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DEPARTMENT OF HEALTH AND HUMAN SERVICES		2000 CODE	Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES			OMB No. 0938-0242
FIRE SAFETY SURVEY REPORT 2000 CODE - HEALTH CARE	1. (A) PROVIDER NUMBER	1. (B) MEDICAID I.D. NO.
FIRE SAFETY SURVEY REPORT 2000 CODE - HEALTH CARE
Medicare – Medicaid	K1	K2
	K1	K2

PART I — Life & Safety Code, New and Existing

PART IV — Waiver Recommendation Form

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)		2. (B) ADDRESS OF FACILITY (STREET, CITY, STATE, ZIP CODE)				A. ■ Fully Sprinklered
		A. BUILDING ________________						(All required areas are sprinklered)
		A. BUILDING ________________						B. ■ Partially Sprinklered
		B. WING	________________					B. ■ Partially Sprinklered
		B. WING	________________					(Not all required areas are sprinklered)
								(Not all required areas are sprinklered)
		C. FLOOR	________________					C. ■ None (No sprinkler system)
		K3						C. ■ None (No sprinkler system)
		K3						K0180
								K0180
3. SURVEY FOR		4. DATE OF SURVEY		DATE OF PLAN APPROVAL		SURVEY UNDER
■ MEDICARE	■ MEDICAID					5. ■ 2000 EXISTING	6. ■ 2000 NEW
■ MEDICARE	■ MEDICAID			K6
		K4		K6		K7
		K4				K7

5. SURVEY FOR CERTIFICATION OF
1. ■ HOSPITAL	2. ■ SKILLED/NURSING FACILITY		4. ■ ICF/MR 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)_________________________________

3. ■ IF DISTINCT PART OF HOSPITAL, IS HOSPITALACCREDITED BY
JCAHO/AOA?
a. ■ YES	b. ■ NO

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/MR BEDS CERTIFIED FOR MEDICAID _______

7. A. ■ THE FACILITY MEETS, BASED UPON (CHECK ALL APPROPRIATE BOXES)
1. ■ COMPLIANCE WITH ALL PROVISIONS	2. ■ ACCEPTANCE OF A PLAN OF CORRECTION 3. ■ RECOMMENDED WAIVERS		4. ■ FSES 5. ■ PERFORMANCE BASED DESIGN
B. ■ THE FACILITY DOES NOT MEET THE STANDARD
K9
SURVEYOR (Signature)	TITLE	OFFICE		DATE

SURVEYOR ID
K10
FIRE AUTHORITY OFFICIAL (Signature)	TITLE	OFFICE		DATE

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0242. The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

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		PART I - LSC REQUIREMENTS - Items in italics relate to the FSES

			BUILDING CONSTRUCTION

K11 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
	shall be protected by approved self-closing fire doors.
18.1.1.4.1, 18.1.1.4.2, 19.1.1.4.1, 19.1.1.4.2

K12 2000 EXISTING
	Building construction type and height meets one of the following:
19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1

1			I (443), I (332), II (222)	Any Height

2			II (111)	One story only
2			II (111)	(non-sprinklered).
				(non-sprinklered).

				Not over three stories with
3			II (111)	complete automatic
				sprinkler system.

4			III (211)

5			V (111)	Not over two stories with
				Not over two stories with
				complete automatic
6			IV (2HH)	complete automatic
6			IV (2HH)	sprinkler system.

7			II (000)

8			III (200)	Not over one story with
				complete automatic
				complete automatic
9			V (000)	sprinkler system.

■Building contains fire treated wood.

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.

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K12 2000 NEW
	Building construction type and height meets one of the following:
18.1.6.2, 18.1.6.3, 18.2.5.1

1		I (443), I (332), II (222)	Any height with complete
1		I (443), I (332), II (222)	automatic sprinkler system
			automatic sprinkler system

			Not over three stories
2		II (111)	with complete automatic
			sprinkler system
	3	III (211)
			Not over one story with
			Not over one story with
4		V (111)	complete automatic
			sprinkler system.
5		IV (2HH)

6		II (000)

7		III (200)
			Not Permitted
8		V (000)	Not Permitted
8		V (000)

■Building contains fire treated wood.

K103 Interior walls and partitions in buildings of Type I or Type II construction shall be noncombustible or limited-combustible materials. 18.1.6.3, 19.1.6.3

(Indicate N/A for existing buildings using listed fire retardant treated wood studs within non-load bearing one-hour rated partitions.)

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	INTERIOR FINISH

K14 2000 EXISTING

	Interior finish for corridors and exitways, including exposed
	interior surfaces of buildings such as fixed or movable walls,
	partitions, columns, and ceilings has a flame spread rating of
	Class A or Class B. 19.3.3.1, 19.3.3.2
	Indicate flame spread rating/s _________
	2000 NEW
	Interior finish for corridors and exitways, including exposed
	interior surfaces of buildings such as fixed or movable walls,
	partitions, columns, and ceilings has a flame spread rating of
	Class A or Class B. Lower portion of corridor walls can be
	Class C. 18.3.3.1, 18.3.3.2
	Indicate flame spread rating/s_________

K15	2000 EXISTING
	Interior finish for rooms and spaces not used for corridors or
	exitways, including exposed interior surfaces of buildings such
	as fixed or movable walls, partitions, columns, and ceilings has
	a flame spread rating of Class A or Class B. (In fully-sprinklered
	buildings, flame spread rating of Class A, Class B, or Class C
	may be continued in use within rooms separated in accordance
	with 19.3.6 from the access corridors.) 19.3.3.1, 19.3.3.2
	Indicate flame spread rating/s_________
	2000 NEW
	Interior finish for rooms and spaces not used for corridors or
	exitways, including exposed interior surfaces of buildings such
	as fixed or movable walls, partitions, columns, and ceilings has
	a flame spread rating of Class A or Class B. (Rooms not over
	4 persons in capacity may have a flame spread rating of Class A,
	Class B, or Class C). 18.3.3.1, 18.3.3.2.
	Indicate flame spread rating/s_________

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K16	Newly installed interior floor finish complying with 10.2.7 shall be
	permitted in corridors and exits if Class I. 18.3.3.3, 19.3.3.3
	(Indicate N/A for existing interior floor finish.)
	In smoke compartments protected throughout by an approved,
	supervised automatic sprinkler system in accordance with
	19.3.5.2, no interior floor finish requirements shall apply.

	CORRIDOR WALLS AND DOORS

K17	2000 EXISTING
	Corridors are separated from use areas by walls constructed with
	at least 1/2 hour fire resistance rating. In fully sprinklered smoke
	compartments, partitions are only required to resist the passage
	of smoke. In non-sprinklered buildings, walls properly extend
	above the ceiling. (Corridor walls may terminate at the underside
	of ceilings where specifically permitted by Code. Charting and
	clerical stations, waiting areas, dining rooms, and activity spaces
	may be open to corridor under certain conditions specified in the
	Code. Gift shops may be separated from corridors by non-fire
	rated walls if the gift shop is fully sprinklered.)
	19.3.6.1, 19.3.6.2.1, 19.3.6.5
	If the walls have a fire resistance rating, give rating_________
	if the walls terminate at the underside of a ceiling, give a brief
	description in REMARKS, of the ceiling, describing the ceiling
	throughout the floor area.
	2000 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.
	18.3.6.1, 18.3.6.2, 18.3.6.5

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K18 2000 EXISTING

	Doors protecting corridor openings in other than required
	enclosures of vertical openings, exits, or hazardous areas shall
	be substantial doors, such as those constructed of 13/4 inch
	solid-bonded core wood, or capable of resisting fire for at least
	20 minutes. Doors in fully sprinklered smoke compartments are
	only required to resist the passage of smoke. There is no
	impediment to the closing of the doors. Doors shall be provided
	with a means suitable for keeping the door closed. Dutch doors
	meeting 19.3.6.3.6 are permitted. 19.3.6.3 Roller latches are
	prohibited by CMS regulations in all health care facilities.

	Show in REMARKS, details of doors, such as fire protection
	ratings, automatic closing devices, etc.

	2000 New
	Doors protecting corridor openings shall be constructed to resist
	the passage of smoke. Doors shall be provided with positive
	latching hardware. Dutch doors meeting 18.3.6.3.6 are permitted.
	Roller latches shall be prohibited. 18.3.6.3

	Show in REMARKS, details of doors, such as fire protection
	ratings, automatic closing devices, etc.

K19	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, 18.3.6.3.1, 19.3.6.2.3, 19.3.6.3.8, 19.3.6.5

K22	Access to exits shall be marked by approved, readily visible
	signs in all cases where the exit or way to reach exit is not
	readily apparent to the occupants. 7.10.1.4

	VERTICAL OPENINGS

K20	2000 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 one hour.
	An atrium may be used in accordance with 8.2.5.6, 19.3.1.1

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If all vertical openings are properly enclosed with construction providing at least a two hour fire resistance rating, also check this box. ■

	If enclosures are less than required, give a brief description and
	specific location in REMARKS.

	2000 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 two hours
	connecting four stories or more. (One hour for single story
	building and sprinklered buildings up to three stories in height.)
	18.3.1.1. An atrium may be used in accordance with 8.2.2.3.5.
	If enclosures are less than required, give a brief description and
	specific location in REMARKS.

K21	Any door in an exit passageway, stairway enclosure, horizontal
	exit, smoke barrier or hazardous area enclosure shall be
	permitted to be held open only by devices arranged to
	automatically close all such doors by zone or throughout the
	facility upon activation of:
	■ (a) The required manual fire alarm system and
	■ (b) Local smoke detectors designed to detect smoke
	passing through the opening or a required smoke
	detection system and
	■ (c) The automatic sprinkler system, if installed
	18.2.2.2.6, 19.2.2.2.6, 7.2.1.8.2

	Describe method used in REMARKS

K33	2000 EXISTING
	Exit components (such as stairways) are enclosed with
	construction having a fire resistance rating of at least one hour,
	are arranged to provide a continuous path of escape, and
	provide protection against fire or smoke from other parts of the
	building. 8.2.5.2, 19.3.1.1

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If all vertical openings are properly enclosed with construction providing at least a two hour fire resistance rating, also check this box. ■

	If enclosures are less than required, give a brief description and
	specific location in REMARKS.

	2000 NEW
	Exit components (such as stairways) in buildings four stories or
	more are enclosed with construction having a fire resistance
	rating of at least two hours, are arranged to provide a continuous
	path of escape, and provide a protection against fire and smoke
	from other parts of the building. In all buildings less than four
	stories, the enclosure is at least one hour. 8.2.5.4, 18.3.1.1

	If enclosures are less than required, give a brief description and
	specific location in REMARKS.

	SMOKE COMPARTMENTATION AND CONTROL

K23	2000 EXISTING
	Smoke barriers shall be provided to form at least two smoke
	compartments on every sleeping room floor for more than 30
	patients. 19.3.7.1, 19.3.7.2
	2000 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. Smoke barriers shall also be
	provided on floors that are usable, but unoccupied. 18.3.7.1,
	18.3.7.2

K24	The smoke compartments shall not exceed 22,500 square feet and
	the travel distance to and from any point to reach a door in the
	required smoke barrier shall not exceed 200 feet. 18.3.7.1, 19.3.7.1
	Detail in REMARKS zone dimensions including length of zones
	Detail in REMARKS zone dimensions including length of zones
	and dead end corridors.

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K25 2000 EXISTING

Smoke barriers shall be constructed to provide at least a one- half hour fire resistance rating and constructed in accordance with 8.3. Smoke barriers shall be permitted to terminate at an atrium wall. Windows shall be protected by fire-rated glazing or by wired glass panels and steel frames. A minimum of two separate compartments shall be provided on each floor. Dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems.19.3.7.3, 19.3.7.5, 19.1.6.3, 19.1.6.4

	2000 NEW
	Smoke barriers shall be constructed to provide at least a one-
	hour fire resistance rating and constructed in accordance with
	8.3. Smoke barriers shall be permitted to terminate at an atrium
	wall. Windows shall be protected by fire-rated glazing or by
	wired glass panels in approved frames. A minimum of two
	separate compartments shall be provided on each floor.
	Dampers shall not be required in duct penetrations of smoke
	barriers in fully ducted heating, ventilating, and air conditioning
	systems. 18.3.7.3, 18.3.7.5, 18.1.6.3

K26	Space shall be provided on each side of smoke barriers to
	adequately accommodate those occupants served. 18.3.7.4, 19.3.7.4

K27	2000 EXISTING
	Door openings in smoke barriers have at least a 20 minute fire
	protection rating or are at least 13/4 inch thick solid bonded core
	wood. Non-rated protective plates that do not exceed 48 inches
	from the bottom of the door are permitted. Horizontal sliding
	doors comply with 7.2.1.14. Doors shall be self-closing or
	automatic-closing in accordance with 19.2.2.2.6. Swinging doors
	are not required to swing with egress and positive latching is not
	required. 19.3.7.5, 19.3.7.6, 19.3.7.7
	2000 NEW
	Door openings in smoke barriers have at least a 20 minute fire
	protection rating or are at least 13/4 inch thick solid bonded core wood.
	Non-rated protective plates that do not exceed 48 inches from the
	bottom of the door 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. 18.3.7.5, 18.3.7.6, 18.3.7.8

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K28 2000 EXISTING

Door openings in smoke barriers shall provide a minimum clear width of 32 inches (81 cm) for swinging or horizontal doors. Vision panels are of fire-rated glazing or wired glass panels and steel frames. 19.3.7.5, 19.3.7.7

2000 NEW

Door openings in smoke barriers are installed as swinging or horizontal doors shall provide a minimum clear width as follows:

Provider Type	Swinging Doors	Horizontal Sliding Doors

Hospitals and	41.5 inches	83 inches
Nursing Facilities	(105 cm)	(211 cm)

Psychiatric Hospitals and	32 inches	64 inches
Limited Care Facilities	(81 cm)	(163 cm)

Vision panels of fire-rated glazing or wired panels in approved frames are provided for each door. 18.3.7.5, 18.3.7.7

K104 Penetrations of smoke barriers by ducts are protected in accordance with 8.3.6.

Describe any mechanical smoke control system in REMARKS.

HAZARDOUS AREA

K29	2000 EXISTING
	One hour fire rated construction (with 3/4 hour fire-rated doors) or
	an approved automatic fire extinguishing system in accordance
	with 8.4.1 and/or 19.3.5.4 protects hazardous areas. When the
	approved automatic fire extinguishing system option is used, the
	areas shall be separated from other spaces by smoke resisting
	partitions and doors. Doors shall be self-closing and non-rated or
	field-applied protective plates that do not exceed 48 inches from
	the bottom of the door are permitted. 19.3.2.1

	Area	Automatic Sprinkler	Separation	N/A
	a. Boiler and Fuel-Fired Heater Rooms
	c. Laundries (greater than 100 sq feet)
	d. Repair Shops and Paint Shops
	e. Laboratories (if classified a Severe Hazard - see K31)
	f. Combustible Storage Rooms/Spaces (over 50 sq feet)
	g. Trash Collection Rooms
	i. Soiled Linen Rooms

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

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2000 NEW

Hazardous areas are protected in accordance with 8.4. The areas shall be enclosed with a one hour fire-rated barrier, with a

3/4 hour fire-rated door, without windows (in accordance with 8.4). Doors shall be self-closing or automatic closing in accordance with 7.2.1.8. 18.3.2.1

Area	Automatic Sprinkler Separation N/A

a.Boiler and Fuel-Fired Heater Rooms c. Laundries (greater than 100 sq feet) d. Repair, Maintenance and Paint Shops

e. Laboratories (if classified a Severe Hazard - see K31)

f.Combustible Storage Rooms/Spaces (over 50 and less than 100 sq feet)

g.Trash Collection Rooms

i. Soiled Linen Rooms

m.Combustible Storage Rooms/Spaces (over 100 sq feet)

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

K30	Gift shops shall be protected as hazardous areas when used for
	storage or display of combustibles in quantities considered
	hazardous. Non-rated walls may separate gift shops that are not
	considered hazardous, have separate protected storage and that
	are completely sprinkled. Gift shops may be open to the corridor
	if they are not considered hazardous, have separate protected
	storage, are completely sprinklered and do not exceed 500
	square ºfeet. 18.3.2.5, 19.3.2.5

	Area	Automatic Sprinkler	Separation	N/A
	L. Gift Shop storing hazardous quantities
	of combustibles


K211	2000 EXISTING
	Where Alcohol Based Hand Rub (ABHR) dispensers are
	installed:
	❏ The corridor is at least 6 feet wide
	❏ The maximum individual fluid dispenser capacity shall be
	1.2 liters (2 liters in suites of rooms)
	❏ The dispensers shall have a minimum spacing of 4 ft from
	each other
	❏ Not more than 10 gallons are used in a single smoke
	compartment outside a storage cabinet.
	❏ Dispensers are not installed over or adjacent to an ignition
	source.
	❏ If the floor is carpeted, the building is fully sprinklered. 19.3.2.7,
	CFR 403.744, 418.100, 460.72, 482.41, 483.70, 483.623, 485.623

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K211 2000 NEW
Where Alcohol Based Hand Rub (ABHR) dispensers are
installed:

❏The corridor is at least 6 feet wide

❏The maximum individual fluid dispenser capacity shall be 1.2 liters (2 liters in suites of rooms)

❏The dispensers shall have a minimum spacing of 4 ft from each other

❏Not more than 10 gallons are used in a single smoke compartment outside a storage cabinet.

❏Dispensers are not installed over or adjacent to an ignition source.

❏If the floor is carpeted, the building is fully sprinklered. 18.3.2.7, CFR 403.744, 418.100, 460.72, 482.41, 483.70, 483.623, 485.623

	EXIT AND EXIT ACCESS

K32	Not less than two exits, remote from each other, are provided
	for each floor or fire section of the building. Only one of these
	two exits may be a horizontal exit. 18.2.4.1, 18.2.4.2, 19.2.4.1,
	19.2.4.2

	EXITS AND EGRESS

K34	Stairways and smokeproof towers used as exits are in
	accordance with 7.2.
	18.2.2.4, 19.2.2.3, 19.2.2.4

K35	Capacity of exits in number of persons per unit of exit width is in
	accordance with 7.3.
	18.2.3.1, 19.2.3.1

K36	Travel distance (exit access) to exits are in accordance with 7.6.
	18.2.6, 19.2.6

K37	2000 EXISTING
	Existing dead-end corridors shall be permitted to be continued to
	be used if it is impractical and unfeasible to alter them so that
	exists are accessible in not less than two different directions
	from all points in aisles, passageways, and corridors. 19.2.5.10

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2000 NEW

	Every exit and exit access shall be arranged so that no
	corridor, aisle or passageway has a pocket or dead-end
	exceeding 30 feet. 18.2.5.10

K38	Exit access is so arranged that exits are readily accessible at all
	times in accordance with 7.1.
	18.2.1, 19.2.1

K39	2000 EXISTING
	Width of aisles or corridors (clear and unobstructed) serving as
	exit access shall be at least 4 feet. 19.2.3.3
	2000 NEW
	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. 18.2.3.3, 18.2.3.4

K40	2000 EXISTING
	Exit access doors and exit doors used by health care occupants
	are of the swinging type and are at least 32 inches in clear width.
	19.2.3.5
	2000 NEW
	Exit access doors and exit doors used by health care occupants
	are of the swinging type, with openings of at least 41.5 inches
	wide. Doors in exit stairway enclosures shall be no less than 32
	inches in clear width. In ICFs/MR, doors are at least 32 inches
	wide. 18.2.3.5

K41	All sleeping rooms have a door leading to a corridor providing
	access to an exit or have a door leading directly to grade. One
	room may intervene in accordance with 18.2.5.1, 19.2.5.1,
	18.2.5.9, 19.2.5.9
	If doors lead directly to grade from each room, check this box. ■

K42	Any room or suite of rooms of more than 1,000 sq. ft. has at least
	2 exit access doors remote from each other. 18.2.5.2, 19.2.5.2

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K43	Patient room doors are arranged such that the patients can open
K43
	the door from inside without using a key.
	Special door locking arrangements are permitted in facilities.
	18.2.2.2.4, 18.2.2.2.5
	If door locking arrangement without delay egress is used
	indicate in REMARKS
	18.2.2.2.2, 19.2.2.2.2

K44	Horizontal exits, if used, are in accordance with 7.2.4.
	18.2.2.5, 19.2.2.5

	ILLUMINATION AND EMERGENCY POWER

K45	Illumination of means of egress, including exit discharge, is
	arranged so that failure of any single lighting fixture (bulb) will
	not leave the area in darkness.
	18.2.8, 19.2.8, 7.8

K46	Emergency lighting of at least 11/2 hour duration is provided in
	accordance with 7.9.
	18.2.9.1, 19.2.9.1.

K47	2000 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 buildings with less than 30 occupants
	where the line of exit travel is obvious.)
	2000 NEW
	Exit and directional signs are displayed with continuous
	illumination also served by the emergency lighting, system in
	accordance with 7.10.
	18.2.10.1

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ID	MET	NOT	N/A	REMARKS
PREFIX	MET	MET	N/A	REMARKS
PREFIX		MET

K105 2000 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. 18.2.9.2., 18.2.10.2,
	18.5.1.1, 18.5.1.2
	(Indicate N/A if life support equipment is for emergency
	purposes only).

K107	2000 NEW (INDICATE N/A FOR EXISTING)
	Required alarm and detection systems are provided with an
	alternative power supply in accordance with NFPA 72.
	9.6.1, 18.3.4.1.3

K108	2000 NEW (INDICATE N/A FOR EXISTING)
	Alarms, emergency communication systems, and illumination of
	generator set locations are in accordance with NFPA 70. 9.1.2

	EMERGENCY PLAN AND FIRE DRILLS

K48	There is a written plan for the protection of all patients and for
	their evacuation in the event of an emergency.
	18.7.1.1, 19.7.1.1

K50	Fire drills are held at 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.
	Responsibility for planning and conducting drills is assigned only
	to competent persons who are qualified to exercise leadership.
	Where drills are conducted between 9:00 PM and 6:00 AM a
	coded announcement may be used instead of audible alarms.
	18.7.1.2, 19.7.1.2

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ID		MET	NOT	N/A	REMARKS
PREFIX		MET	MET	N/A	REMARKS
PREFIX			MET

	FIRE ALARM SYSTEMS

K51 2000 EXISTING

	A fire alarm system with approved component, devices or
	equipment installed according to NFPA 72, National Fire Alarm
	Code to provide effective warning of fire in any part of the
	building. Activation of the complete fire alarm system shall be by
	manual fire alarm initiation, automatic detection or extinguishing
	system operation. Pull stations in patient sleeping areas, may
	be omitted provided that manual pull stations are within 200 ft of
	nurse’s stations. Pull stations are located in the path of egress.
	Electronic or written records of tests shall be available. A reliable
	second source of power must be provided. Fire alarm systems
	shall be in accordance with NFPA72, and records of maintenance
	kept readily available. There shall be annunciation of the fire
	alarm system to an approved central station. 19.3.4, 9.6
	2000 NEW
	A fire alarm system with approved component, devices or
	equipment installed according to NFPA 72, to provide effective
	warning of fire in any part of the building. Activation of the
	complete fire alarm system shall be by manual fire alarm initiation,
	automatic detection or extinguishing system operation. Pull
	stations are located in the path of egress. Electronic or written
	records of tests shall be available. A reliable second source of
	power must be provided. Fire alarm systems shall be maintained
	in accordance with NFPA72, and records of maintenance kept
	readily available. There shall be remote annunciation of the fire
	alarm system to an approved central station. 18.3.4, 9.6

K52	A fire alarm system required for life safety shall be installed,
	tested, and maintained in accordance with NFPA 70 National
	Electrical Code and NFPA 72. The system shall have an
	approved maintenance and testing program complying with
	applicable requirement of NFPA 70 and 72. 9.6.1.4

K155	Where a required fire alarm system is out of service 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. 9.6.1.8

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PREFIX	MET	MET	N/A	REMARKS
PREFIX		MET

K53 2000 EXISTING (INDICATE N/A FOR HOSPITAL AND FULLY
SPRINKLERED NURSING HOMES)

	In an existing nursing home, not fully sprinklered, the resident
	sleeping rooms and public areas (dining rooms, activity rooms,
	resident meeting rooms, etc) are to be equipped with single
	station battery-operated smoke detectors. There will be a testing,
	maintenance and battery replacement program to ensure proper
	operation. CFR 483.70
	2000 NEW (NURSING HOME AND EXISTING LIMITED
	CARE FACILITIES)
	An automatic smoke detection system is installed in all corridors.
	(As an alternative to the corridor smoke detection system on
	patient sleeping room floors, smoke detectors may be installed in
	each patient sleeping room and at smoke barrier or horizontal
	exit doors in the corridor.) Such detectors are electrically
	interconnected to the fire alarm system. 18.3.4.5.3

K109	2000 EXISTING LIMITED CARE FACILITIES
	(INDICATE N/A FOR HOSPITALS OR NURSING HOMES)
	An automatic smoke detection system is installed in all corridors
	with detector spacing no further apart than 30 ft on center in
	accordance with NFPA 72. (As an alternative to the corridor
	smoke detection system on patient sleeping room floors, smoke
	detectors may be installed in each patient sleeping room and at
	smoke barrier or horizontal exit doors in the corridors.) Such
	detectors are electrically interconnected to the fire alarm system.
	19.3.4.5.1
	Smoke Detection System
	❏ Corridors
	❏ Rooms
	❏ Bath

K54	All required smoke detectors, including those activating door
	hold-open devices, are approved, maintained, inspected and
	tested in accordance with the manufacturer’s specifications.
	9.6.1.3
	Give a brief description, in REMARKS of any smoke detection
	system which may be installed.

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PREFIX		MET

K55 2000 EXISTING

Every patient sleeping room shall have an outside window or outside door. Except for newborn nurseries and rooms intended for occupancy for less than 24 hours. 19.3.8

	2000 NEW
	Every patient sleeping room shall have an outside window or
	outside door. The allowable sill height shall not exceed 36 inches
	(91 cm) above the floor. Windows are not required for recovery
	rooms, newborn nurseries, emergency rooms, and similar rooms
	intended for occupancy for less than 24 hours. Window sill height
	for limited care facilities shall not exceed 44 inches (112 cm)
	above the floor. 18.3.8

	AUTOMATIC SPRINKLER SYSTEMS

K56	2000 EXISTING
	Where required by section 19.1.6, Health care facilities shall be
	protected throughout by an approved, supervised automatic
	sprinkler system in accordance with section 9.7. Required
	sprinkler systems are equipped with water flow and tamper
	switches which are electrically interconnected to the building fire
	alarm. 19.3.5, NPFA 13
	2000 NEW
	There is an automatic sprinkler system installed in accordance
	with NFPA13, Standard for the Installation of Sprinkler Systems,
	with approved components, device and equipment, to provide
	complete coverage of all portions of the facility. Systems are
	equipped with waterflow and tamper switches, which are
	connected to the fire alarm system. 18.3.5.

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ID		MET	NOT	N/A	REMARKS
PREFIX		MET	MET	N/A	REMARKS
PREFIX			MET

K154	Where a required automatic sprinkler system is out of service
	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 system be provided for all parties left
	unprotected by the shutdown until the sprinkler system has been
	returned to service. 9.7.6.1.

	A. Date sprinkler system last checked and necessary
	maintenance provided. _______________________________

	B. Show who provided the service. _______________________

	C. Note the source of water supply for the automatic
	sprinkler system.____________________________________
	(Provide, in REMARKS, information on coverage for any
	non-required or partial automatic sprinkler system.)

K60	Initiation of the required fire alarm systems shall be by manual
	means in accordance with 9.6.2 and by means of any required
	sprinkler system waterflow alarms, detection devices, or detection
	systems. 18.3.4.2, 19.3.4.2, 9.6.2.1

K61	Required automatic sprinkler systems shall have valves
	supervised so that at least a local alarm will sound when the
	valves are closed. 9.7.2.1, NFPA 72

K62	Automatic sprinkler systems are continuously maintained
	in reliable operating condition and are inspected and tested
	periodically. 18.7.6, 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

K63	Required automatic sprinkler systems have an adequate and
	reliable water supply which provides continuous and automatic
	pressure. 9.7.1.1, NFPA 13

K64	Portable fire extinguishers shall be provided in all health care
	occupancies in accordance with 9.7.4.1, NFPA 10.
	18.3.5.6, 19.3.5.6

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PREFIX	MET	MET	N/A	REMARKS
PREFIX		MET

SMOKING REGULATIONS
K66 Smoking regulations shall be adopted and shall include not less
than the following provisions: 18.7.4, 19.7.4

	■ (1) Smoking shall be prohibited in any room, ward, or
	compartment where flammable liquids, combustible gases,
	or oxygen is used or stored 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) Smoking by patients classified as not responsible shall be
	prohibited, except when under direct supervision.
	■ (3) Ashtrays of noncombustible material and safe design shall
	be provided in all areas where smoking is permitted.
	■ (4) Metal containers with self-closing cover devices into which
	ashtrays can be emptied shall be readily available to all
	areas where smoking is permitted.

	BUILDING SERVICE EQUIPMENT

K67	Heating, ventilating, 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, NFPA 90A, 18.5.2.2, 19.5.2.2

K68	Combustion and ventilation air for boiler, incinerator and heater
	rooms is taken from and discharged to the outside air.
	18.5.2.2, 19.5.2.2.

K69	Cooking facilities shall be protected in accordance with 9.2.3.
	18.3.2.6, 19.3.2.6, NFPA 96

K70	Portable space heating devices shall be prohibited in all health
	care occupancies. Except it shall be permitted to be used in
	non-sleeping staff and employee areas where the heating
	elements of such devices do not exceed 212oF (100oC).
	18.7.8, 19.7.8

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PREFIX		MET

K71 Rubbish Chutes, Incinerators and Laundry Chutes.
18.5.4, 19.5.4, 9.5, 8.4, NFPA 82

■(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.

■(4) Existing flue-fed incinerators shall be sealed by fire resistive construction to prevent further use.

K160 2000 EXISTING

All existing elevators, having a travel distance of 25 ft or more above or below the level that best serves the needs of emergency personnel for fire fighting purposes, conform with Firefighter’s Service Requirements of ASME/ ANSI A17.3, Safety Code for Existing Elevators and Escalators.

19.5.3, 9.4.3.2

ANSI A17.1 states 25 ft or more above or below the designated level and defines “designated level” as the main floor or other floor level that best serves the needs of emergency personnel for fire fighting purposes or rescue purposes identified by the building code or fire authority. Depending on floor slab thickness and heights this would generally apply to a three-story building, and almost certainly to a four-story building.

Includes firefighters service phase I key recall and smoke detector automatic recall, firefighters service phase II emergency in-car key operation, machine room smoke detectors, and elevator lobby smoke detectors. 19.5.3, 9.4.3.2

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PREFIX	MET	MET	N/A	REMARKS
PREFIX		MET

K161 2000 EXISTING

All existing escalators, dumbwaiters, and moving walks conform to the requirements of ASME/ ANSI A17.3, Safety Code for Existing Elevators and Escalators. 19.5.3, 9.4.2.2

	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.
	2000 NEW
	All elevators, escalators, and conveyors comply with
	ASME/ ANSI A17.1, Safety Code for Elevators and Escalators
	(Includes car emergency signaling, firefighters service phase I
	key and smoke detector automatic recall, firefighters service
	phase II emergency in-car operation, machine room smoke
	detectors, elevator lobby smoke detectors). 18.5.3, 9.4

	FURNISHINGS AND DECORATIONS

K72	Means of egress shall be continuously maintained free of all
	obstructions or impediments to full instant use in the case of fire
	or other emergency. No furnishings, decorations, or other objects
	shall obstruct exits, access thereto, egress there from, or visibility
	thereof shall be in accordance with 7.1.10

K73	No furnishings or decorations of highly flammable character shall
	be used. 18.7.5.2, 18.7.5.3, 18.7.5.4, 19.7.5.2, 19.7.5.3, 19.7.5.4

K74	Draperies, curtains, including cubicle curtains, and other loosely
	hanging fabrics and films serving as furnishings or decorations in
	health care occupancies shall be in accordance with provisions
	of 10.3.1 and NFPA 13 Standard for the Installation of Sprinkler
	Systems. Except shower curtains shall be in accordance with
	NFPA 701.
	■ Newly introduced upholstered furniture shall meet the
	criteria specified when tested in accordance with the methods
	cited in 10.3.2 (2) and 10.3.1. 18.3.5.3 and NFPA 13
	■ Newly introduced mattresses shall meet the criteria specified
	when tested in accordance with the method cited in 10.3.2 (3)
	and 10.3.4. 18.7.5.3, 19.7.5.3
	Newly introduced upholstered furniture and mattresses means
	purchased since March, 2003.

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PREFIX		MET	MET	N/A	REMARKS
PREFIX			MET

K75	Soiled linen or trash collection receptacles shall not exceed 32
	gal (121 L) in capacity. The average density of container capacity
	in a room or space shall not exceed .5 gal/ft2 (20.4 L/m2). A
	capacity of 32 gal (121 L) shall not be exceeded within any 64-ft2
	(5.9-m2) area. Mobile soiled linen or trash collection receptacles
	with capacities greater than 32 gal (121 L) shall be located in a
	room protected as a hazardous area when not attended.
	18.7.5.5, 19.7.5.5

	LABORATORIES

K31	Laboratories employing quantities of flammable, combustible, or
	hazardous materials that are considered a severe hazard shall be
	protected in accordance with NFPA 99. (Laboratories that are not
	considered to be severe hazard shall meet the provision of K29.)
	Laboratories in Health Care occupancies and medical and dental
	offices shall be in accordance with NFPA 99, Standard for Health
	Care Facilities 10.5.1.
K136	Procedures for laboratory emergencies shall be developed.
	Such procedures shall include alarm actuation, evacuation,
	and equipment shutdown procedures, and provisions for control
	of emergencies that could occur in the laboratory, including
	specific detailed plans for control operations by an emergency
	control group within the organization or a public fire department
	in accordance with NFPA 99, 10.2.1.3.1, 18.3.2.2., 19.3.2.1

K131	Emergency procedures shall be established for controlling
	chemical spills in accordance with NFPA 99. 10.2.1.3.2

K132	Continuing safety education and supervision shall be provided,
	incidents shall be reviewed monthly, and procedures reviewed
	annually shall be in accordance with NFPA 99. 10.2.1.4.2

K133	Fume hoods shall be in accordance with NFPA 99. 5.4.3, 5.6.2

K134	Emergency Shower:
	Where the eyes or body of any person can be exposed to
	injurious corrosive materials, suitable fixed facilities for quick
	drenching or flushing of the eyes and body shall be provided
	within the work area for immediate emergency use. Fixed eye
	baths designed and installed to avoid injurious water pressure
	shall be in accordance with NFPA 99, 10.6.

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ID		MET	NOT	N/A	REMARKS
PREFIX		MET	MET	N/A	REMARKS
PREFIX			MET

K135	Flammable and combustible liquids shall be used from and
	stored in approved containers in accordance with NFPA 30,
	Flammable and Combustible Liquids Code, and NFPA 45,
	Standard on Fire Protection for Laboratories Using Chemicals.
	Storage cabinets for flammable and combustible liquids shall be
	constructed in accordance with NFPA 30, Flammable and
	Combustible liquids Code NFPA 99, 4.3, 10.7.2.1.

	MEDICAL GASES AND ANESTHETIZING AREAS

K76	Medical gas storage and administration areas shall be protected
	in accordance with NFPA 99, Standard for Health Care Facilities.

(a)Oxygen storage locations of greater than 3,000 cu.ft. are enclosed by a one-hour separation.

(b)Locations for supply systems of greater than 3,000 cu.ft. are vented to the outside. NFPA 99, 4.3.1.1.2, 18.3.2.4, 19.3.2.4

K77	Piped in medical gas systems comply with NFPA 99, Chapter 4.

K78	Anesthetizing locations shall be protected in accordance with
	NFPA 99, Standard for Health Care Facilities.

(a)Shutoff valves are located outside each anesthetizing location and arranged so that shutting off one room or location will not affect others.

(b)Relative humidity is maintained equal to or great than 35%

NFPA 99 4.3.1.2.3(n) and 5.4.1.1, 18.3.2.3, 19.3.2.3

K140	(a) Master alarm panels are in two separate locations and
	have audible and visible signals.
	(b) There are high/low alarms for +/- 20% operating pressure.
	This section shall be in accordance with NFPA 99, 4.3.1.2.2
	(c) Where a level 2 gas system is used, one alarm panel that
	complies with 4.3.1.2.2(b) 3 a, b, c and d and with 4.3.1.2.2(c)
	2 and 5 shall be permitted. (4.4.1 exception No. 4).

K141	Non-smoking and no smoking signs in areas where oxygen is
	used or stored shall be in accordance with 18.3.2.4, 19.3.2.4,
	NFPA 99, 8.6.4.2

K142	All occupancies containing hyperbaric facilities shall comply with
	NFPA 99, Standard for Health Care Facilities, Chapter 19.

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K143 Transferring of oxygen shall be:

(a)separated from any portion of a facility wherein patients are housed, examined, or treated by a separation of a fire barrier of 1-hour fire-resistive construction; and

(b)the area that is mechanically ventilated, sprinklered, and has ceramic or concrete flooring; and

(c)in an area that is posted with signs indicating that transferring is occurring, and that smoking in the immediate area is not permitted in accordance with NFPA 99 and Compressed Gas Association. 8.6.2.5.2

	ELECTRICAL
K106	The hospital and all nursing homes and hospices with life support
	equipment has a Type I Essential Electrical System powered by
	a generator with a transfer switch and separate power supply.
	The EES is in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4

K144	Generators inspected weekly and exercised under load for
	30 minutes per month and shall be in accordance with NFPA 99,
	3.4.4.1, NFPA 110, 8.4.2

K145	The Type I EES is divided into the critical branch, life safety
	branch and the emergency system and shall be in accordance
	with NFPA 99, 3.4.2.2.2

K146	The nursing home/hospice with no life support equipment shall
	have an alternate source of power separate and independent
	from the normal source that will be effective for minimum of 11/2
	hour after loss of the normal source NFPA 99, 3.6.

K147	Electrical wiring and equipment shall be in accordance with
	NFPA 70, National Electrical Code. 9.1.2

K130	Miscellaneous
	List in the REMARKS sections, any items that are not listed
	previously, 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 (06/07) EF 06/2007

Page 25

Name of Facility

2000 CODE

PART IV RECOMMENDATION FOR WAIVER OF SPECIFIC LIFE SAFETY 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)

K84

JUSTIFICATION

Surveyor (Signature)	Title	Office	Date

Fire Authority Official (Signature)	Title	Office	Date

Form CMS-2786R (06/07) EF 06/2007

Page 26

FIRE SAFETY SURVEY REPORT

CRUCIAL DATA EXTRACT

(TO BE USED WITH CMS-2786 FORMS)

PROVIDER NUMBER

FACILITY NAME

SURVEY DATE

* K4

K6 DATE OF PLAN	K3 MULTIPLE CONSTRUCTION
K6 DATE OF PLAN
APPROVAL	TOTAL NUMBER OF BUILDINGS ____________
	NUMBER OF THIS BUILDING ____________

ABUILDING

BWING

CFLOOR

DAPARTMENT UNIT

LSC FORM INDICATOR

			Health Care Form

	12		2786R	2000	EXISTING

	13		2786R	2000 NEW


			ASC Form

	14		2786U	2000	EXISTING

	15		2786U	2000 NEW


			ICF/MR Form

	16		2786V, W, X	2000	EXISTING

	17		2786V, W, X	2000	NEW

* K7		SELECT NUMBER OF FORM USED FROM ABOVE
* K7		SELECT NUMBER OF FORM USED FROM ABOVE

(Check if K29 or K56 are marked as not applicable in the 2786 M, R, T, U, V, W, X and Y.)

K29:		K56:

COMPLETE IF ICF/MR IS SURVEYED UNDER CHAPTER 21

SMALL		(16 BEDS OR LESS)
		1 PROMPT
K8:		2 SLOW
		3 IMPRACTICAL
		3 IMPRACTICAL

LARGE
		4 PROMPT
K8:		5 SLOW

6IMPRACTICAL

APARTMENT HOUSE

7PROMPT

K8:

8 SLOW

9IMPRACTICAL

ENTER E – SCORE HERE

K5:		e.g. 2.5

*K9: FACILITY MEETS LSC BASED ON (Check all that apply)

A1.

A2.

A3.

A4.

A5.

(COMP. WITH	(ACCEPTABLE POC)	(WAIVERS)	(FSES)	(PERFORMANCE
ALL PROVISIONS)				BASED DESIGN)

FACILITY DOES NOT MEET LSC	K0180
FACILITY DOES NOT MEET LSC	K0180
	A.	B.	C.

B.
B.	FULLY SPRINKLERED	PARTIALLY SPRINKLERED	NONE
	(All required areas are sprinklered)	(Not all required areas are sprinklered)	(No sprinkler system)
	(All required areas are sprinklered)	(Not all required areas are sprinklered)	(No sprinkler system)

* MANDATORY

Form CMS-2786R (06/07) EF 06/2007

Page 27

Question	Answer
Form Name	Form Cms 2786R
Form Length	27 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	6 min 45 sec
Other names	2007, occupancies, fillable cms2786r form, ICF

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