Form Cms-2786R is a newly released form that was created in order to help improve the quality of care provided to Medicare beneficiaries. The new form is designed to help hospitals and other healthcare providers better assess the health of their patients, and will be used as part of the Hospital Quality reporting Program. Those who are required to use Form Cms-2786R include critical access hospitals, long term care hospitals, rehabilitation hospitals, and psychiatric hospitals. All healthcare providers should become familiar with this new form and its requirements. Additional information can be found on the Centers for Medicare & Medicaid Services website. Thank you for your time.
| Question | Answer |
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| 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 |
DEPARTMENT OF HEALTH AND HUMAN SERVICES |
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2000 CODE |
Form Approved |
CENTERS FOR MEDICARE & MEDICAID SERVICES |
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OMB No. |
FIRE SAFETY SURVEY REPORT 2000 CODE - HEALTH CARE |
1. (A) PROVIDER NUMBER |
1. (B) MEDICAID I.D. NO. |
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Medicare – Medicaid |
K1 |
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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 |
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2. (A) MULTIPLE CONSTRUCTION (BLDGS) |
2. (B) ADDRESS OF FACILITY (STREET, CITY, STATE, ZIP CODE) |
A. ■ Fully Sprinklered |
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A. BUILDING ________________ |
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(All required areas are sprinklered) |
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B. ■ Partially Sprinklered |
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B. WING |
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(Not all required areas are sprinklered) |
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C. FLOOR |
________________ |
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C. ■ None (No sprinkler system) |
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K3 |
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K0180 |
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3. SURVEY FOR |
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4. DATE OF SURVEY |
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DATE OF PLAN APPROVAL |
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SURVEY UNDER |
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■ MEDICARE |
■ MEDICAID |
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5. ■ 2000 EXISTING |
6. ■ 2000 NEW |
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K6 |
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K4 |
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K7 |
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5. SURVEY FOR CERTIFICATION OF |
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1. ■ HOSPITAL |
2. ■ SKILLED/NURSING FACILITY |
4. ■ ICF/MR UNDER HEALTH CARE |
5. ■ HOSPICE |
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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 |
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JCAHO/AOA? |
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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) |
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1. ■ COMPLIANCE WITH ALL PROVISIONS |
2. ■ ACCEPTANCE OF A PLAN OF CORRECTION 3. ■ RECOMMENDED WAIVERS |
4. ■ FSES 5. ■ PERFORMANCE BASED DESIGN |
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B. ■ THE FACILITY DOES NOT MEET THE STANDARD |
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K9 |
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SURVEYOR (Signature) |
TITLE |
OFFICE |
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DATE |
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SURVEYOR ID |
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K10 |
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FIRE AUTHORITY OFFICIAL (Signature) |
TITLE |
OFFICE |
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DATE |
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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
Form |
Page 1 |
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Name of Facility |
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2000 CODE |
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ID |
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MET |
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N/A |
REMARKS |
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PREFIX |
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MET |
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PART I - LSC REQUIREMENTS - Items in italics relate to the FSES |
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BUILDING CONSTRUCTION |
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K11 If the building has a common wall with a nonconforming building, |
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the common wall is a fire barrier having at least a two hour fire |
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resistance rating constructed of materials as required for the |
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addition. Communicating openings occur only in corridors and |
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shall be protected by approved |
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18.1.1.4.1, 18.1.1.4.2, 19.1.1.4.1, 19.1.1.4.2 |
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K12 2000 EXISTING |
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Building construction type and height meets one of the following: |
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19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1 |
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1 |
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I (443), I (332), II (222) |
Any Height |
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2 |
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II (111) |
One story only |
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Not over three stories with |
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3 |
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II (111) |
complete automatic |
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sprinkler system. |
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4 |
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III (211) |
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5 |
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V (111) |
Not over two stories with |
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complete automatic |
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IV (2HH) |
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sprinkler system. |
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7 |
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II (000) |
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8 |
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III (200) |
Not over one story with |
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complete automatic |
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V (000) |
sprinkler system. |
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■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.
Form |
Page 2 |
Name of Facility |
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2000 CODE |
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ID |
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MET |
NOT |
N/A |
REMARKS |
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PREFIX |
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MET |
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K12 2000 NEW |
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Building construction type and height meets one of the following: |
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18.1.6.2, 18.1.6.3, 18.2.5.1 |
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1 |
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I (443), I (332), II (222) |
Any height with complete |
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automatic sprinkler system |
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Not over three stories |
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2 |
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II (111) |
with complete automatic |
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sprinkler system |
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3 |
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III (211) |
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Not over one story with |
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4 |
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V (111) |
complete automatic |
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sprinkler system. |
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5 |
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IV (2HH) |
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6 |
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II (000) |
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7 |
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III (200) |
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Not Permitted |
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8 |
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V (000) |
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■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.
K103 Interior walls and partitions in buildings of Type I or Type II construction shall be noncombustible or
(Indicate N/A for existing buildings using listed fire retardant treated wood studs within
Form |
Page 3 |
Name of Facility |
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2000 CODE |
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ID |
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MET |
NOT |
N/A |
REMARKS |
PREFIX |
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MET |
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INTERIOR FINISH |
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K14 2000 EXISTING |
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Interior finish for corridors and exitways, including exposed |
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interior surfaces of buildings such as fixed or movable walls, |
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partitions, columns, and ceilings has a flame spread rating of |
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Class A or Class B. 19.3.3.1, 19.3.3.2 |
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Indicate flame spread rating/s _________ |
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2000 NEW |
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Interior finish for corridors and exitways, including exposed |
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interior surfaces of buildings such as fixed or movable walls, |
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partitions, columns, and ceilings has a flame spread rating of |
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Class A or Class B. Lower portion of corridor walls can be |
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Class C. 18.3.3.1, 18.3.3.2 |
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Indicate flame spread rating/s_________ |
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K15 |
2000 EXISTING |
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Interior finish for rooms and spaces not used for corridors or |
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exitways, including exposed interior surfaces of buildings such |
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as fixed or movable walls, partitions, columns, and ceilings has |
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a flame spread rating of Class A or Class B. (In |
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buildings, flame spread rating of Class A, Class B, or Class C |
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may be continued in use within rooms separated in accordance |
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with 19.3.6 from the access corridors.) 19.3.3.1, 19.3.3.2 |
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Indicate flame spread rating/s_________ |
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2000 NEW |
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Interior finish for rooms and spaces not used for corridors or |
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exitways, including exposed interior surfaces of buildings such |
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as fixed or movable walls, partitions, columns, and ceilings has |
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a flame spread rating of Class A or Class B. (Rooms not over |
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4 persons in capacity may have a flame spread rating of Class A, |
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Class B, or Class C). 18.3.3.1, 18.3.3.2. |
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Indicate flame spread rating/s_________ |
Form |
Page 4 |
Name of Facility |
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2000 CODE |
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ID |
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MET |
NOT |
N/A |
REMARKS |
PREFIX |
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MET |
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K16 |
Newly installed interior floor finish complying with 10.2.7 shall be |
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permitted in corridors and exits if Class I. 18.3.3.3, 19.3.3.3 |
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(Indicate N/A for existing interior floor finish.) |
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In smoke compartments protected throughout by an approved, |
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supervised automatic sprinkler system in accordance with |
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19.3.5.2, no interior floor finish requirements shall apply. |
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CORRIDOR WALLS AND DOORS |
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K17 |
2000 EXISTING |
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Corridors are separated from use areas by walls constructed with |
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at least 1/2 hour fire resistance rating. In fully sprinklered smoke |
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compartments, partitions are only required to resist the passage |
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of smoke. In |
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above the ceiling. (Corridor walls may terminate at the underside |
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of ceilings where specifically permitted by Code. Charting and |
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clerical stations, waiting areas, dining rooms, and activity spaces |
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may be open to corridor under certain conditions specified in the |
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Code. Gift shops may be separated from corridors by |
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rated walls if the gift shop is fully sprinklered.) |
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19.3.6.1, 19.3.6.2.1, 19.3.6.5 |
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If the walls have a fire resistance rating, give rating_________ |
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if the walls terminate at the underside of a ceiling, give a brief |
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description in REMARKS, of the ceiling, describing the ceiling |
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throughout the floor area. |
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2000 NEW |
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Corridor walls shall form a barrier to limit the transfer of smoke. |
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Such walls shall be permitted to terminate at the ceiling where |
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the ceiling is constructed to limit the transfer of smoke. No fire |
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resistance rating is required for the corridor walls. |
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18.3.6.1, 18.3.6.2, 18.3.6.5 |
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Form |
Page 5 |
Name of Facility |
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2000 CODE |
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ID |
MET |
NOT |
N/A |
REMARKS |
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PREFIX |
MET |
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K18 2000 EXISTING |
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Doors protecting corridor openings in other than required |
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enclosures of vertical openings, exits, or hazardous areas shall |
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be substantial doors, such as those constructed of 13/4 inch |
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20 minutes. Doors in fully sprinklered smoke compartments are |
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only required to resist the passage of smoke. There is no |
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impediment to the closing of the doors. Doors shall be provided |
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with a means suitable for keeping the door closed. Dutch doors |
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meeting 19.3.6.3.6 are permitted. 19.3.6.3 Roller latches are |
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prohibited by CMS regulations in all health care facilities. |
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Show in REMARKS, details of doors, such as fire protection |
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ratings, automatic closing devices, etc. |
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2000 New |
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Doors protecting corridor openings shall be constructed to resist |
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the passage of smoke. Doors shall be provided with positive |
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latching hardware. Dutch doors meeting 18.3.6.3.6 are permitted. |
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Roller latches shall be prohibited. 18.3.6.3 |
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Show in REMARKS, details of doors, such as fire protection |
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ratings, automatic closing devices, etc. |
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K19 |
Vision panels in corridor walls or doors shall be fixed window |
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assemblies in approved frames. (In fully sprinklered smoke |
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compartments, there are no restrictions in the area and fire |
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resistance of glass and frames.) |
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18.3.6.5, 18.3.6.3.1, 19.3.6.2.3, 19.3.6.3.8, 19.3.6.5 |
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K22 |
Access to exits shall be marked by approved, readily visible |
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signs in all cases where the exit or way to reach exit is not |
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readily apparent to the occupants. 7.10.1.4 |
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VERTICAL OPENINGS |
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K20 |
2000 EXISTING |
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Stairways, elevator shafts, light and ventilation shafts, chutes, |
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and other vertical openings between floors are enclosed with |
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construction having a fire resistance rating of at least one hour. |
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An atrium may be used in accordance with 8.2.5.6, 19.3.1.1 |
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Form |
Page 6 |
Name of Facility |
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2000 CODE |
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ID |
MET |
NOT |
N/A |
REMARKS |
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PREFIX |
MET |
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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. ■
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If enclosures are less than required, give a brief description and |
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specific location in REMARKS. |
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2000 NEW |
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Stairways, elevator shafts, light and ventilation shafts, chutes, |
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and other vertical openings between floors are enclosed with |
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construction having a fire resistance rating of at least two hours |
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connecting four stories or more. (One hour for single story |
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building and sprinklered buildings up to three stories in height.) |
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18.3.1.1. An atrium may be used in accordance with 8.2.2.3.5. |
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If enclosures are less than required, give a brief description and |
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specific location in REMARKS. |
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K21 |
Any door in an exit passageway, stairway enclosure, horizontal |
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exit, smoke barrier or hazardous area enclosure shall be |
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permitted to be held open only by devices arranged to |
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automatically close all such doors by zone or throughout the |
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facility upon activation of: |
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■ (a) The required manual fire alarm system and |
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■ (b) Local smoke detectors designed to detect smoke |
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passing through the opening or a required smoke |
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detection system and |
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■ (c) The automatic sprinkler system, if installed |
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18.2.2.2.6, 19.2.2.2.6, 7.2.1.8.2 |
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Describe method used in REMARKS |
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K33 |
2000 EXISTING |
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Exit components (such as stairways) are enclosed with |
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construction having a fire resistance rating of at least one hour, |
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are arranged to provide a continuous path of escape, and |
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provide protection against fire or smoke from other parts of the |
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building. 8.2.5.2, 19.3.1.1 |
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Form |
Page 7 |
Name of Facility |
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2000 CODE |
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ID |
MET |
NOT |
N/A |
REMARKS |
|
PREFIX |
MET |
||||
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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 |
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||
|
specific location in REMARKS. |
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||
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2000 NEW |
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|||
|
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 |
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If enclosures are less than required, give a brief description and |
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specific location in REMARKS. |
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SMOKE COMPARTMENTATION AND CONTROL |
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K23 |
2000 EXISTING |
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Smoke barriers shall be provided to form at least two smoke |
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|
compartments on every sleeping room floor for more than 30 |
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patients. 19.3.7.1, 19.3.7.2 |
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2000 NEW |
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Smoke barriers shall be provided to form at least two smoke |
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|
compartments on every floor used by inpatients for sleeping or |
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|
treatment, and on every floor with an occupant load of 50 or |
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more persons, regardless of use. Smoke barriers shall also be |
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provided on floors that are usable, but unoccupied. 18.3.7.1, |
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18.3.7.2 |
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K24 |
The smoke compartments shall not exceed 22,500 square feet and |
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the travel distance to and from any point to reach a door in the |
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required smoke barrier shall not exceed 200 feet. 18.3.7.1, 19.3.7.1 |
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Detail in REMARKS zone dimensions including length of zones |
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and dead end corridors. |
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Form |
Page 8 |
Name of Facility |
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2000 CODE |
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|
ID |
MET |
NOT |
N/A |
REMARKS |
|
PREFIX |
MET |
||||
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K25 2000 EXISTING |
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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
|
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 |
|
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. |
|
from the bottom of the door are permitted. Horizontal sliding |
|
doors comply with 7.2.1.14. Doors shall be |
|
|
|
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. |
|
|
|
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 |
|
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 |
Form |
Page 9 |
Name of Facility |
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|
2000 CODE |
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|
ID |
MET |
NOT |
N/A |
REMARKS |
|
PREFIX |
MET |
||||
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|||
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K28 2000 EXISTING |
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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
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
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 |
|
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|
|
One hour fire rated construction (with 3/4 hour |
||||
|
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 |
||||
|
|||||
|
the bottom of the door are permitted. 19.3.2.1 |
||||
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Area |
Automatic Sprinkler |
Separation |
N/A |
|
|
a. Boiler and |
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c. Laundries (greater than 100 sq feet) |
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d. Repair Shops and Paint Shops |
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e. Laboratories (if classified a Severe Hazard - see K31) |
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f. Combustible Storage Rooms/Spaces (over 50 sq feet) |
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g. Trash Collection Rooms |
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|
i. Soiled Linen Rooms |
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|
Describe the floor and zone locations of hazardous areas that |
||||
|
are deficient in REMARKS. |
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|
Form |
Page 10 |
Name of Facility |
|
|
|
2000 CODE |
|
|
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|
|
|
|
ID |
MET |
NOT |
N/A |
REMARKS |
|
PREFIX |
MET |
||||
|
|
|
2000 NEW
Hazardous areas are protected in accordance with 8.4. The areas shall be enclosed with a one hour
3/4 hour
Area |
Automatic Sprinkler Separation N/A |
a.Boiler and
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. |
||||
|
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 |
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Area |
Automatic Sprinkler |
Separation |
N/A |
|
|
L. Gift Shop storing hazardous quantities |
|
|
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|
|
of combustibles |
|
|
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|
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 |
||||
Form |
Page 11 |
Name of Facility |
|
|
|
2000 CODE |
|
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|
|
|
|
|
ID |
MET |
NOT |
N/A |
REMARKS |
|
PREFIX |
MET |
||||
|
|
|
|||
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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, |
|
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|
|
19.2.4.2 |
|
|
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|
|
EXITS AND EGRESS |
|
||||
|
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|
|
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 |
|
|
|
|
|
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|
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|
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|
|
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 |
|
|
|
|
|
|
|
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|
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|
|
K37 |
2000 EXISTING |
|
|
|
|
|
|
Existing |
|
|
|
|
|
|
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 |
|
|
|
|
|
|
|
|
|
|
|
|
Form |
Page 12 |
Name of Facility |
|
|
|
2000 CODE |
|
|
|
|
|
|
|
ID |
MET |
NOT |
N/A |
REMARKS |
|
PREFIX |
MET |
||||
|
|
|
2000 NEW
|
Every exit and exit access shall be arranged so that no |
||
|
corridor, aisle or passageway has a pocket or |
||
|
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 |
||
Form |
Page 13 |
Name of Facility |
|
|
2000 CODE |
||
|
|
|
|
|
|
ID |
|
MET |
NOT |
N/A |
REMARKS |
PREFIX |
|
MET |
|||
|
|
|
|
||
|
|
|
|
|
|
K43 |
Patient room doors are arranged such that the patients can open |
|
|
|
|
|
|
|
|
||
|
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 |
|
|
|
|
|
|
|
|
|
|
Form |
Page 14 |
Name of Facility |
|
|
|
2000 CODE |
|
|
|
|
|
|
|
ID |
MET |
NOT |
N/A |
REMARKS |
|
PREFIX |
MET |
||||
|
|
|
|||
|
|
|
|
|
|
K105 2000 NEW (INDICATE N/A FOR EXISTING) |
|
|
|
|
|
Buildings equipped with or requiring the use of life support |
|
||||
|
systems |
|
||||
|
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 |
|
|
|
|
|
|
|
|
|
|
|
|
Form |
Page 15 |
Name of Facility |
|
|
|
|
2000 CODE |
|
|
|
|
|
|
ID |
|
MET |
NOT |
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 |
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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 |
|
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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 |
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K155 |
Where a required fire alarm system is out of service for more |
|
than 4 hours in a |
|
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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Page 16 |
Name of Facility |
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2000 CODE |
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ID |
MET |
NOT |
N/A |
REMARKS |
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PREFIX |
MET |
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K53 2000 EXISTING (INDICATE N/A FOR HOSPITAL AND FULLY |
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SPRINKLERED NURSING HOMES) |
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In an existing nursing home, not fully sprinklered, the resident |
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sleeping rooms and public areas (dining rooms, activity rooms, |
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resident meeting rooms, etc) are to be equipped with single |
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station |
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maintenance and battery replacement program to ensure proper |
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operation. CFR 483.70 |
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2000 NEW (NURSING HOME AND EXISTING LIMITED |
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CARE FACILITIES) |
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An automatic smoke detection system is installed in all corridors. |
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(As an alternative to the corridor smoke detection system on |
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patient sleeping room floors, smoke detectors may be installed in |
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each patient sleeping room and at smoke barrier or horizontal |
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exit doors in the corridor.) Such detectors are electrically |
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interconnected to the fire alarm system. 18.3.4.5.3 |
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K109 |
2000 EXISTING LIMITED CARE FACILITIES |
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(INDICATE N/A FOR HOSPITALS OR NURSING HOMES) |
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An automatic smoke detection system is installed in all corridors |
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with detector spacing no further apart than 30 ft on center in |
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|
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 |
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|
smoke barrier or horizontal exit doors in the corridors.) Such |
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detectors are electrically interconnected to the fire alarm system. |
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19.3.4.5.1 |
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Smoke Detection System |
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❏ Corridors |
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❏ Rooms |
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❏ Bath |
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K54 |
All required smoke detectors, including those activating door |
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tested in accordance with the manufacturer’s specifications. |
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9.6.1.3 |
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Give a brief description, in REMARKS of any smoke detection |
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system which may be installed. |
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Form |
Page 17 |
Name of Facility |
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2000 CODE |
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ID |
MET |
NOT |
N/A |
REMARKS |
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PREFIX |
MET |
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K55 2000 EXISTING |
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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
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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 |
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AUTOMATIC SPRINKLER SYSTEMS |
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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. |
Form |
Page 18 |
Name of Facility |
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2000 CODE |
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ID |
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MET |
NOT |
N/A |
REMARKS |
PREFIX |
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MET |
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K154 |
Where a required automatic sprinkler system is out of service |
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for more than 4 hours in a |
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jurisdiction shall be notified, and the building shall be evacuated |
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or an approved fire watch system be provided for all parties left |
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unprotected by the shutdown until the sprinkler system has been |
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returned to service. 9.7.6.1. |
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A. Date sprinkler system last checked and necessary |
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maintenance provided. _______________________________ |
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B. Show who provided the service. _______________________ |
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C. Note the source of water supply for the automatic |
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sprinkler system.____________________________________ |
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(Provide, in REMARKS, information on coverage for any |
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K60 |
Initiation of the required fire alarm systems shall be by manual |
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means in accordance with 9.6.2 and by means of any required |
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|
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sprinkler system waterflow alarms, detection devices, or detection |
|
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|
systems. 18.3.4.2, 19.3.4.2, 9.6.2.1 |
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K61 |
Required automatic sprinkler systems shall have valves |
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|
supervised so that at least a local alarm will sound when the |
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|
valves are closed. 9.7.2.1, NFPA 72 |
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K62 |
Automatic sprinkler systems are continuously maintained |
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in reliable operating condition and are inspected and tested |
|
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periodically. 18.7.6, 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5 |
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|
K63 |
Required automatic sprinkler systems have an adequate and |
|
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|
|
reliable water supply which provides continuous and automatic |
|
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|
|
pressure. 9.7.1.1, NFPA 13 |
|
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|
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|
K64 |
Portable fire extinguishers shall be provided in all health care |
|
|
|
|
|
occupancies in accordance with 9.7.4.1, NFPA 10. |
|
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18.3.5.6, 19.3.5.6 |
|
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Form |
Page 19 |
Name of Facility |
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2000 CODE |
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ID |
MET |
NOT |
N/A |
REMARKS |
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PREFIX |
MET |
||||
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|||
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SMOKING REGULATIONS |
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K66 Smoking regulations shall be adopted and shall include not less |
|
|
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|
|
than the following provisions: 18.7.4, 19.7.4 |
|
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|
|
■ (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 |
|
|
ashtrays can be emptied shall be readily available to all |
|
|
areas where smoking is permitted. |
|
|
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|
|
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 |
|
|
||
|
elements of such devices do not exceed 212oF (100oC). |
|
|
18.7.8, 19.7.8 |
|
Form |
Page 20 |
Name of Facility |
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2000 CODE |
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ID |
MET |
NOT |
N/A |
REMARKS |
|
PREFIX |
MET |
||||
|
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|
|||
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K71 Rubbish Chutes, Incinerators and Laundry Chutes. |
|
|
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|
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
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
Includes firefighters service phase I key recall and smoke detector automatic recall, firefighters service phase II emergency
Form |
Page 21 |
Name of Facility |
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|
|
2000 CODE |
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|
|
ID |
MET |
NOT |
N/A |
REMARKS |
|
PREFIX |
MET |
||||
|
|
|
|||
|
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|
|
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 |
|
||||
|
detectors, elevator lobby smoke detectors). 18.5.3, 9.4 |
|
||||
|
|
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|
|
FURNISHINGS AND DECORATIONS |
|
||||
|
|
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|
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|
|
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. |
|
|
|
|
|
|
|
|
|
|
|
|
Form |
Page 22 |
Name of Facility |
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|
2000 CODE |
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ID |
|
MET |
NOT |
N/A |
REMARKS |
PREFIX |
|
MET |
|||
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|
||
|
|
|
|
|
|
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 |
|
|
|
|
|
|
|
|
|
|
|
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. |
|
|
|
|
|
|
|
|
|
|
Form |
Page 23 |
Name of Facility |
|
|
2000 CODE |
||
|
|
|
|
|
|
ID |
|
MET |
NOT |
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
(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 |
|
|
|
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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Page 24 |
Name of Facility |
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2000 CODE |
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ID |
MET |
NOT |
N/A |
REMARKS |
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MET |
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K143 Transferring of oxygen shall be: |
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(a)separated from any portion of a facility wherein patients are housed, examined, or treated by a separation of a fire barrier of
(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
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ELECTRICAL |
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K106 |
The hospital and all nursing homes and hospices with life support |
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equipment has a Type I Essential Electrical System powered by |
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a generator with a transfer switch and separate power supply. |
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The EES is in accordance with NFPA 99, 3.4.2.2, 3.4.2.1.4 |
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K144 |
Generators inspected weekly and exercised under load for |
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30 minutes per month and shall be in accordance with NFPA 99, |
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3.4.4.1, NFPA 110, 8.4.2 |
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K145 |
The Type I EES is divided into the critical branch, life safety |
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branch and the emergency system and shall be in accordance |
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with NFPA 99, 3.4.2.2.2 |
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K146 |
The nursing home/hospice with no life support equipment shall |
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have an alternate source of power separate and independent |
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from the normal source that will be effective for minimum of 11/2 |
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hour after loss of the normal source NFPA 99, 3.6. |
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K147 |
Electrical wiring and equipment shall be in accordance with |
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NFPA 70, National Electrical Code. 9.1.2 |
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K130 |
Miscellaneous |
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List in the REMARKS sections, any items that are not listed |
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previously, but are deficient. This information, along with the |
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applicable Life Safety Code or NFPA standard citation, should |
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be included on Form |
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Form |
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 |
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Fire Authority Official (Signature) |
Title |
Office |
Date |
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Form |
Page 26 |
FIRE SAFETY SURVEY REPORT
CRUCIAL DATA EXTRACT
(TO BE USED WITH
PROVIDER NUMBER
K1
FACILITY NAME
SURVEY DATE
* K4
K6 DATE OF PLAN |
K3 MULTIPLE CONSTRUCTION |
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APPROVAL |
TOTAL NUMBER OF BUILDINGS ____________ |
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NUMBER OF THIS BUILDING ____________ |
ABUILDING
BWING
CFLOOR
DAPARTMENT UNIT
LSC FORM INDICATOR
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Health Care Form |
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12 |
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2786R |
2000 |
EXISTING |
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13 |
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2786R |
2000 NEW |
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ASC Form |
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14 |
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2786U |
2000 |
EXISTING |
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15 |
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2786U |
2000 NEW |
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ICF/MR Form |
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16 |
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2786V, W, X |
2000 |
EXISTING |
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17 |
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2786V, W, X |
2000 |
NEW |
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* K7 |
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SELECT NUMBER OF FORM USED FROM ABOVE |
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(Check if K29 or K56 are marked as not applicable in the 2786 M, R, T, U, V, W, X and Y.)
K29: |
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K56: |
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COMPLETE IF ICF/MR IS SURVEYED UNDER CHAPTER 21
SMALL |
(16 BEDS OR LESS) |
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1 PROMPT |
K8: |
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2 SLOW |
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3 IMPRACTICAL |
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LARGE |
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4 PROMPT |
K8: |
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5 SLOW |
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6IMPRACTICAL
APARTMENT HOUSE
7PROMPT
K8: |
8 SLOW |
9IMPRACTICAL
ENTER E – SCORE HERE
K5: |
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e.g. 2.5 |
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*K9: FACILITY MEETS LSC BASED ON (Check all that apply)
A1.
A2.
A3.
A4.
A5.
(COMP. WITH |
(ACCEPTABLE POC) |
(WAIVERS) |
(FSES) |
(PERFORMANCE |
ALL PROVISIONS) |
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BASED DESIGN) |
FACILITY DOES NOT MEET LSC |
K0180 |
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A. |
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B. |
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C. |
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B. |
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FULLY SPRINKLERED |
PARTIALLY SPRINKLERED |
NONE |
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(All required areas are sprinklered) |
(Not all required areas are sprinklered) |
(No sprinkler system) |
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* MANDATORY
Form |
Page 27 |