Audit

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. At least 1" horizontally from ignition source.

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 and approved by AHJ.

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

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)

"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

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)

Approved Power strips are used in resident rooms

GFIC outlets installed within eight 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) (completed by 15th MAHC )

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 10 hours in any continuious 24 hour period or AHJ.

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)

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

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

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

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

Combustibles are stored in authorized metal cabinet

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

Fuel sources are automatically disconnected when the extinguishing system is activated

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

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

Curtains have labels or tags indicating non flammability rating

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

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

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

Full and empty cylinders are are stored seperately or labeled area

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

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

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

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)

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

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 (COMAR only)

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

Single station smoke detectors (Battery operated)

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

CO2 DETECTORS replaced every five years

CO2 alarm in location that have fuel burning equipment or vessel

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

Inspected and tested monthly according to manufacturers instructions

Inspection and testing is documented and available

Replace batteries according to manufacturers instructions (at least yearly)

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

Fire pump

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

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
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.