CMS-2786R

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICE

2012 LIF E SAFET Y CODE

Form Approved OMB Exempt

FIRE SAFETY SURVEY REPORT - 2012 LIFE SAFETY CODE

HEALTHCARE

1. (A) PROVIDER NUMBER

1. (B) MEDICAID I.D. NO.

PART I — Life Safety Code, New and Existing

PART II — Health Care Facilities Code, New and Existing

PART III — Recommendation for Waiver

PART IV – Crucial Data Extract

OPTIONAL

— Chapter 4 – NFPA 101A - Fire Safety Evaluation System for Health Care Occupancies – CMS-2786T

Identifying information as shown in applicable records. Enter changes, if any, alongside each item, giving date of change.

2. NAME OF FACILITY 2. (A) MULTIPLE CONSTRUCTION (BLDGS)

A. BUILDING

B. WING

C. FLOOR

2. (B) ADDRESS OF FACILITY (STREET, CITY, STATE, ZIP CODE)

Fully Sprinklered

(All required areas are sprinklered)

Partially Sprinklered

(Not all required areas are

sprinklered)

None

(No sprinkler system)

K0180

3. SURVEY FOR

MEDICARE

MEDICAID

4. DATE OF SURVEY

DATE OF PLAN APPROVAL

SURVEY UNDER

5. 2012 EXISTING

6. 2012 NEW

5. SURVEY FOR CERTIFICATION OF

1. HOSPITAL

SKILLED/NURSING FACILITY 4. ICF/IID UNDER HEALTH CARE 5. HOSPICE

_______________

________________

IF “2” OR “5” ABOVE IS MARKED, CHECK APPROPRIATE ITEM(S) BELOW

1. ENTIRE FACILITY 2. DISTINCT PART OF (SPECIFY

OSPITAL, IS HOSPITAL ACCREDITED?

3. IF DISTINCT PART OF H

a. YES b

6. BED COMPOSITION

a. TOTAL NO. OF BEDS IN

THE FACILITY

b. NUMBER OF HOSPITAL BEDS

CERTIFIED FOR MEDICARE

c. NUMBER OF SKILLED BEDS

CERTIFIED FOR MEDICARE _

d. NUMBER OF SKILLED BEDS

CERTIFIED FOR MEDICAID

e. NUMBER OF NF or ICF/IID BEDS

CERTIFIED FOR MEDICAID

) _____________________________________

_____

____ _____ ____

____

7. A. THE FACILITY MEETS THE STANDARD, BASED UPON (CHECK ALL APPROPRIATE BOXES)

1. COMPLIANCE WITH ALL PROVISIONS 2. ACCEPTANCE OF A PLAN OF CORRECTION

3. RECOMMENDED WAIVERS

FSES

PERFORMANCE BASED DESIGN

THE FACILITY DOES NOT MEET THE STANDARD

SURVEYOR (Signature) TITLE OFFICE DATE

SURVEYOR ID

K10

FIRE AUTHORITY OFFICIAL (Signature) TITLE OFFICE DATE

CMS FORMS SHALL BE COMPLETED AND RETAINED AS PART OF THE SURVEY RECORD.

Form CMS-2786R (07/2018)

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2012 LIFE SAFETY CODE

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PART I – NFPA 101 LSC REQUIREMENTS

(Items in italics relate to the FSES)

SECTION 1 – GENERAL REQUIREMENTS

K100

General Requirements – Other

List in the REMARKS section any LSC Section 18.1 and 19.1 General

Requirements that are not addressed by the provided K-tags, but are

deficient. This information, along with the applicable Life Safety Code or

NFPA standard citation, should be included on Form CMS-2567.

K111

Building Rehabilitation

Repair, Renovation, Modification, or Reconstruction

Any building undergoing repair, renovation, modification, or reconstruction

complies with both of the following:

 Requirements of Chapter 18 and 19.

 Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6.

18.1.1.4.3, 19.1.1.4.3, 43.1.2.1

Change of Use or Change of Occupancy

Any building undergoing change of use or change of occupancy

classification complies with the requirements of Section 43.7, unless

permitted by 18.1.1.4.2 or 19.1.1.4.2.

18.1.1.4.2 (4.6.7 and 4.6.11), 19.1.1.4.2 (4.6.7 and 4.6.11), 43.1.2.2 (43.7)

Additions

Any building undergoing an addition shall comply with the requirements of

Section 43.8. If the building has a common wall with a nonconforming

building, the common wall is a fire barrier having at least a two hour fire

resistance rating constructed of materials as required for the addition.

Communicating openings occur only in corridors and are protected by

approved self-closing fire doors with at least a 1-1/2 hour fire resistance

rating. Additions comply with the requirements of Section 43.8.

18.1.1.4.1 (4.6.7 and 4.6.11), 18.1.1.4.1.1 (8.3), 18.1.1.4.1.2, 18.1.1.4.1.3,

19.1.1.4.1 (4.6.7 and 4.6.11), 19.1.1.4.1.1 (8.3), 19.1.1.4.1.2, 19.1.1.4.1.3,

43.1.2.3(43.8)

Form CMS-2786R (07/2018) Page 2

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2012 LIFE SAFETY CODE

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K112

Sprinkler Requirements for Major Rehabilitation

If a nonsprinklered smoke compartment has undergone major rehabilitation

the automatic sprinkler requirements of 18.3.5 have been applied to the

smoke compartment.

In cases where the building is not protected throughout by a sprinkler

system, the requirements of 18.4.3.2, 18.4.3.3, and 18.4.3.8 are also met.

Note: Major rehabilitation involves the modification of more than 50 percent,

or more than 4500 ft² of the area of the smoke compartment.

18.1.1.4.3.3, 19.1.1.4.3.3

K131

Multiple Occupancies – Sections of Health Care Facilities

Sections of health care facilities classified as other occupancies meet all of

the following:

 They are not intended to serve four or more inpatients for purposes of

housing, treatment, or customary access.

 They are separated from areas of health care occupancies by

construction having a minimum two hour fire resistance rating in

accordance with Chapter 8.

 The entire building is protected throughout by an approved, supervised

automatic sprinkler system in accordance with Section 9.7.

Hospital outpatient surgical departments are required to be classified as an

Ambulatory Health Care Occupancy regardless of the number of patients

served.

18.1.3.3, 19.1.3.3, 42 CFR 482.41, 42 CFR 485.623

K132

Multiple Occupancies – Contiguous Non-Health Care Occupancies

Non-health care occupancies that are located immediately next to a Health

Care Occupancy, but are primarily intended to provide outpatient services

are permitted to be classified as Business or Ambulatory Health Care

Occupancies, provided the facilities are separated by construction having

not less than two hour fire resistance-rated construction, and are not

intended to provide services simultaneously for four or more inpatients.

Outpatient surgical departments must be classified as Ambulatory Health

Care Occupancy regardless of the number of patients served.

18.1.3.4.1, 19.1.3.4.1

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2012 LIFE SAFETY CODE

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K133

Multiple Occupancies – Construction Type

Where separated occupancies are in accordance with 18/19.1.3.2 or

18/19.1.3.4, the most stringent construction type is provided throughout the

building, unless a two hour separation is provided in accordance with

8.2.1.3, in which case the construction type is determined as follows:

 The construction type and supporting construction of the health care

occupancy is based on the story in which it is located in the building in

accordance with 18/19.1.6 and Tables 18/19.1.6.1.

 The construction type of the areas of the building enclosing the other

occupancies shall be based on the applicable occupancy chapters.

18.1.3.5, 19.1.3.5, 8.2.1.3

K161

Building Construction Type and Height

2012 EXISTING

Building construction type and stories meets Table 19.1.6.1, unless

otherwise permitted by 19.1.6.2 through 19.1.6.7

19.1.6.4, 19.1.6.5

Construction Type

1 I (442), I (332), II (222)

Any number of stories

non-sprinklered or sprinklered

2 II (111)

One story non-sprinklered

Maximum 3 stories sprinklered

3 II (000)

Not allowed non-sprinklered

Maximum 2 stories sprinklered

4 III (211)

5 IV (2HH)

6 V (111)

7 III (200)

Not allowed non-sprinklered

Maximum 1 story sprinklered

8 V (000)

Sprinklered stories must be sprinklered throughout by an approved,

supervised automatic system in accordance with section 9.7. (See 19.3.5)

Give a brief description, in REMARKS, of the construction, the number of stories,

including basements, floors on which patients are located, location of smoke or

fire barriers and dates of approval. Complete sketch or attach small floor

plan of the building as appropriate.

Form CMS-2786R (07/2018) Page 4

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K161 2012 NEW

Building construction type and stories meets Table 18.1.6.1, unless

otherwise permitted by 18.1.6.2 through 18.1.6.7

18.1.6.4, 18.1.6.5

Construction Type

Not allowed non-sprinklered

1 I (442), I (332), II (222)

Any number of stories sprinklered

Not allowed non-sprinklered

II (111)

Maximum 3 stories sprinklered

II (000)

III (211)

Not allowed non-sprinklered

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Maximum 1 story sprinklered

5 IV (2HH)

6 V (111)

7 III (200)

Not allowed non-sprinklered

8 V (000)

Sprinklered stories must be sprinklered throughout by an approved,

supervised automatic system in accordance with section 9.7. (See 18.3.5)

Give a brief

description, in REMARKS, of the construction, the number of stories,

including basements, floors on

which patients are located, location of smoke or

fire barriers and dates of approval. Complete sketch or attach small floor

plan of the building as appropriate.

K162

Roofing Systems Involving Combustibles

2012 EXISTING

Buildings of Type I (442), Type I (332), Type II (222), or Type II (111)

having roof systems employing combustible roofing supports, decking or

roofing meet the following:

1. roof covering meets Class C requirements.

2. roof is separated from occupied building portions with a

noncombustible floor assembly using not less than 2½ inches concrete

or gypsum fill.

3. attic or other space is either unoccupied or protected throughout by an

approved automatic sprinkler system.

19.1.6.2*, ASTM E108, ANSI/UL 790

Name of Facility

2012 LIFE SAFETY CODE

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K162 2012 NEW

Buildings of Type I (442), Type I (332), Type II (222), Type II (111) having

roof systems employing combustible roofing supports, decking or roofing

meet the following:

1. roof covering meets Class A requirements.

2. roof is separated from occupied building portions with 2 hour fire

resistive noncombustible floor assembly using not less than 2½ inches

concrete or gypsum fill.

3. the structural elements supporting the rated floor assembly meet the

required fire resistance rating of the building.

18.1.6.2, ASTM E108, ANSI/UL 790

K163

Interior Nonbearing Wall Construction

Interior nonbearing walls in Type I or II construction are constructed of

noncombustible or limited-combustible materials.

Interior nonbearing walls required to have a minimum 2 hour fire

resistance rating are permitted to be fire-retardant-treated wood enclosed

within noncombustible or limited-combustible materials, provided they are

not used as shaft enclosures.

18.1.6.4, 18.1.6.5, 19.1.6.4, 19.1.6.5

SECTION 2 – MEANS OF EGRESS REQUIREMENTS

K200

Means of Egress Requirements – Other

List in the REMARKS section any LSC Section 18.2 and 19.2 Means of

Egress requirements that are not addressed by the provided K-tags, but are

deficient. This information, along with the applicable Life Safety Code or

NFPA standard citation, should be included on Form CMS-2567.

18.2, 19.2

K211

Means of Egress – General

Aisles, passageways, corridors, exit discharges, exit locations, and

accesses are in accordance with Chapter 7, and the means of egress is

continuously maintained free of all obstructions to full use in case of

emergency, unless modified by 18/19.2.2 through 18/19.2.11.

18.2.1, 19.2.1, 7.1.10.1

Name of Facility

2012 LIFE SAFETY CODE

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K221

Patient Sleeping Room Doors

Locks on patient sleeping room doors are not permitted unless the key-

locking device that restricts access from the corridor does not restrict

egress from the patient room, or the locking arrangement is permitted for

patient clinical, security or safety needs in accordance with 18.2.2.2.5 or

19.2.2.2.5.

18.2.2.2, 19.2.2.2, TIA 12-4

K222

Egress Doors

Doors in a required means of egress shall not be equipped with a latch or a

lock that requires the use of a tool or key from the egress side unless using

one of the following special locking arrangements:

☐ CLINICAL NEEDS OR SECURITY THREAT LOCKING

Where special locking arrangements for the clinical security needs of the

patient are used, only one locking device shall be permitted on each door

and provisions shall be made for the rapid removal of occupants by: remote

control of locks; keying of all locks or keys carried by staff at all times; or

other such reliable means available to the staff at all times.

18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6

☐ SPECIAL NEEDS LOCKING ARRANGEMENTS

Where special locking arrangements for the safety needs of the patient are

used, all of the Clinical or Security Locking requirements are being met. In

addition, the locks must be electrical locks that fail safely so as to release

upon loss of power to the device; the building is protected by a supervised

automatic sprinkler system and the locked space is protected by a complete

smoke detection system (or is constantly monitored at an attended location

within the locked space); and both the sprinkler and detection systems are

arranged to unlock the doors upon activation.

18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4

Name of Facility

2012 LIFE SAFETY CODE

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K222

K223

☐ DELAYED-EGRESS LOCKING ARRANGEMENTS

Approved, listed delayed-egress locking systems installed in accordance

with 7.2.1.6.1 shall be permitted on door assemblies serving low and

ordinary hazard contents in buildings protected throughout by an approved,

supervised automatic fire detection system or an approved, supervised

automatic sprinkler system.

18.2.2.2.4, 19.2.2.2.4

☐ ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS

Access-Controlled Egress Door assemblies installed in accordance with

7.2.1.6.2 shall be permitted.

18.2.2.2.4, 19.2.2.2.4

☐ ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS

Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall

be permitted on door assemblies in buildings protected throughout by an

approved, supervised automatic fire detection system and an approved,

supervised automatic sprinkler system.

18.2.2.2.4, 19.2.2.2.4

Doors with Self-Closing Devices

Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke

barrier, or hazardous area enclosure are self-closing and kept in the closed

position, unless held open by a release device complying with 7.2.1.8.2 that

automatically closes all such doors throughout the smoke compartment or

entire facility upon activation of:

 Required manual fire alarm system; and

 Local smoke detectors designed to detect smoke passing through the

opening or a required smoke detection system; and

 Automatic sprinkler system, if installed; and

 Loss of power.

18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

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2012 LIFE SAFETY CODE

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K224

K225

K226

K227

K231

Horizontal-Sliding Doors

Horizontal-sliding doors permitted by 7.2.1.14 that are not automatic-closing

are limited to a single leaf and shall have a latch or other mechanism to

ensure the door will not rebound.

Horizontal-sliding doors serving an occupant load fewer than 10 shall be

permitted, providing all of the following criteria are met:

 Area served by the door has no high hazard contents.

 Door is operable from either side without special knowledge or effort.

 Force required to operate the door in the direction of travel is ≤ 30 lbf to

set the door in motion and ≤ 15 lbf to close or open to the required

width.

 Assembly is appropriately fire rated, and where rated, is self-or

automatic-closing by smoke detection per 7.2.1.8, and installed per

NFPA 80.

 Where required to latch, the door has a latch or other mechanism to

ensure the door will not rebound.

18.2.2.2.10, 19.2.2.2.10

Stairways and Smokeproof Enclosures

Stairways and Smokeproof enclosures used as exits are in accordance with

7.2.

18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Horizontal Exits

Horizontal exits, if used, are in accordance with 7.2.4 and the provisions of

18.2.2.5.1 through 18.2.2.5.7, or 19.2.2.5.1 through 19.2.2.5.4.

18.2.2.5, 19.2.2.5

Ramps and Other Exits

Ramps, exit passageways, fire and slide escapes, alternating tread devices,

and areas of refuge are in accordance with the provisions 7.2.5 through

7.2.12.

18.2.2.6 to 18.2.2.10 or 19.2.2.6 to 19.2.2.10

Means of Egress Capacity

The capacity of required means of egress is in accordance with 7.3.

18.2.3.1, 19.2.3.1

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2012 LIFE SAFETY CODE

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K232

K233

Aisle, Corridor or Ramp Width

2012 EXISTING

The width of aisles or corridors (clear or unobstructed) serving as exit

access shall be at least 4 feet and maintained to provide the convenient

removal of nonambulatory patients on stretchers, except as modified by

19.2.3.4, exceptions 1-5.

19.2.3.4, 19.2.3.5

2012 NEW

The width of aisles or corridors (clear and unobstructed) serving as exit

access in hospitals and nursing homes shall be at least 8 feet. In limited

care facility and psychiatric hospitals, width of aisles or corridors shall be at

least 6 feet, except as modified by the 18.2.3.4 or 18.2.3.5 exceptions.

18.2.3.4, 18.2.3.5

Clear Width of Exit and Exit Access Doors

2012 EXISTING

Exit access doors and exit doors are of the swinging type and are at least

32 inches in clear width. Exceptions are provided for existing 34-inch doors

and for existing 28-inch doors where the fire plan does not require

evacuation by bed, gurney, or wheelchair.

19.2.3.6, 19.2.3.7

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K241

2012 NEW

Exit access doors and exit doors are of the swinging type and are at least

41.5 inches in clear width. In psychiatric hospitals or limited care facilities,

doors are at least 32 inches wide. Doors not subject to patient use, in exit

stairway enclosures, or serving newborn nurseries shall be no less than 32

inches in clear width. If using a pair of doors, the doors shall be provided

with a rabbet, bevel, or astragal at the meeting edge, at least one of the

doors shall provide 32 inches in clear width, and the inactive leaf of the pair

shall be secured with automatic flush bolts.

18.2.3.6, 18.2.3.7

Number of Exits – Story and Compartment

Not less than two exits, remote from each other, and accessible from every

part of every story are provided for each story. Each smoke compartment

shall likewise be provided with two distinct egress paths to exits that do not

require the entry into the same adjacent smoke compartment.

18.2.4.1-18.2.4.4, 19.2.4.1-19.2.4.4

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2012 LIFE SAFETY CODE

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K251

K252

K253

K254

K255

Dead-End Corridors and Common Path of Travel

2012 EXISTING

Dead-end corridors shall not exceed 30 feet. Existing dead-end corridors

greater than 30 feet shall be permitted to be continued to be used if it is

impractical and unfeasible to alter them.

19.2.5.2

2012 NEW

Dead-end corridors shall not exceed 30 feet. Common path of travel shall

not exceed 100 feet.

18.2.5.2, 18.2.5.3

Number of Exits – Corridors

Every corridor shall provide access to not less than two approved exits in

accordance with Sections 7.4 and 7.5 without passing through any

intervening rooms or spaces other than corridors or lobbies.

18.2.5.4, 19.2.5.4

Number of Exits – Patient Sleeping and Non-Sleeping Rooms

Patient sleeping rooms of more than 1,000 square feet or nonsleeping

rooms of more than 2,500 square feet have at least two exit access doors

remotely located from each other.

18.2.5.5.1, 18.2.5.5.2, 19.2.5.5.1, 19.2.5.5.2

Corridor Access

All habitable rooms not within suites have a door leading directly outside to

grade or have a door leading to an exit access corridor. Patient sleeping

rooms with less than eight patient beds may have one room intervening to

reach an exit access corridor provided the intervening room is equipped

with an approved automatic smoke detection system.

18.2.5.6.1 through 18.2.5.6.4, 19.2.5.6.1 through 19.2.5.6.4

Suite Separation, Hazardous Content, and Subdivision

All suites are separated from the remainder of the building (including from

other suites) by construction meeting the separation provisions for corridor

construction (18.3.6.2-18.3.6.5 or 19.3.6.2-19.3.6.5). Existing approved

barriers shall be allowed to continue to be used provided they limit the

transfer of smoke. Intervening rooms have no hazardous areas and

hazardous areas within suites comply with 18/19.2.5.7.1.3. Subdivision of

suites shall be by noncombustible or limited-combustible construction.

18.2.5.7.1.2 through 18.2.5.7.1.4, 19.2.5.7.1.2, 19.2.5.7.1.3, 19.2.5.7.1.4

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2012 LIFE SAFETY CODE

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K256

K257

Sleeping Suites

Occupants shall have exit access to a corridor or direct access to a

horizontal exit. Where ≥ 2 exits are required, one exit access door may be

to a stairway, passageway or to the exterior. Suites shall be provided with

constant staff supervision. Staff shall have direct visual supervision of

patient sleeping rooms, from a constantly attended location or the room

shall be provided with an automatic smoke detection system.

Suites more than 1,000 ft² shall have 2 or more remote exits. One means of

egress from the suite shall be to a corridor and one may be into an adjacent

suite separated in accordance with corridor requirements.

Suites shall not exceed the following size limitations:

 5,000 square feet if the suite is not fully smoke detected or fully

sprinklered.

 7,500 square feet if the suite is either fully smoke detected or fully

sprinklered.

 10,000 square feet if the suite is both fully smoke detected and fully

sprinklered and the sleeping rooms have direct supervision from a

constantly attended location.

Travel distance between any point in a suite to exit access shall not exceed

100 feet and distance to an exit shall not exceed 150 feet (200 feet if

building is fully sprinklered).

18.2.5.7.2, 19.2.5.7.2

Non-Sleeping Suites

Occupants shall have exit access to a corridor or direct access to a

horizontal exit. Where ≥ 2 exits are required, one exit access door may be

to a stairway, passageway or to the exterior.

Suites more than 2,500 ft² shall have 2 or more remote exits. One means of

egress from the suite shall be to a corridor and one may be into an adjacent

suite separated in accordance with corridor requirements.

Suites shall not exceed 10,000 ft².

Travel distance between any point in a suite to exit access shall not exceed

100 feet and distance to an exit shall not exceed 150 feet (200 feet if

building is fully sprinklered).

18.2.5.7.3, 19.2.5.7.3

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K261

K271

K281

K291

K292

Travel Distance to Exits

Travel distance (excluding suites) to exits are measured in accordance with

7.6.

 From any point in the room or suite to exit less than or equal to 150

feet (less than or equal to 200 feet if the building is fully

sprinklered).

 Point in a room to room door less than or equal to 50 feet.

18.2.6, 19.2.6

Discharge from Exits

Exit discharge is arranged in accordance with 7.7, provides a level walking

surface meeting the provisions of 7.1.7 with respect to changes in elevation

and shall be maintained free of obstructions. Additionally, the exit

discharge shall be a hard packed all-weather travel surface.

18.2.7, 19.2.7

Illumination of Means of Egress

Illumination of means of egress, including exit discharge, is arranged in

accordance with 7.8 and shall be either continuously in operation or

capable of automatic operation without manual intervention.

18.2.8, 19.2.8

Emergency Lighting

Emergency lighting of at least 1-1/2 hour duration is provided automatically

in accordance with 7.9.

18.2.9.1, 19.2.9.1

Life Support Means of Egress

2012 NEW (INDICATE N/A FOR EXISTING)

Buildings equipped with or requiring the use of life support systems (electro-

mechanical or inhalation anesthetics) have illumination of means of egress,

emergency lighting equipment, exit, and directional signs supplied by the

life safety branch of the electrical system described in NFPA 99.

(Indicate N/A if life support equipment is for emergency purposes only.)

18.2.9.2, 18.2.10.5

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2012 LIFE SAFETY CODE

Form CMS-2786R (07/2018) Page 13

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K293

Exit Signage

2012 EXISTING

Exit and directional signs are displayed in accordance with 7.10 with

continuous illumination also served by the emergency lighting system.

19.2.10.1

(Indicate N/A in one-story existing occupancies with less than 30 occupants

where the line of exit travel is obvious.)

2012 NEW

Exit and directional signs are displayed in accordance with 7.10 with

continuous illumination also served by the emergency lighting system.

18.2.10.1

SECTION 3 – PROTECTION

K300

Protection – Other

List in the REMARKS section any LSC Section 18.3 and 19.3 Protection

requirements that are not addressed by the provided K-tags, but are

deficient. This information, along with the applicable Life Safety Code or

NFPA standard citation, should be included on Form CMS-2567.

K311

Vertical Openings – Enclosure

2012 EXISTING

Stairways, elevator shafts, light and ventilation shafts, chutes, and other

vertical openings between floors are enclosed with construction having a

fire resistance rating of at least 1-hour. An atrium may be used in

accordance with 8.6.

19.3.1.1 through 19.3.1.6

If all vertical openings are properly enclosed with construction providing at

least a 2 hour fire resistance rating, also check this

box. ☐

2012 NEW

Stairways, elevator shafts, light and ventilation shafts, chutes, and other

vertical openings between floors are enclosed with construction having a

fire resistance rating of at least 2 hours connecting four or more stories. (1-

hour for single story building and buildings up to three stories in height.) An

atrium may be used in accordance with 8.6.7.

18.3.1 through 18.3.1.5

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K321

Hazardous Areas – Enclosure

2012 EXISTING

Hazardous areas are protected by a fire barrier having 1-hour fire

resistance rating (with ¾ hour fire rated doors) or an automatic fire

extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the

approved automatic fire extinguishing system option is used, the areas

shall be separated from other spaces by smoke resisting partitions and

doors in accordance with 8.4. Doors shall be self-closing or automatic-

closing and permitted to have nonrated or field-applied protective plates

that do not exceed 48 inches from the bottom of the door.

Describe the floor and zone locations of hazardous areas that are deficient

in REMARKS.

19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A

a. Boiler and Fuel-Fired Heater Rooms

b. Laundries (larger than 100 sq. ft.)

c. Repair, Maintenance, and Paint Shops

d. Soiled Linen Rooms

(exceeding 64 gal.)

e. Trash Collection Rooms

(exceeding 64 gal.)

f. Combustible Storage Rooms/Spaces

(over 50 sq. ft.)

g. Laboratories (if classifie

d as Severe

zard -

see



K322)

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K321 2012 NEW

Hazardous areas are protected in accordance with 18.3.2.1. The areas

shall be enclosed with a 1-hour fire-rated barrier, with a ¾ hour fire-rated

door without windows (in accordance with 8.7.1.1). Doors shall be self-

closing or automatic-closing in accordance with 7.2.1.8. Hazardous areas

are protec ted by a sprinkler system in accordance with 9.7, 18.3.2.1, and

8.4.

Describe the floor and zone locations of hazardous areas that are deficient

in REMARKS .

18.3.2.1, 7.2.1.8, 8.4, 8.7, 9.7

Area Automatic Sprinkler Separation N/A 

a. Boiler and Fuel-Fired Heater Rooms

b. Laundries (larger than 100 sq. ft.)

c. Repair, Maintenance, and Paint Shops

d. Soiled Linen Rooms



(exceeding 64 gal.)

e. Trash Collection Rooms



(exceeding 64 gal.)

f. Combustible Storage Rooms/Spaces



(over 50 and less than 100 sq. ft.)

g. Combustible Storage Rooms/Spaces



(over 100 sq. ft.)

h. Laboratories (if classified as Severe

Hazard -



see K322)

Form CMS-2786R (07/2018) Page 16

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K322

Laboratories

Laboratories employing quantities of flammable, combustible, or

hazardous materials that are considered a severe hazard are protected by

1-hour fire resistance-rated separation, automatic sprinkler system, and

are in accordance with 8.7 and with NFPA 99.

Laboratories not considered a severe hazard are protected as hazardous

areas (see K321).

Laboratories using chemicals are in accordance with NFPA 45, Standard

on Fire Protection for Laboratories Using Chemicals.

Gas appliances are of appropriate design and installed in accordance with

NFPA 54. Shutoff valves are marked to identify material they control.

Devices requiring medical grade oxygen from the piped distribution system

meet the requirements under 11.4.2.2 (NFPA 99).

18.3.2.2, 19.3.2.2, 8.7, 8.7.4.1 (LSC)

9.3.1.2, 11.4.3.2, 15.4 (NFPA 99)

Form CMS-2786R (07/2018) Page 17

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K323

Anesthetizing Locations

Areas designated for administration of general anesthesia (i.e., inhalation

anesthetics) are in accordance with 8.7 and NFPA 99.

Zone valves are: located immediately outside each life-support, critical

care, and anesthetizing location of moderate sedation, deep sedation, or

general anesthesia for medical gas or vacuum; readily accessible in an

emergency; and arranged so shutting off any one anesthetizing location will

not affect others.

Area alarm panels are provided to monitor all medical gas, medical-

surgical vacuum, and piped WAGD systems. Panels are at locations that

provide for surveillance, indicate medical gas pressure decreases of 20

percent and vacuum decreases of 12 inch gauge HgV, and provide visual

and audible indication. Alarm sensors are installed either on the source

side of individual room zone valve box assemblies or on the patient/use

side of each of the individual zone box valve assemblies.

The EES critical branch supplies power for task illumination, fixed

equipment, select receptacles, and select power circuits, and EES

equipment system supplies power to ventilation system.

Heating, cooling, and ventilation are in accordance with ASHRAE 170.

Medical supply and equipment manufacturer’s instructions for use are

considered before reducing humidity levels to those allowed by ASHRAE,

per S&C 13-58.

18.3.2.3, 19.3.2.3 (LSC)

5.1.4.8.7, 5.1.4.8.7.2, 5.1.9.3, 5.1.9.3.4, 6.4.2.2.4.2 (NFPA 99)

Form CMS-2786R (07/2018) Page 18

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K324

Cooking Facilities

Cooking equipment is protected in accordance with NFPA 96, Standard for

Ventilation Control and Fire Protection of Commercial Cooking Operations,

unless:

 residential cooking equipment (i.e., small appliances such as

microwaves, hot plates, toasters) are used for food warming or limited

cooking in accordance with 18.3.2.5.2, 19.3.2.5.2.

 cooking facilities open to the corridor in smoke compartments with 30 or

fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3,

 cooking facilities in smoke compartments with 30 or fewer patients

comply with conditions under 18.3.2.5.4, 19.3.2.5.4.

Cooking facilities protected according to NFPA 96 per 9.2.3 are not required

to be enclosed as hazardous areas, but shall not be open to the corridor.

18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

K325

Alcohol Based Hand Rub Dispenser (ABHR)

ABHRs are protected in accordance with 8.7.3.1, unless all conditions are

met:

 Corridor is at least 6 feet wide.

 Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in

suites) of fluid and 18 ounces of Level 1 aerosols.

 Dispensers shall have a minimum of four foot horizontal spacing.

 Not more than an aggregate of 10 gallons of fluid or 1135 ounces of

aerosol are used in a single smoke compartment outside a storage

cabinet, excluding one individual dispenser per room.

 Storage in a single smoke compartment greater than 5 gallons complies

with NFPA 30.

 Dispensers are not installed within 1 inch of an ignition source.

 Dispensers over carpeted floors are in sprinklered smoke

compartments.

 ABHR does not exceed 95 percent alcohol.

 Operation of the dispenser shall comply with Section 18.3.2.6(11) or

19.3.2.6(11).

 ABHR is protected against inappropriate access.

18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485

Form CMS-2786R (07/2018) Page 19

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K331

Interior Wall and Ceiling Finish

2012 EXISTING

Interior wall and ceiling finishes, including exposed interior surfaces of

buildings such as fixed or movable walls, partitions, columns, and have a

flame spread rating of Class A or Class B. The reduction in class of interior

finish for a sprinkler system as prescribed in 10.2.8.1 is permitted.

10.2, 19.3.3.1, 19.3.3.2

Indicate flame spread rating(s). _____________________

2012 NEW

Interior wall and ceiling finishes, including exposed interior surfaces of

buildings such as fixed or movable walls, partitions and columns have a

flame spread rating of Class A. The reduction in class of interior finish for a

sprinkler system as prescribed in 10.2.8.1 is permitted.

Individual rooms not exceeding four persons may have a Class A or B

finish.

Lower half of corridor walls, not exceeding 4 feet in height, may have a

Class A or B flame spread rating.

10.2, 18.3.3.1, 18.3.3.2

Indicate flame spread rating(s). _____________________

K332

Interior Floor Finish

2012 NEW (Indicate N/A for 2012 EXISTING)

Interior finishes shall comply with 10.2. Floor finishes in exit enclosures and

exit access corridors and spaces not separated by walls that resist the

passage of smoke shall be Class I or II.

18.3.3.3.1, 18.3.3.3.2, 18.3.3.3.3, 10.2, 10.2.7.1, 10.2.7.2

K341

Fire Alarm System – Installation

A fire alarm system is installed with systems and components approved for

the purpose in accordance with NFPA 70, National Electric Code, and

NFPA 72, National Fire Alarm Code to provide effective warning of fire in

any part of the building. In areas not continuously occupied, detection is

installed at each fire alarm control unit. In new occupancy, detection is also

installed at notification appliance circuit power extenders, and supervising

station transmitting equipment. Fire alarm system wiring or other

transmission paths are monitored for integrity.

18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8

Form CMS-2786R (07/2018) Page 20

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K342

Fire Alarm System – Initiation

Initiation of the fire alarm system is by manual means and by any required

sprinkler system alarm, detection device, or detection system. Manual

alarm boxes are provided in the path of egress near each required exit.

Manual alarm boxes in patient sleeping areas shall not be required at exits

if manual alarm boxes are located at all nurse’s stations or other

continuously attended staff location, provided alarm boxes are visible,

continuously accessible, and 200’ travel distance is not exceeded.

18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5

K343

Fire Alarm – Notification

2012 EXISTING

Positive alarm sequence in accordance with 9.6.3.4 are permitted in

buildings protected throughout by a sprinkler system. Occupant notification

is provided automatically in accordance with 9.6.3 by audible and visual

signals.

In critical care areas, visual alarms are sufficient. The fire alarm system

transmits the alarm automatically to notify emergency forces in the event of

a fire.

19.3.4.3, 19.3.4.3.1, 19.3.4.3.2, 9.6.4, 9.7.1.1(1)

2012 NEW

Positive alarm sequence in accordance with 9.6.3.4 are permitted.

Occupant notification is provided automatically in accordance with 9.6.3 by

audible and visual signals.

In critical care areas, visual alarms are sufficient. The fire alarm system

transmits the alarm automatically to notify emergency forces in the event of

a fire.

Annunciation and annunciation zoning for fire alarm and sprinklers shall be

provided by audible and visual indicators and zones shall not be larger than

22,500 square feet per zone.

18.3.4.3 through 18.3.4.3.3, 9.6.4

K344

Fire Alarm – Control Functions

The fire alarm automatically activates required control functions and is

provided with an alternative power supply in accordance with NFPA 72.

18.3.4.4, 19.3.4.4, 9.6.1, 9.6.5, NFPA 72

Form CMS-2786R (07/2018) Page 21

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K345

Fire Alarm System – Testing and Maintenance

A fire alarm system is tested and maintained in accordance with an

approved program complying with the requirements of NFPA 70, National

Electric Code, and NFPA 72, National Fire Alarm and Signaling Code.

Records of system acceptance, maintenance and testing are readily

available.

9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

K346

Fire Alarm – Out of Service

Where required fire alarm system is out of services for more than 4 hours in

a 24 hour period, the authority having jurisdiction shall be notified, and the

building shall be evacuated or an approved fire watch shall be provided for

all parties left unprotected by the shutdown until the fire alarm system has

been returned to service.

9.6.1.6

K347

Smoke Detection

2012 EXISTING

Smoke detection systems are provided in spaces open to corridors as

required by 19.3.6.1.

19.3.4.5.2

2012 NEW

Smoke detection systems are provided in spaces open to corridors as

required by 18.3.6.1

In nursing homes, an automatic smoke detection system is installed in the

corridors of all smoke compartments containing resident sleeping rooms,

unless the resident sleeping rooms have:

 smoke detection, or

 automatic door closing devices with integral smoke detectors on the

room side that provide occupant notification.

Such detectors are electrically interconnected to the fire alarm system.

18.3.4.5.2, 18.3.4.5.3

Form CMS-2786R (07/2018) Page 22

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K351

Sprinkler System – Installation

2012 EXISTING

Nursing homes, and hospitals where required by construction type, are

protected throughout by an approved automatic sprinkler system in

accordance with NFPA 13, Standard for the Installation of Sprinkler

Systems.

In Type I and II construction, alternative protection measures are permitted

to be substituted for sprinkler protection in specific areas where state or

local regulations prohibit sprinklers.

In hospitals, sprinklers are not required in clothes closets of patient sleeping

rooms where the area of the closet does not exceed 6 ft² and sprinkler

coverage covers the closet footprint as required by NFPA 13, Standard for

Installation of Sprinkler Systems.

19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7,

9.7.1.1(1)

2012 NEW

Buildings are to be protected throughout by an approved automatic

sprinkler system in accordance with NFPA 13, Standard for the Installation

of Sprinkler Systems.

In Type I and II construction, alternative protection measures are permitted

to be substituted for sprinkler protection in specific areas where State and

local regulations prohibit sprinklers.

Listed quick-response or listed residential sprinklers are used throughout

smoke compartments with patient sleeping rooms.

In hospitals, sprinklers are not required in clothes closets of patient sleeping

rooms where the area of the closet does not exceed 6 ft² and sprinkler

coverage covers the closet footprint as required by NFPA 13, Standard for

Installation of Sprinkler Systems.

18.3.5.1, 18.3.5.4, 18.3.5.5, 18.3.5.6, 9.7, 9.7.1.1(1), 18.3.5.10

K352

Sprinkler System – Supervisory Signals

Automatic sprinkler system supervisory attachments are installed and

monitored for integrity in accordance with NFPA 72, National Fire Alarm

and Signaling Code, and provide a signal that sounds and is displayed at a

continuously attended location or approved remote facility when sprinkler

operation is impaired.

9.7.2.1, NFPA 72

Form CMS-2786R (07/2018) Page 23

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K353

Sprinkler System – Maintenance and Testing

Automatic sprinkler and standpipe systems are inspected, tested, and

maintained in accordance with NFPA 25, Standard for the Inspection,

Testing, and Maintaining of Water-based Fire Protection Systems. Records

of system design, maintenance, inspection and testing are maintained in a

secure location and readily available.

a) Date sprinkler system last checked. _____________________

b) Who provided system test. ____________________________

c) Water system supply source. __________________________

Provide in REMARKS information on coverage for any non-required or

partial automatic sprinkler system.

9.7.5, 9.7.7, 9.7.8, and NFPA 25

K354

Sprinkler System – Out of Service

Where the sprinkler system is impaired, the extent and duration of the

impairment has been determined, areas or buildings involved are inspected

and risks are determined, recommendations are submitted to management

or designated representative, and the fire department and other authorities

having jurisdiction have been notified. Where the sprinkler system is out of

service for more than 10 hours in a 24 hour period, the building or portion of

the building affected are evacuated or an approved fire watch is provided

until the sprinkler system has been returned to service.

18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25)

K355

Portable Fire Extinguishers

Portable fire extinguishers are selected, installed, inspected, and

maintained in accordance with NFPA 10, Standard for Portable Fire

Extinguishers.

18.3.5.12, 19.3.5.12, NFPA 10

K361

Corridors – Areas Open to Corridor

Spaces (other than patient sleeping rooms, treatment rooms and hazardous

areas), waiting areas, nurse’s stations, gift shops, and cooking facilities,

open to the corridor are in accordance with the criteria under 18.3.6.1 and

19.3.6.1.

18.3.6.1, 19.3.6.1

Form CMS-2786R (07/2018) Page 24

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K362

Corridors – Construction of Walls

2012 EXISTING

Corridors are separated from use areas by walls constructed with at least

½ hour fire resistance rating. In fully sprinklered smoke compartments,

partitions are only required to resist the transfer of smoke. In nonsprinklered

buildings, walls extend to the underside of the floor or roof deck above the

ceiling. Corridor walls may terminate at the underside of ceilings where

specifically permitted by Code.

Fixed fire window assemblies in corridor walls are in accordance with

Section 8.3, but in sprinklered compartments there are no restrictions in

area or fire resistance of glass or frames.

If the walls have a fire resistance rating, give the rating _____________ if

the walls terminate at the underside of the ceiling, give brief description in

REMARKS, describing the ceiling throughout the floor area.

19.3.6.2, 19.3.6.2.7

2012 NEW

Corridor walls shall form a barrier to limit the transfer of smoke. Such walls

shall be permitted to terminate at the ceiling where the ceiling is constructed

to limit the transfer of smoke. No fire resistance rating is required for the

corridor walls.

18.3.6.2

Form CMS-2786R (07/2018) Page 25

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K363

Corridor – Doors

2012 EXISTING

Doors protecting corridor openings in other than required enclosures of

vertical openings, exits, or hazardous areas resist the passage of smoke

and are made of 1¾ inch solid-bonded core wood or other material capable

of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke

compartments are only required to resist the passage of smoke. Corridor

doors and doors to rooms containing flammable or combustible materials

have positive latching hardware. Roller latches are prohibited by CMS

regulation. These requirements do not apply to auxiliary spaces that do not

contain flammable or combustible material.

Powered doors complying with 7.2.1.9 are permissible if provided with a

device capable of keeping the door closed when a force of 5lbf is applied,

whether or not power is applied.

Clearance between bottom of door and floor covering is not exceeding 1

inch. There is no impediment to the closing of the doors. Hold open

devices that release when the door is pushed or pulled are permitted.

Nonrated protective plates of unlimited height are permitted. Dutch doors

meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made

of steel or other materials in compliance with 8.3, unless the smoke

compartment is sprinklered. Fixed fire window assemblies are allowed per

8.3. In sprinklered compartments there are no restrictions in area or fire

resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485

Show in REMARKS details of doors such as fire protection ratings,

automatics closing devices, etc.

2012 NEW

Doors protecting corridor openings shall be constructed to resist the

passage of smoke. Corridor doors and doors to rooms containing

flammable or combustible materials have self-latching and positive latching

hardware. Roller latches are prohibited by CMS regulation. These

requirements do not apply to auxiliary spaces that do not contain

flammable or combustible material.

Powered doors complying with 7.2.1.9 are permissible if provided with a

device capable of keeping the door closed when a force of 5lbf is applied,

whether or not power is applied.

Clearance between bottom of door and floor covering is not exceeding 1

inch.

There is no impediment to the closing of the doors. Hold open

devices that release when the door is pushed or pulled are permitted.

Nonrated protective plates of unlimited height are permitted. Dutch doors

meeting 18.3.6.3.6 are permitted.

18.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485

Show in REMARKS details of doors such as fire protection ratings,

automatic closing devices, etc.

Name of Facility

2012 LIFE SAFETY CODE

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2012 LIFE SAFETY CODE

PREFIX

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NOT

MET

N/A REMARKS

K364

Corridor – Openings

Transfer grilles are not used in corridor walls or doors. Auxiliary spaces

that do not contain flammable or combustible materials are permitted to

have louvers or be undercut.

In other than smoke compartments containing patient sleeping rooms,

miscellaneous openings are permitted in vision panels or doors, provided

the openings per room do not exceed 20 in² and are at or below half the

distance from floor to ceiling. In sprinklered rooms, the openings per room

do not exceed 80 in².

Vision panels in corridor walls or doors shall be fixed window assemblies in

approved frames. (In fully sprinklered smoke compartments, there are no

restrictions in the area and fire resistance of glass and frames.)

18.3.6.5.1, 19.3.6.5.2, 8.3

K371

Subdivision of Building Spaces – Smoke Compartments

2012 EXISTING

Smoke barriers shall be provided to form at least two smoke compartments

on every sleeping floor with a 30 or more patient bed capacity. Size of

compartments cannot exceed 22,500 square feet or a 200-foot travel

distance from any point in the compartment to a door in the smoke barrier.

19.3.7.1, 19.3.7.2

Detail in REMARKS zone dimensions including length of zones and dead-

end corridors.

2012 NEW

Smoke barriers shall be provided to form at least two smoke compartments

on every floor used by inpatients for sleeping or treatment, and on every

floor with an occupant load of 50 or more persons, regardless of use.

Size of compartments cannot exceed 22,500 square feet or a 200-foot

travel distance from any point in the compartment to a door in the smoke

barrier.

Smoke subdivision requirements do not apply to any of the stories or areas

described in 18.3.7.2.

18.3.7.1, 18.3.7.2

Detail in REMARKS zone dimensions including length of zones and dead-

end corridors.

Form CMS-2786R (07/2018) Page 27

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K372

Subdivision of Building Spaces – Smoke Barrier Construction

2012 EXISTING

Smoke barriers shall be constructed to a ½ hour fire resistance rating per

8.5. Smoke barriers shall be permitted to terminate at an atrium wall.

Smoke dampers are not required in duct penetrations in fully ducted HVAC

systems where an approved sprinkler system is installed for smoke

compartments adjacent to the smoke barrier.

19.3.7.3, 8.6.7.1(1)

Describe any mechanical smoke control system in REMARKS.

2012 NEW

Smoke barriers shall be constructed to provide at least a 1-hour fire

resistance rating and constructed in accordance with 8.5. Smoke barriers

shall be permitted to terminate at an atrium wall. Smoke dampers are not

required in duct penetrations of fully ducted HVAC systems.

18.3.7.3, 18.3.7.4, 18.3.7.5, 8.3

Describe any mechanical smoke control system in REMARKS.

K373

Subdivision of Building Spaces – Accumulation Space

Space shall be provided on each side of smoke barriers to adequately

accommodate the total number of occupants in adjoining compartments.

18.3.7.5.1, 18.3.7.5.2, 19.3.7.5.1, 19.3.7.5.2

K374

Subdivision of Building Spaces – Smoke Barrier Doors

2012 EXISTING

Doors in smoke barriers are 1¾-inch thick solid bonded wood-core doors or

of construction that resists fire for 20 minutes. Nonrated protective plates of

unlimited height are permitted. Doors are permitted to have fixed fire

window assemblies per 8.5. Doors are self-closing or automatic-closing, do

not require latching, and are not required to swing in the direction of egress

travel. Door opening provides a minimum clear width of 32 in for swinging

or horizontal doors.

19.3.7.6, 19.3.7.8, 19.3.7.9

Form CMS-2786R (07/2018) Page 28

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K374 2012 NEW

Doors in smoke barriers have at least a 20-minute fire protection rating or

are at least 1¾-inch thick solid bonded core wood.

Required clear widths are provided per 18.3.7.6(4) and (5).

Nonrated protective plates of unlimited height are permitted. Horizontal-

sliding doors comply with 7.2.1.14. Swinging doors shall be arranged so

that each door swings in an opposite direction.

Doors shall be self-closing and rabbets, bevels, or astragals are required at

the meeting edges. Positive latching is not required.

18.3.7.6, 18.3.7.7, 18.3.7.8

K379

Smoke Barrier Door Glazing

2012 EXISTING

Openings in smoke barrier doors shall be fire-rated glazing or wired glass

panels in steel frames.

19.3.7.6, 19.3.7.6.2, 8.5

2012 NEW

Windows in smoke barrier doors shall be installed in each cross corridor

swinging or horizontal-sliding door protected by fire-rated glazing or by

wired glass panels in approved frames.

18.3.7.9

K381

Sleeping Room Outside Windows and Doors

Every patient sleeping room has an outside window or outside door. In new

occupancies, sill height does not exceed 36 inches above the

floor. Windows in atrium walls are considered outside windows. Newborn

nurseries and rooms intended for occupancy less than 24 hours have no

outside window or door requirements. Window sills in special nursing care

areas (e.g., ICU, CCU, hemodialysis, neonatal) do not exceed 60 inches

above the floor.

42 CFR 403, 418, 460, 482, 483, and 485

SECTION 4 – SPECIAL PROVISIONS

K400

Special Provisions – Other

List in the REMARKS section any LSC Section 18.4 and 19.4 Special

Provisions requirements that are not addressed by the provided K-tags, but

are deficient. This information, along with the applicable Life Safety Code or

NFPA standard citation, should be included on Form CMS-2567.

Form CMS-2786R (07/2018) Page 29

(10/2016)

Page 30

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K421

High-Rise Buildings

2012 EXISTING

High-rise buildings are protected throughout by an approved, supervised

automatic sprinkler system in accordance with Section 9.7 within 12 years

of LSC final rule effective date.

19.4.2

2012 NEW

High-rise buildings comply with section 11.8.

18.4.2

SECTION 5 – BUILDING SERVICES

K500

Building Services – Other

List in the REMARKS section any LSC Section 18.5 and 19.5 Building

Services requirements that are not addressed by the provided K-tags, but

are deficient. This information, along with the applicable Life Safety Code or

NFPA standard citation, should be included on Form CMS-2567.

K511

Utilities – Gas and Electric

Equipment using gas or related gas piping complies with NFPA 54, National

Fuel Gas Code, electrical wiring and equipment complies with NFPA 70,

National Electric Code. Existing installations can continue in service

provided no hazard to life.

18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2

K521

HVAC

Heating, ventilation, and air conditioning shall comply with 9.2 and shall be

installed in accordance with the manufacturer’s specifications.

18.5.2.1, 19.5.2.1, 9.2

K522

18.5.2.2, 19.5.2.2

HVAC – Any Heating Device

Any heating device, other than a central heating plant, is designed and

installed so combustible materials cannot be ignited by device, and has a

safety feature to stop fuel and shut down equipment if there is excessive

temperature or ignition failure. If fuel fired, the device also:

 is chimney or vent connected.

 takes air for combustion from outside.

 provides for a combustion system separate from occupied area

atmosphere.

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K523

HVAC – Suspended Unit Heaters

Suspended unit heaters are permitted provided the following are met:

 Not located in means of egress or in patient rooms.

 Located high enough to be out of reach of people in the area.

 Has a safety feature to stop fuel and shut down equipment if there is

excessive temperature or ignition failure.

18.5.2.3(1), 19.5.2.3(1)

K524

HVAC – Direct-Vent Gas Fireplaces

Direct-vent gas fireplaces, as defined in NFPA 54, inside of all smoke

compartments containing patient sleeping areas comply with the

requirements of 18.5.2.3(2), 19.5.2.3(2).

18.5.2.3(2), 19.5.2.3(2), NFPA 54

K525

HVAC – Solid Fuel-Burning Fireplaces

Solid fuel-burning fireplaces are permitted in other than patient sleeping

areas provided:

 Areas are separated by 1-hour fire resistance construction.

 Fireplace complies with 9.2.2.

 Fireplace enclosure resists breakage up to 650°F and has heat-

tempered glass.

 Room has supervised CO detection per 9.8.

18.5.2.3(3) and 19.5.2.3(3)

K531

Elevators

2012 EXISTING

Elevators comply with the provision of 9.4. Elevators are inspected and

tested as specified in ASME A17.1, Safety Code for Elevators and

Escalators. Firefighter’s Service is operated monthly with a written record.

Existing elevators conform to ASME/ANSI A17.3, Safety Code for Existing

Elevators and Escalators. All existing elevators, having a travel distance of

25 feet or more above or below the level that best serves the needs of

emergency personnel for firefighting purposes, conform with Firefighter’s

Service Requirements of ASME/ANSI A17.3. (Includes firefighter’s service

Phase I key recall and smoke detector automatic recall, firefighter’s service

Phase II emergency in-car key operation, machine room smoke detectors,

and elevator lobby smoke detectors.)

19.5.3, 9.4.2, 9.4.3

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K531 2012 NEW

Elevators comply with the provision of 9.4. Elevators are inspected and

tested as specified in ASME A17.1, Safety Code for Elevators and

Escalators. Firefighter’s Service is operated monthly with a written record.

New elevators conform to ASME/ANSI A17.1, Safety Code for Elevators

and Escalators, including Firefighter’s Service Requirements. (Includes

firefighter’s Phase I key recall and smoke detector automatic recall,

firefighter’s service Phase II emergency in-car key operation, machine room

smoke detectors, and elevator lobby smoke detectors.)

18.5.3, 9.4.2, 9.4.3

K532

Escalators, Dumbwaiters, and Moving Walks

2012 EXISTING

Escalators, dumbwaiters, and moving walks comply with the provisions of

9.4.

All existing escalators, dumbwaiters, and moving walks conform to the

requirements of ASME/ANSI A17.3, Safety Code for Existing Elevators and

Escalators.

(Includes escalator emergency stop buttons and automatic skirt obstruction

stop. For power dumbwaiters, includes hoistway door locking to keep doors

closed except for floor where car is being loaded or unloaded.)

19.5.3, 9.4.2.2

2012 NEW

Escalators, dumbwaiters, and moving walks comply with the provisions of

9.4.

18.5.3, 9.4.2.2

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K541

Rubbish Chutes, Incinerators, and Laundry Chutes

2012 EXISTING

(1)

Any existing linen and trash chute, including pneumatic rubbish and

linen systems, that opens directly onto any corridor shall be sealed by

fire resistive construction to prevent further use or shall be provided with

a fire door assembly having a fire protection rating of 1-hour. All new

chutes shall comply with 9.5.

(2)

Any rubbish chute or linen chute, including pneumatic rubbish and linen

systems, shall be provided with automatic extinguishing protection in

accordance with 9.7.

(3)

Any trash chute shall discharge into a trash collection room used for no

other purpose and protected in accordance with 8.4. (Existing laundry

chutes permitted to discharge into same room are protected by

automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)

(4)

Existing fuel-fed incinerators shall be sealed by fire resistive

construction to prevent further use.

19.5.4, 9.5, 8.4, NFPA 82

2012 NEW

Rubbish chutes, incinerators, and laundry chutes shall comply with the

provisions of Section 9.5, unless otherwise specified in 18.5.4.2.

 The fire resistance rating of chute charging room shall not be required

to exceed 1-hour.

 Any rubbish chute or linen chute shall be provided with automatic

extinguishing protection in accordance with Section 9.7.

 Chutes shall discharge into a trash collection room used for no other

purpose and shall be protected in accordance with 8.7.

18.5.4.2, 8.7, 9.5, 9.7, NFPA 82

SECTION 6 – RESERVED

SECTION 7 – OPERATING FEATURES

K700

Operating Features – Other

List in the REMARKS section any LSC Section 18.7 and 19.7 Operating

Features requirements that are not addressed by the provided K-tags, but

are deficient. This information, along with the applicable Life Safety Code or

NFPA standard citation, should be included in Form CMS-2567.

Form CMS-2786R (07/2018) Page 33

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K711

Evacuation and Relocation Plan

There is a written plan for the protection of all patients and for their

evacuation in the event of an emergency.

Employees are periodically instructed and kept informed with their duties

under the plan, and a copy of the plan is readily available with telephone

operator or with security. The plan addresses the basic response required

of staff per 18/19.7.2.1.2 and provides for all of the fire safety plan

components per 18/19.7.2.2.

18.7.1.1 through 18.7.1.3, 18.7.2.1.2, 18.7.2.2, 18.7.2.3, 19.7.1.1 through

19.7.1.3, 19.7.2.1.2, 19.7.2.2, 19.7.2.3

K712

Fire Drills

Fire drills include the transmission of a fire alarm signal and simulation of

emergency fire conditions. Fire drills are held at expected and unexpected

times under varying conditions, at least quarterly on each shift. The staff is

familiar with procedures and is aware that drills are part of established

routine. Where drills are conducted between 9:00 PM and 6:00 AM, a

coded announcement may be used instead of audible alarms.

18.7.1.4 through 18.7.1.7, 19.7.1.4 through 19.7.1.7

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K741

Smoking Regulations

Smoking regulations shall be adopted and shall include not less than the

following provisions:

(1)

Smoking shall be prohibited in any room, ward, or compartment where

flammable liquids, combustible gases, or oxygen is used or stored and

in any other hazardous location, and such area shall be posted with

signs that read NO SMOKING or shall be posted with the international

symbol for no smoking.

(2)

In health care occupancies where smoking is prohibited and signs are

prominently placed at all major entrances, secondary signs with

language that prohibits smoking shall not be required.

(3)

Smoking by patients classified as not responsible shall be prohibited.

(4)

The requirement of 18.7.4(3) shall not apply where the patient is under

direct supervision.

(5)

Ashtrays of noncombustible material and safe design shall be provided

in all areas where smoking is permitted.

(6)

Metal containers with self-closing cover devices into which ashtrays can

be emptied shall be readily available to all areas where smoking is

permitted.

18.7.4, 19.7.4

K751

Draperies, Curtains, and Loosely Hanging Fabrics

Draperies, curtains including cubicle curtains and loosely hanging fabric or

films shall be in accordance with 10.3.1. Excluding curtains and draperies:

at showers and baths; on windows in patient sleeping room located in

sprinklered compartments; and in non-patient sleeping rooms in sprinklered

compartments where individual drapery or curtain panels do not exceed 48

square feet or total area does not exceed 20 percent of the wall.

18.7.5.1, 18.3.5.11, 19.7.5.1, 19.3.5.11, 10.3.1

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K752

Upholstered Furniture and Mattresses

Newly introduced upholstered furniture meets Class I or char length, and

heat release criteria in accordance with 10.3.2.1 and 10.3.3, unless the

building is fully sprinklered.

Newly introduced mattresses shall meet char length and heat release

criteria in accordance with 10.3.2.2 and 10.3.4, unless the building is fully

sprinklered.

Upholstered furniture and mattresses belonging to nursing home

residents do not have to meet these requirements as all nursing homes

are required to be fully sprinklered.

Newly introduced upholstered furniture and mattresses means purchased

on or after the LSC final rule effective date.

18.7.5.2, 18.7.5.4, 19.7.5.2, 19.7.5.4

K753

Combustible Decorations

Combustible decorations shall be prohibited unless one of the following is met:

 Flame retardant or treated with approved fire-retardant coating that is

listed and labeled for product.

 Decorations meet NFPA 701.

 Decorations exhibit heat release less than 100 kilowatts in accordance

with NFPA 289.

 Decorations, such as photographs, paintings and other art are attached

to the walls, ceilings and non-fire-rated doors in accordance with

18.7.5.6(4) or 19.7.5.6(4).

 The decorations in existing occupancies are in such limited quantities

that a hazard of fire development or spread is not present.

18.7.5.6, 19.7.5.6

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K761

Maintenance, Inspection & Testing - Doors

Fire doors assemblies are inspected and tested annually in accordance

with NFPA 80 Standard for Fire Doors and Other Opening Protectives.

Fire doors that are not located in required fire barriers, including corridor

doors to patient rooms and smoke barrier doors, are routinely inspected as

part of the facility maintenance program.

Individuals performing the door inspection and testing have an

understanding of the operating components of the doors. Written records of

inspection and testing are maintained and are available for review.

18.7.6, 19.7.6, 8.3.3.1 (LSC), 5.2, 5.2.3 (NFPA 80)

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K754

Soiled Linen and Trash Containers

Soiled linen or trash collection receptacles shall not exceed 32 gallons in

capacity. The average density of container capacity in a room or space

shall not exceed 0.5 gallons/square feet. A total container capacity of 32

gallons shall not be exceeded within any 64 square feet area. Mobile soiled

linen or trash collection receptacles with capacities greater than 32 gallons

shall be located in a room protected as a hazardous area when not

attended.

Containers used solely for recycling are permitted to be excluded from the

above requirements where each container is ≤ 96 gal. unless attended, and

containers for combustibles are labeled and listed as meeting FM Approval

Standard 6921 or equivalent.

18.7.5.7, 19.7.5.7

K771

Engineer Smoke Control Systems

2012 EXISTING

When installed, engineered smoke control systems are tested in

accordance with established engineering principles. Test documentation is

maintained on the premises.

19.7.7

2012 NEW

When installed, engineered smoke control systems are tested in

accordance with NFPA 92, Standard for Smoke Control Systems. Test

documentation is maintained on the premises.

18.7.7

K781

Portable Space Heaters

Portable space heating devices shall be prohibited in all health care

occupancies. Unless used in nonsleeping staff and employee areas where

the heating elements do not exceed 212 degrees Fahrenheit (100 degrees

Celsius).

18.7.8, 19.7.8

K791

Construction, Repair, and Improvement Operations

Construction, repair, and improvement operations shall comply with 4.6.10.

Any means of egress in any area undergoing construction, repair, or

improvements shall be inspected daily to ensure its ability to be used

instantly in case of emergency and compliance with NFPA 241.

18.7.9, 19.7.9, 4.6.10, 7.1.10.1

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PART II – HEALTH CARE FACILITIES CODE REQUIREMENTS

K900

Health Care Facilities Code - Other

List in the REMARKS section any NFPA 99 requirements (excluding

Chapter 7, 8, 12, and 13) that are not addressed by the provided K-Tags,

but are deficient. This information, along with the applicable Health Care

Facilities Code or NFPA standard citation, should be included on Form

CMS-2567.

K901

Fundamentals – Building System Categories

Building systems are designed to meet Category 1 through 4 requirements

as detailed in NFPA 99. Categories are determined by a formal and

documented risk assessment procedure performed by qualified personnel.

Chapter 4 (NFPA 99)

K902

Gas and Vacuum Piped Systems – Other

List in the REMARKS section any NFPA 99 Chapter 5 Gas and Vacuum

Systems requirements that are not addressed by the provided K-Tags, but

are deficient. This information, along with the applicable Life Safety Code or

NFPA standard citation, should be included on Form CMS-2567.

Chapter 5 (NFPA 99)

K903

Gas and Vacuum Piped Systems – Categories

Medical gas, medical air, surgical vacuum, WAGD, and air supply systems

are designated:

☐ Category 1. Systems in which failure is likely to cause major injury or death.

☐ Category 2. Systems in which failure is likely to cause minor injury.

☐ Category 3. Systems in which failure is not likely to cause injury, but can

cause discomfort.

K904

Gas and Vacuum Piped Systems – Warning Systems

All master, area, and local alarm systems used for medical gas and vacuum

systems comply with appropriate Category warning system requirements,

as applicable.

5.1.9, 5.2.9, 5.3.6.2.2 (NFPA 99)

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Deep sedation and general anesthesia are not to be administered using a

Category 3 medical gas system.

5.1.1.1, 5.2.1, 5.3.1.1, 5.3.1.5 (NFPA 99)

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K905

Gas and Vacuum Piped Systems – Central Supply System

Identification and Labeling

Containers, cylinders and tanks are designed, fabricated, tested, and

marked in accordance with 5.1.3.1.1 through 5.1.3.1.7. Locations

containing only oxygen or medical air have doors labeled with "Medical

Gases, NO Smoking or Open Flame". Locations containing other gases

have doors labeled "Positive Pressure Gases, NO Smoking or Open Flame,

Room May Have Insufficient Oxygen, Open Door and Allow Room to

Ventilate Before Opening.”

5.1.3.1, 5.2.3.1, 5.3.10 (NFPA 99)

K906

Gas and Vacuum Piped Systems – Central Supply System Operations

Adaptors or conversion fittings are prohibited. Cylinders are handled in

accordance with 11.6.2. Only cylinders, reusable shipping containers, and

their accessories are stored in rooms containing central supply systems or

cylinders. No flammable materials are stored with cylinders. Cryogenic

liquid storage units intended to supply the facility are not used to transfill.

Cylinders are kept away from sources of heat. Valve protection caps are

secured in place, if supplied, unless cylinder is in use. Cylinders are not

stored in tightly closed spaces. Cylinders in use and storage are prevented

from exceeding 130°F, and nitrous oxide and carbon dioxide cylinders are

prevented from reaching temperatures lower than manufacture

recommendations or 20°F. Full or empty cylinders, when not connected, are

stored in locations complying with 5.1.3.3.2 through 5.1.3.3.3, and are not

stored in enclosures containing motor-driven machinery, unless for

instrument air reserve headers.

5.1.3.2, 5.1.3.3.17, 5.1.3.3.1.8, 5.1.3.3.4, 5.2.3.2, 5.2.3.3, 5.3.6.20.4,

5.6.20.5, 5.3.6.20.7, 5.3.6.20.8, 5.3.6.20.9 (NFPA 99)

K907

Gas and Vacuum Piped Systems – Maintenance Program

Medical gas, vacuum, WAGD, or support gas systems have documented

maintenance programs. The program includes an inventory of all source

systems, control valves, alarms, manufactured assemblies, and outlets.

Inspection and maintenance schedules are established through risk

assessment considering manufacturer recommendations. Inspection

procedures and testing methods are established through risk assessment.

Persons maintaining systems are qualified as demonstrated by training and

certification or credentialing to the requirements of AASE 6030 or 6040.

5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99)

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K908

Gas and Vacuum Piped Systems – Inspection and Testing Operations

The gas and vacuum systems are inspected and tested as part of a

maintenance program and include the required elements. Records of the

inspections and testing are maintained as required.

5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99)

K909

Gas and Vacuum Piped Systems – Information and Warning Signs

Piping is labeled by stencil or adhesive markers identifying the gas or

vacuum system, including the name of system or chemical symbol, color

code (Table 5.1.11), and operating pressure if other than standard. Labels

are at intervals not more than 20 feet, are in every room, at both sides of

wall penetrations, and on every story traversed by riser. Piping is not

painted. Shutoff valves are identified with the name or chemical symbol of

the gas or vacuum system, room or area served, and caution to not use the

valve except in emergency.

5.1.14.3, 5.1.11.1, 5.1.11.2, 5.2.11, 5.3.13.3, 5.3.11 (NFPA 99)

K910

Gas and Vacuum Piped Systems – Modifications

Whenever modifications are made that breach the pipeline, any necessary

installer and verification test specified in 5.1.2 is conducted on the

downstream portion of the medical gas piping system. Permanent records

of all tests required by system verification tests are maintained.

5.1.14.4.1, 5.1.14.4.6, 5.2.13, 5.3.13.4.3 (NFPA 99)

K911

Electrical Systems – Other

List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems

requirements that are not addressed by the provided K-Tags, but are

deficient. This information, along with the applicable Life Safety Code or

NFPA standard citation, should be included on Form CMS-2567.

Chapter 6 (NFPA 99)

K912

Electrical Systems – Receptacles

Power receptacles have at least one, separate, highly dependable

grounding pole capable of maintaining low-contact resistance with its

mating plug. In pediatric locations, receptacles in patient rooms,

bathrooms, play rooms, and activity rooms, other than nurseries, are listed

tamper-resistant or employ a listed cover.

If used in patient care room, ground-fault circuit interrupters (GFCI) are

listed.

6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)

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K913

Electrical Systems – Wet Procedure Locations

Operating rooms are considered wet procedure locations, unless otherwise

determined by a risk assessment conducted by the facility governing body.

Operating rooms defined as wet locations are protected by either isolated

power or ground-fault circuit interrupters. A written record of the risk

assessment is maintained and available for inspection.

6.3.2.2.8.4, 6.3.2.2.8.7, 6.4.4.2

K914

Electrical Systems – Maintenance and Testing

Hospital-grade receptacles at patient bed locations and where deep

sedation or general anesthesia is administered, are tested after initial

installation, replacement or servicing. Additional testing is performed at

intervals defined by documented performance data. Receptacles not listed

as hospital-grade at these locations are tested at intervals not exceeding 12

months. Line isolation monitors (LIM), if installed, are tested at intervals of

≤ 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates

both visual and audible alarm. For LIM circuits with automated self-testing,

this manual test is performed at intervals ≤ 12 months. LIM circuits are

tested per 6.3.3.3.2 after any repair or renovation to the electric distribution

system. Records are maintained of required tests and associated repairs or

modifications, containing date, room or area tested, and results.

6.3.4 (NFPA 99)

K915

Electrical Systems – Essential Electric System Categories

☐ Critical care rooms (Category 1) in which electrical system failure is likely

to cause major injury or death of patients, including all rooms where electric

life support equipment is required, are served by a Type 1 EES.

☐ General care rooms (Category 2) in which electrical system failure is

likely to cause minor injury to patients (Category 2) are served by a Type 1

or Type 2 EES.

☐ Basic care rooms (Category 3) in which electrical system failure is not

likely to cause injury to patients and rooms other than patient care rooms

are not required to be served by an EES. Type 3 EES life safety branch has

an alternate source of power that will be effective for 1 1/2 hours.

3.3.138, 6.3.2.2.10, 6.6.2.2.2, 6.6.3.1.1 (NFPA 99), TIA 12-3

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K916

Electrical Systems – Essential Electric System Alarm Annunciator

A remote annunciator that is storage battery powered is provided to operate

outside of the generating room in a location readily observed by operating

personnel. The annunciator is hard-wired to indicate alarm conditions of

the emergency power source. A centralized computer system (e.g.,

building information system) is not to be substituted for the alarm

annunciator.

6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99)

K917

Electrical Systems – Essential Electric System Receptacles

Electrical receptacles or cover plates supplied from the life safety and

critical branches have a distinctive color or marking.

6.4.2.2.6, 6.5.2.2.4.2, 6.6.2.2.3.2 (NFPA 99)

K918

Electrical Systems – Essential Electric System Maintenance and

Testing

The generator or other alternate power source and associated equipment is

capable of supplying service within 10 seconds. If the 10-second criterion is

not met during the monthly test, a process shall be provided to annually

confirm this capability for the life safety and critical branches. Maintenance

and testing of the generator and transfer switches are performed in

accordance with NFPA 110.

Generator sets are inspected weekly, exercised under load 30 minutes 12

times a year in 20-40 day intervals, and exercised once every 36 months for

4 continuous hours. Scheduled test under load conditions include a

complete simulated cold start and automatic or manual transfer of all EES

loads, and are conducted by competent personnel. Maintenance and

testing of stored energy power sources (Type 3 EES) are in accordance

with NFPA 111. Main and feeder circuit breakers are inspected annually,

and a program for periodically exercising the components is established

according to manufacturer requirements. Written records of maintenance

and testing are maintained and readily available. EES electrical panels and

circuits are marked, readily identifiable, and separate from normal power

circuits. Minimizing the possibility of damage of the emergency power

source is a design consideration for new installations.

6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

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K919

Electrical Equipment – Other

List in the REMARKS section any NFPA 99 Chapter 10, Electrical

Equipment, requirements that are not addressed by the provided K-Tags,

but are deficient. This information, along with the applicable Life Safety

Code or NFPA standard citation, should be included on Form CMS-2567.

Chapter 10 (NFPA 99)

K920

Electrical Equipment – Power Cords and Extension Cords

Power strips in a patient care vicinity are only used for components of

movable patient-care-related electrical equipment (PCREE) assembles that

have been assembled by qualified personnel and meet the conditions of

10.2.3.6. Power strips in the patient care vicinity may not be used for non-

PCREE (e.g., personal electronics), except in long-term care resident

rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or

UL 60601-1. Power strips for non-PCREE in the patient care rooms

(outside of vicinity) meet UL 1363. In non-patient care rooms, power strips

meet other UL standards. All power strips are used with general

precautions. Extension cords are not used as a substitute for fixed wiring of

a structure. Extension cords used temporarily are removed immediately

upon completion of the purpose for which it was installed and meets the

conditions of 10.2.4.

10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA

70), TIA 12-5

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K921

Electrical Equipment – Testing and Maintenance Requirements

The physical integrity, resistance, leakage current, and touch current tests

for fixed and portable patient-care related electrical equipment (PCREE) is

performed as required in 10.3. Testing intervals are established with

policies and protocols. All PCREE used in patient care rooms is tested in

accordance with 10.3.5.4 or 10.3.6 before being put into service and after

any repair or modification. Any system consisting of several electrical

appliances demonstrates compliance with NFPA 99 as a complete system.

Service manuals, instructions, and procedures provided by the

manufacturer include information as required by 10.5.3.1.1 and are

considered in the development of a program for electrical equipment

maintenance. Electrical equipment instructions and maintenance manuals

are readily available, and safety labels and condensed operating

instructions on the appliance are legible. A record of electrical equipment

tests, repairs, and modifications is maintained for a period of time to

demonstrate compliance in accordance with the facility's policy. Personnel

responsible for the testing, maintenance and use of electrical appliances

receive continuing training.

10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8

K922

Gas Equipment – Other

List in the REMARKS section any NFPA 99 Chapter 11 Gas Equipment

requirements that are not addressed by the provided K-Tags, but are

deficient. This information, along with the applicable Life Safety Code or

NFPA standard citation, should be included on Form CMS-2567.

Chapter 11 (NFPA 99)

Form CMS-2786R (07/2018) Page 44

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2012 LIFE SAFETY CODE

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K923

Gas Equipment – Cylinder and Container Storage

≥ 3,000 cubic feet

Storage locations are designed, constructed, and ventilated in accordance

with 5.1.3.3.2 and 5.1.3.3.3.

> 300 but <3,000 cubic feet

Storage locations are outdoors in an enclosure or within an enclosed

interior space of non- or limited- combustible construction, with door (or

gates outdoors) that can be secured. Oxidizing gases are not stored with

flammables, and are separated from combustibles by 20 feet (5 feet if

sprinklered) or enclosed in a cabinet of noncombustible construction having

a minimum 1/2 hr. fire protection rating.

≤ 300 cubic feet

In a single smoke compartment, individual cylinders available for immediate

use in patient care areas with an aggregate volume of ≤ 300 cubic feet are

not required to be stored in an enclosure. Cylinders must be handled with

precautions as specified in 11.6.2.

A precautionary sign readable from 5 feet is on each door or gate of a

cylinder storage room, where the sign includes the wording as a minimum

"CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING".

Storage is planned so cylinders are used in order of which they are

received from the supplier. Empty cylinders are segregated from full

cylinders. When facility employs cylinders with integral pressure gauge, a

threshold pressure considered empty is established. Empty cylinders are

marked to avoid confusion. Cylinders stored in the open are protected from

weather.

11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

K924

Gas Equipment – Testing and Maintenance Requirements

Anesthesia apparatus are tested at the final path to patient after any

adjustment, modification or repair. Before the apparatus is returned to

service, each connection is checked to verify proper gas and an oxygen

analyzer is used to verify oxygen concentration. Defective equipment is

immediately removed from service. Areas designated for servicing of

oxygen equipment are clean and free of oil, grease, or other flammables.

Manufacturer service manuals are used to maintain equipment and a

scheduled maintenance program is followed.

11.4.1.3, 11.5.1.3, 11.6.2.5, 11.6.2.6 (NFPA 99)

Form CMS-2786R (07/2018) Page 45

Name of Facility

2012 LIFE SAFETY CODE

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K925

Gas Equipment – Respiratory Therapy Sources of Ignition

Smoking materials are removed from patients receiving respiratory therapy.

When a nasal cannula is delivering oxygen outside of a patient’s room, no

sources of ignition are within in the site of intentional expulsion (1-foot).

When other oxygen deliver equipment is used or oxygen is delivered inside

a patient’s room, no sources of ignition are within the area are of

administration (15-feet). Solid fuel-burning appliances is not in the area of

administration. Nonmedical appliances with hot surfaces or sparking

mechanisms are not within oxygen-delivery equipment or site of intentional

expulsion.

11.5.1.1, TIA 12-6 (NFPA 99)

K926

Gas Equipment – Qualifications and Training of Personnel

Personnel concerned with the application, maintenance and handling of

medical gases and cylinders are trained on the risk. Facilities provide

continuing education, including safety guidelines and usage requirements.

Equipment is serviced only by personnel trained in the maintenance and

operation of equipment.

11.5.2.1 (NFPA 99)

K927

Gas Equipment – Transfilling Cylinders

Transfilling of oxygen from one cylinder to another is in accordance with

CGA P-2.5, Transfilling of High Pressure Gaseous Oxygen Used for

Respiration. Transfilling of any gas from one cylinder to another is

prohibited in patient care rooms. Transfilling to liquid oxygen containers or

to portable containers over 50 psi comply with conditions under 11.5.2.3.1

(NFPA 99). Transfilling to liquid oxygen containers or to portable containers

under 50 psi comply with conditions under 11.5.2.3.2 (NFPA 99).

11.5.2.2 (NFPA 99)

Form CMS-2786R (07/2018) Page 46

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2012 LIFE SAFETY CODE

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K928

Gas Equipment – Labeling Equipment and Cylinders

Equipment listed for use in oxygen-enriched atmospheres are so labeled.

Oxygen metering equipment and pressure reducing regulators are labeled

"OXYGEN-USE NO OIL". Flowmeters, pressure reducing regulators, and

oxygen-dispensing apparatus are clearly and permanently labeled

designating the gases for which they are intended. Oxygen-metering

equipment, pressure reducing regulators, humidifiers, and nebulizers are

labeled with name of manufacturer or supplier. Cylinders and containers

are labeled in accordance with CGA C-7. Color coding is not utilized as the

primary method of determining cylinder or container contents. All labeling is

durable and withstands cleaning or disinfecting.

11.5.3.1 (NFPA 99)

K929

Gas Equipment – Precautions for Handling Oxygen Cylinders and

Manifolds

Handling of oxygen cylinders and manifolds is based on CGA G-4, Oxygen.

Oxygen cylinders, containers, and associated equipment are protected from

contact with oil and grease, from contamination, protected from damage,

and handled with care in accordance with precautions provided under

11.6.2.1 through 11.6.2.4 (NFPA 99).

11.6.2 (NFPA 99)

K930

Gas Equipment – Liquid Oxygen Equipment

The storage and use of liquid oxygen in base reservoir containers and

portable containers comply with sections 11.7.2 through 11.7.4 (NFPA 99).

11.7 (NFPA 99)

K931

Hyperbaric Facilities

All occupancies containing hyperbaric facilities comply with construction,

equipment, administration, and maintenance requirements of NFPA 99.

Chapter 14 (NFPA 99)

K932

Features of Fire Protection – Other

List in the REMARKS section any NFPA 99 Chapter 15 Features of Fire

Protection requirements that are not addressed by the provided K-Tags, but

are deficient. This information, along with the applicable Life Safety Code or

NFPA standard citation, should be included on Form CMS-2567.

Chapter 15 (NFPA 99)

Form CMS-2786R (07/2018) Page 47

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2012 LIFE SAFETY CODE

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K933

Features of Fire Protection – Fire Loss Prevention in Operating Rooms

Periodic evaluations are made of hazards that could be encountered during

surgical procedures, and fire prevention procedures are established. When

flammable germicides or antiseptics are employed during surgeries utilizing

electrosurgery, cautery or lasers:

 packaging is non-flammable.

 applicators are in unit doses.

 Preoperative "time-out" is conducted prior the initiation of any surgical

procedure to verify:

o application site is dry prior to draping and use of surgical

equipment.

o pooling of solution has not occurred or has been corrected.

o solution-soaked materials have been removed from the OR prior to

draping and use of surgical devices.

o policies and procedures are established outlining safety precautions

related to the use of flammable germicide or antiseptic use.

Procedures are established for operating room emergencies including

alarm activation, evacuation, equipment shutdown, and control operations.

Emergency procedures include the control of chemical spills, and

extinguishment of drapery, clothing and equipment fires. Training is

provided to new OR personnel (including surgeons), continuing education is

provided, incidents are reviewed monthly, and procedures are reviewed

annually.

15.13 (NFPA 99)

Form CMS-2786R (07/2018) Page 48

Name of Facility

2012 LIFE SAFETY CODE

PART III – RECOMMENDATION FOR WAIVER OF SPECIFI C LIFE SAF ETY CODE PROVISIONS

For each item of the Life Safety Code recommended for waiver, list the survey report form item number and state the reason for the conclusion that:

(a) the specific provisions of the code, if rigidly applied, would result in unreasonable hardship on the facility, and (b) the waiver of such unmet

provisions will not adversely affect the health and safety of the patients. If additional space is required, attach additional sheet(s).

PROVISION NUMBER(S) JUSTIFICATION

K400

Surveyor (Signature)

Title Office Date

Fire Authority Official (Signature)

Title Office Date

Form CMS-2786R (07/2018) Page 49

PART IV - FIRE SAFETY SURVEY REPORT

CRUCIAL DATA EXTRACT

(TO BE USED WITH CMS 2786 FORMS)

Provider Number Facility Name Survey Date

K1 *K4

DATE OF PLAN

APPROVAL

MULTIPLE CONSTRUCTION

󠇃

A. BUILDING

TOTAL NUMBER OF BUILDINGS ______

B. WING

C. FLOOR

NUMBER OF THIS BUILDING _______ D. APARTMENT UNIT

LSC FORM INDICATOR

HEALTH CARE FORM

12 2786R 2012 EXISTING

13 2786R 2012 NEW

AHCO FORM

14 2786U 2012 EXISTING

15 2786U 2012 NEW

ICF/IID FORM

16 2786V, W, X 2012 EXISTING

17 2786V, W, X 2012 NEW

*K7

󠇃SELECT NUMBER OF FORM USED FROM ABOVE

COMPLETE IF ICF/IID IS SURVEYED UNDER CHAPTER 33,

EXISTING

SMALL (16 BEDS OR LESS)

󠇃

1. PROMPT

2. SLOW

3. IMPRACTICAL

LARGE

󠇃

4. PROMPT

5. SLOW

6. IMPRACTICAL

APARTMENT HOUSE

󠇃

7. PROMPT

8. SLOW

9. IMPRACTICAL

(Check if K321 or K351 are marked as not applicable

in the 2786 M, R, T, U, V, W, X, and Y.)

K321:

󠇃

K351:

󠇃

COMPLETE IF ICF/IID IS SURVEYED UNDER CHAPTER 33,

EXISTING

ENTER E – SCORE

K5:

󠇃

e.g. 2.5

*K9

FACILITY MEETS LSC BASED ON (Check all that Apply)

A1.

A2. A3. A4. A5.

󠇃 󠇃 󠇃 󠇃 󠇃

(COMP. WITH ALL (ACCEPTABLE POC) (WAIVERS) (FSES) (PERFORMANCE

PROVISIONS) BASED DESIGN)

K0180

FACILITY DOES NOT MEET LSC

A. B. C.

󠇃 󠇃 󠇃

FULLY SPRINKLERED PARTIALLY SPRINKLERED NONE

(All required areas are (Not all required areas are (No sprinkler system)

sprinklered) sprinklered)

󠇃

*MANDATORY

Form CMS-2786R (07/2018) Page 50