chained or supported in an appropriate cylinder stand or cart

  • Full and empty cylinders are are stored seperately

  • Community ensures that smoking, open flames, electrical heating elements and other sources of ignition do not occur in storage locations

  • 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)

OXYGEN (TRANSFERRING LIQUID OXYGEN) (K-143)

  • Liquid oxygen is transferred in an area separated away from resident sleeping rooms

  • Liquid oxygen is transferred in an area seperated by 1-hour fire resistive construction

  • Liquid oxygen is transferred in an area seperated by 1-hour fire resistive construction has a door rating of 3/4 hour fire rating

  • Liquid oxygen transfering area is mechanically ventilated

  • Liquid oxygen transfering area has either a concrete or ceramic tile floor

  • Liquid oxygen transferring area is posted with signage indicating oxygen transfering is occuring and smoking is prohibited in the immediate area

PORTABLE SPACE HEATERS (K-70)

  • There are no portable space heaters used in the facility

SMOKE DETECTORS (K-53, K-54)

  • Smoke detectors are tested annually to ensure each detector is operative and produces intended results

  • Smoke detector sensitivity is checked within one year of installation and every 2 years after that

  • Date of last sensitivity testing

  • Records are available showing the past two sensitivity testing by a qualified firm

  • Testing company name

  • Smoke detector sensitivity testing shows the exact response of each detector as it relates to the manufactures sensitive rating for that model detector

  • Smoke detectors are maintain and calibrated in accordance with NFPA 72

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

  • Single station smoke detectors (Battery operated)

  • Inspected and tested monthly according to manufacturers instructions

  • Replace batteries according to manufacturers instructions (at least yearly)

  • Inspection and testing is documented and available

SMOKING REGULATIONS (K-66)

  • Metal containers with self closing cover devices which ashtrays can be emptied area available and used

  • Required Oxygen in Use - NO SMOKING signage is posted on all exterior doors

  • Community enforces its no smoking regulation

  • There are no cigarette butts visible on the ground or in areas where smoking is prohibited

SPRINKLER SYSTEMS (K-56, K-58, K-61, K-62)

  • The sprinkler system is inspected and maintained according to NFPA 25

  • Inspection records for the past 12 months are available for inspection

  • Inspection recommendations have been addressed from previous inspections

  • There are no gaps in celing and/or tiles adjacent to sprinkler heads (escussions are used)

  • High pile storage is a minimum of 18" below and away from sprinkler heads

  • Cubicle curtains are installed to prevent interference with the sprinkler system

  • There are at least two (2) replacement sprinkler heads for each type of sprinkler head used in the facility

  • There is a sprinkler head wrench kept with the spare sprinkler heads

  • Each compartment has the same type of sprinkler head in use

  • Sprinkler heads are clean, dust free and clear of paint or other obstructions

  • Note source of water supply for sprinkler system

  • Date sprinkler system last checked and necessary maintenance provided

  • If Michigan, is contractor Act 144 certified and documentation of contractors certification is available at the community

  • Gauges have been replaced or calibrated once every five (5) years

  • Date performed

WAIVERS

  • Record any waivers and expiration dates

SIGNATURES

  • SIGNATURE OF AUDITOR

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