NFPA 101 2012 Life Safety Code Audit for MAHC

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

ALCOHOL BASED HAND RUB ABHR (K-211)

• Corridors are at least 6 feet wide

  Yes

  No

  N/A

• Dispensers are installed at least 4 feet apart

  Yes

  No

  N/A

• Dispensers are not installed over or adjacent to an ignition source such as electrical switches and/or outlets. At least 1" horizontally from ignition source.

  Yes

  No

  N/A

• Dispensers do not exceed a capacity of 1.2 liters

  Yes

  No

  N/A

• Not more than 10 gallons in a single smoke compartment

  Yes

  No

  N/A

CONSTRUCTION / RENOVATIONS

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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.

  Yes

  No

  N/A

• 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

  Yes

  No

  N/A

• Penetrations are sealed with rated materials. (No expanding foam unless fire rated and approved by AHJ.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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 are not stored in hallways for longer than 30 min. (Isolation carts, and crash carts, lifts and wheelchairs are permissible in the corridors)

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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) 30% coverage

  Yes

  No

  N/A

• 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)

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Door latches open with one motion

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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)

  Yes

  No

  N/A

• Magnetically locked or delay egress locking arrangements

• Doors release appropriately

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

• Approved Power strips are used in resident rooms

  Yes

  No

  N/A

• GFIC outlets installed within eight feet of wet areas.

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

• Power strips are not used in typically wet locations

  Yes

  No

  N/A

• Hair dryers, refridgerators are not plugged into power strips

  Yes

  No

  N/A

• Heat producing appliances are not plugged into power strips

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Maintain 3 foot clearance around all electrical panels

  Yes

  No

  N/A

• All electrical equipment is in good repair

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Electrical outlets have appropriate cover plates

  Yes

  No

  N/A

• Light switches have appropriate cover plates

  Yes

  No

  N/A

• Junction boxes have appropriate cover plates

  Yes

  No

  N/A

EMERGENCY LIGHTING (K-45, K-46)

• Emergency battery lighting is tested for 30 seconds every month

  Yes

  No

  N/A

• Monthly testing information is maintained on a log

  Yes

  No

  N/A

• Emergency battery lighting is tested for 1.5 hours annually

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Exterior emergency lighting is either battery powered or generator supplied

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

• Exit and directional signage properly provide direction for egress path

  Yes

  No

  N/A

• Exit signs provide continuious illumination

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Exit discharges outside the building have a hard surface to the public way

  Yes

  No

  N/A

• Exit discharges outside the building are usable in inclement weather (snow, rain) without impediments

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Fire alarm testing and maintenance records are available for inspection

  Yes

  No

  N/A

• Fire alarm panel is installed in a supervised location

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Date fire alarm last checked and necessary maintenance provided

  Date

• Name of licensed contractor providing inspection / service

  Yes

  No

  N/A

FIRE DRILLS (K-50)

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

  Yes

  No

  N/A

• Fire drills are conducted, One drill, per shift, per quarter (drills at shift change count as ONE drill) (completed by 15th MAHC )

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

  Yes

  No

  N/A

• Third shift fire drills

• QUARTER 1

  Date

• QUARTER 2

  Date

• QUARTER 3

  Date

• QUARTER 4

  Date

• First shift fire drills

• QUARTER 1

  Date

• QUARTER 2

  Date

• QUARTER 3

  Date

• QUARTER 4

  Date

• Second shift fire drills

• QUARTER 1

  Date

• QUARTER 2

  Date

• QUARTER 3

  Date

• QUARTER 4

  Date

• 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

  Yes

  No

  N/A

• By facility staff

• By outside vendor

• Portable fire extinguishers are maintained annually

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Hydrostatic testing of vessels every twelve (12) years

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Extinguishers do not exceed a gross weight of 40 lbs

  Yes

  No

  N/A

• 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

  Yes

  No

  N/A

• 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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

FIRE SAFETY PLAN (K-48)

• Last date reviewed

  Date

• 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 10 hours in any continuious 24 hour period or AHJ.

  Yes

  No

  N/A

• The community has a policy on approved fire watch

  Yes

  No

  N/A

• Approved fire watch must include the following elements:

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

• 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

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

• A log is available to document and review fire watch

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

• Generator(s) are inspected weekly

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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

  Yes

  No

  N/A

• hazardous areas doors latch positively

  Yes

  No

  N/A

• Mechanical rooms are clean and orderly

  Yes

  No

  N/A

• Mechanical rooms are not used for combustable storage

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Fire dampers are cleaned and lubricated as necessary and documentated

  Yes

  No

  N/A

• Combustibles are stored in authorized metal cabinet

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• The hood suppression system is UL 300 compliant

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Is deep fryer at least 16 inches from stove

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Curtains have labels or tags indicating non flammability rating

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Records are maintained of any community treated fire resistance materials

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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'

  Yes

  No

  N/A

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

• Storage areas are secured against unauthorized entry

  Yes

  No

  N/A

• Storage area doors are equipped with self closing devices

  Yes

  No

  N/A

• Storage area doors are positive latching

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Full and empty cylinders are are stored seperately or labeled area

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• 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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

OXYGEN (TRANSFERRING LIQUID OXYGEN) (K-143)

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Liquid oxygen transfering area is mechanically ventilated

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

PORTABLE SPACE HEATERS (K-70)

• There are no portable space heaters used in the facility (COMAR only)

  Yes

  No

  N/A

SMOKING REGULATIONS (K-66)

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Community enforces its no smoking regulation

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Single station smoke detectors (Battery operated)

SMOKE and CO2 DETECTORS (K-53, K-54)

• CO2 DETECTORS replaced every five years

  Yes

  No

  N/A

• CO2 alarm in location that have fuel burning equipment or vessel

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Date of last sensitivity testing

  Date

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

  Yes

  No

  N/A

• 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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Inspected and tested monthly according to manufacturers instructions

  Yes

  No

  N/A

• Inspection and testing is documented and available

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

Fire pump

• Do you have a fire pump, if yes. Do you run weekly ?

  Yes

  No

  N/A

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

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Inspection recommendations have been addressed from previous inspections

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Note source of water supply for sprinkler system

• Date sprinkler system last checked and necessary maintenance provided

  Date

• 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

  Date

WAIVERS

• Record any waivers and expiration dates

SIGNATURES

• SIGNATURE OF AUDITOR

  Sign