Northside Hospital / Life Safety Inspection / Existing Healthcare Occupancy

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

1. Previous Inspection

• 1.1 Has the previous Life Safety Inspection been reviewed?

  Yes

  No

  N/A

• 1.2 Have previous discrepancies been resolved?

  Yes

  No

  N/A

• 1.3 Do the facility's Life Safety drawing match current conditions?

  Yes

  No

  N/A

• 1.4 Is the facility currently using any waivers provided by CMS?

  Yes

  No

  N/A

A1. Fire Doors

• A1.1. Are fire doors provided with positive latching?

  Yes

  No

  N/A

• A1.2. Is the fire door self-closing or automatic closing?

  Yes

  No

  N/A

• A1.3. Is the gap between fire doors 1/8" or less and the gap between the fire door and the floor 3/4" or less?

  Yes

  No

  N/A

• A1.4. Is the fire door free from decorations, door stops, unprotected penetrations, and non-rated hardware?

  Yes

  No

  N/A

• A1.5. Is the fire door free from damaged hardware?

  Yes

  No

  N/A

• A1.6. Does the fire door and frame each have a label indicating the rating?

  Yes

  No

  N/A

• A1.7. If the rated door has a window, does the window have fire wire and or a fire rated label?

  Yes

  No

  N/A

A2. Fire rated walls, ceiling, and floors.

• A2.1. Are penetrations in rated walls as provided on the facility's life safety drawings properly sealed with fire rated material?

  Yes

  No

  N/A

• A2.2. Are penetrations in floors and ceiling properly sealed with fire rated material?

  Yes

  No

  N/A

A3. Fire alarm and sprinkler systems.

• A3.1. Does the fire alarm panel have a smoke detector above it?

  Yes

  No

  N/A

• A3.2. Does the fire alarm panel show all systems normal?

  Yes

  No

  N/A

• A3.3. Have all discrepancies found in the annual fire alarm report been corrected and or repaired?

  Yes

  No

  N/A

• A3.4. Are there any escutcheon plates missing from existing sprinkler heads?

  Yes

  No

  N/A

• A3.5. Where quick response type sprinkler heads are being used are all heads within the compartment of the quick response type?

  Yes

  No

  N/A

• A3.6. Have all discrepancies found during the annual sprinkler inspection report been corrected and or repaired?

  Yes

  No

  N/A

• A3.7. Is sprinkler protection provided throughout the compartment?

  Yes

  No

  N/A

A4. Rooms

• A4.1. Are waiting areas open to the corridor < 600 sqft, with smoke detection, and arranged to not obstruct exit access?

  Yes

  No

  N/A

• A4.2. In all patient sleeping rooms >1000 sqft are there two remotely located exit access doors?

  Yes

  No

  N/A

• A4.3. Are exit access doors < 100 ft from any point in patient sleeping rooms?

  Yes

  No

  N/A

• A4.4. Is the travel distance from any point in a sleeping suite to an exit < 200 ft?

  Yes

  No

  N/A

• A4.5. Are all soiled linen and trash collection rooms rated at 1 hour?

  Yes

  No

  N/A

A5. Corridors

• A5.1. Is the corridor constructed as to limit the passage of smoke?

  Yes

  No

  N/A

• A5.2. Are all dead-end corridors less than 30 ft?

  Yes

  No

  N/A

• A5.3. Is there a minimum of 48" of clear width where serving as a means of egress from patient sleeping rooms?

  Yes

  No

  N/A

• A5.4. Are projections into the corridor < 6"?

  Yes

  No

  N/A

• A5.5. Where fixed furniture is located in a corridor that is a minimum of 8ft are all 8 requirements met per section 19.2.3.4(5), LSC 101, 2012 Edition?

  Yes

  No

  N/A

A6. General

• A6.1. Are exit signs properly illuminated?

  Yes

  No

  N/A

• A6.2. Is there adequate exit signage?

  Yes

  No

  N/A

• A6.3. Are pull stations, exit signs, exit doors, notification appliances, extinguishers, and any other life safety systems component obstructed?

  Yes

  No

  N/A

• A6.4. Are fire extinguishers tagged appropriately and within annual certification and with monthly checks?

  Yes

  No

  N/A

• A6.5. Are all stored materials a minimum of 18" from the sprinkler head?

  Yes

  No

  N/A

• A6.6. Is the area free from signs of smoking?

  Yes

  No

  N/A

• A6.7. Are electrical panels unobstructed and locked with a minimum storage free space of 30"?

  Yes

  No

  N/A

A7. Documentation

• A7.1. After meeting with the facility's Engineering Manager have you confirmed that all Life Safety/EC documentation is up-to-date and being recorded appropriately?

  Yes

  No

  N/A

Signatures:

• Facility Engineering Manager

  Sign

• Life Safety Compliance Specialist

  Sign