2000 CODE DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 1. (A) PROVIDER NUMBER 1. (B) MEDICAID I.D. NO. K1 FIRE SAFETY SURVEY REPORT 2000 CODE - HEALTH CARE Medicare – Medicaid Form Approved OMB No. 0938-0242 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. B. WING B. ________________ C. FLOOR ________________ C. DATE OF PLAN APPROVAL K4 s s None (No sprinkler system) K0180 4. DATE OF SURVEY s MEDICARE s Partially Sprinklered (Not all required areas are sprinklered) K3 3. SURVEY FOR s Fully Sprinklered (All required areas are sprinklered) A. BUILDING ________________ SURVEY UNDER K6 5. MEDICAID s 2000 EXISTING 6. s 2000 NEW K7 5. SURVEY FOR CERTIFICATION OF 1. s HOSPITAL 2. s SKILLED/NURSING FACILITY 4. s ICF/MR UNDER HEALTH CARE 5. s HOSPICE K5 IF “2” OR “5” ABOVE IS MARKED, CHECK APPROPRIATE ITEM(S) BELOW 1. s ENTIRE FACILITY 6. BED COMPOSITION a. TOTAL NO. OF BEDS IN THE FACILITY _______ 2. 3. s DISTINCT PART OF (SPECIFY)_________________________________ b. NUMBER OF HOSPITAL BEDS CERTIFIED FOR MEDICARE ____ c. NUMBER OF SKILLED BEDS CERTIFIED FOR MEDICARE ______ s THE FACILITY MEETS, BASED UPON (CHECK ALL APPROPRIATE BOXES) 1. s COMPLIANCE WITH ALL PROVISIONS 2. s ACCEPTANCE OF A PLAN OF CORRECTION B. s THE FACILITY DOES NOT MEET THE STANDARD s IF DISTINCT PART OF HOSPITAL, IS HOSPITAL ACCREDITED BY JCAHO/AOA? a. s YES b. s NO d. NUMBER OF SKILLED BEDS e. NUMBER OF NF or ICF/MR BEDS CERTIFIED FOR MEDICAID ______ CERTIFIED FOR MEDICAID _______ 7. A. 3. s RECOMMENDED WAIVERS 4. s FSES 5. s PERFORMANCE BASED DESIGN K9 SURVEYOR (Signature) TITLE OFFICE DATE TITLE OFFICE DATE SURVEYOR ID K10 FIRE AUTHORITY OFFICIAL (Signature) 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. Form CMS-2786R (06/07) EF 06/2007 Page 1 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility 2000 CODE ID PREFIX MET NOT MET N/A REMARKS 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 TA9 1 I (443), I (332), II (222) Any Height 2 II (111) One story only (non-sprinklered). 3 II (111) Not over three stories with complete automatic sprinkler system. 4 III (211) 5 V (111) 6 IV (2HH) 7 II (000) 8 III (200) 9 V (000) Not over two stories with complete automatic sprinkler system. Not over one story with complete automatic sprinkler system. s 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 CMS-2786R (06/07) EF 06/2007 Page 2 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility 2000 CODE ID PREFIX K12 MET NOT MET N/A REMARKS 2000 NEW Building construction type and height meets one of the following: 18.1.6.2, 18.1.6.3, 18.2.5.1 K13 1 I (443), I (332), II (222) Any height with complete automatic sprinkler system 2 II (111) Not over three stories with complete automatic sprinkler system 3 III (211) 4 V (111) 5 IV (2HH) 6 II (000) 7 III (200) 8 V (000) Not over one story with complete automatic sprinkler system. Not Permitted s 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 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.) Form CMS-2786R (06/07) EF 06/2007 Page 3 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility 2000 CODE ID PREFIX MET NOT MET N/A REMARKS 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_________ Form CMS-2786R (06/07) EF 06/2007 Page 4 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility 2000 CODE ID PREFIX K16 MET NOT MET N/A REMARKS 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 Form CMS-2786R (06/07) EF 06/2007 Page 5 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility 2000 CODE ID PREFIX K18 MET NOT MET N/A REMARKS 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 Form CMS-2786R (06/07) EF 06/2007 Page 6 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility ID PREFIX 2000 CODE MET NOT MET N/A REMARKS If all vertical openings are properly enclosed with construction providing at least a two hour fire resistance rating, also check this box. s 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: s (a) The required manual fire alarm system and s (b) Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system and s (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 Form CMS-2786R (06/07) EF 06/2007 Page 7 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility ID PREFIX 2000 CODE MET NOT MET N/A REMARKS If all vertical openings are properly enclosed with construction providing at least a two hour fire resistance rating, also check this box. s 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 and dead end corridors. Form CMS-2786R (06/07) EF 06/2007 Page 8 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility ID PREFIX K25 2000 CODE MET NOT MET N/A REMARKS 2000 EXISTING Smoke barriers shall be constructed to provide at least a onehalf 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 onehour 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 Form CMS-2786R (06/07) EF 06/2007 Page 9 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility 2000 CODE ID PREFIX K28 MET NOT MET N/A REMARKS 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 Nursing Facilities 41.5 inches (105 cm) 83 inches (211 cm) Psychiatric Hospitals and Limited Care Facilities 32 inches (81 cm) 64 inches (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 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 Separation N/A Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. Form CMS-2786R (06/07) EF 06/2007 Page 10 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility 2000 CODE ID PREFIX MET NOT MET N/A REMARKS 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 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) Separation N/A 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 L. Gift Shop storing hazardous quantities of combustibles K211 Automatic Sprinkler Separation N/A 2000 EXISTING Where Alcohol Based Hand Rub (ABHR) dispensers are installed: t The corridor is at least 6 feet wide t The maximum individual fluid dispenser capacity shall be 1.2 liters (2 liters in suites of rooms) t The dispensers shall have a minimum spacing of 4 ft from each other t Not more than 10 gallons are used in a single smoke compartment outside a storage cabinet. t Dispensers are not installed over or adjacent to an ignition source. t 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 CMS-2786R (06/07) EF 06/2007 Page 11 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility 2000 CODE ID PREFIX K211 MET NOT MET N/A REMARKS 2000 NEW Where Alcohol Based Hand Rub (ABHR) dispensers are installed: t The corridor is at least 6 feet wide t The maximum individual fluid dispenser capacity shall be 1.2 liters (2 liters in suites of rooms) t The dispensers shall have a minimum spacing of 4 ft from each other t Not more than 10 gallons are used in a single smoke compartment outside a storage cabinet. t Dispensers are not installed over or adjacent to an ignition source. t 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 Form CMS-2786R (06/07) EF 06/2007 Page 12 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility ID PREFIX 2000 CODE MET NOT MET N/A REMARKS 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. s 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 CMS-2786R (06/07) EF 06/2007 Page 13 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility 2000 CODE ID PREFIX K43 MET NOT MET N/A REMARKS 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 CMS-2786R (06/07) EF 06/2007 Page 14 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility 2000 CODE ID PREFIX K105 MET NOT MET N/A REMARKS 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 Form CMS-2786R (06/07) EF 06/2007 Page 15 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility 2000 CODE ID PREFIX MET NOT MET N/A REMARKS 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 Form CMS-2786R (06/07) EF 06/2007 Page 16 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility ID PREFIX K53 2000 CODE MET NOT MET N/A REMARKS 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 t Corridors t Rooms t 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. Form CMS-2786R (06/07) EF 06/2007 Page 17 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility 2000 CODE ID PREFIX K55 MET NOT MET N/A REMARKS 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. Form CMS-2786R (06/07) EF 06/2007 Page 18 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility ID PREFIX K154 2000 CODE MET NOT MET N/A REMARKS 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 Form CMS-2786R (06/07) EF 06/2007 Page 19 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility 2000 CODE ID PREFIX MET NOT MET N/A REMARKS SMOKING REGULATIONS K66 Smoking regulations shall be adopted and shall include not less than the following provisions: 18.7.4, 19.7.4 s (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. s (2) Smoking by patients classified as not responsible shall be prohibited, except when under direct supervision. s (3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. s (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 Form CMS-2786R (06/07) EF 06/2007 Page 20 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility ID PREFIX K71 2000 CODE MET NOT MET N/A REMARKS Rubbish Chutes, Incinerators and Laundry Chutes. 18.5.4, 19.5.4, 9.5, 8.4, NFPA 82 s (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. s (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. s (3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. s (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 Form CMS-2786R (06/07) EF 06/2007 Page 21 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility 2000 CODE ID PREFIX K161 MET NOT MET N/A REMARKS 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. s 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 s 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 CMS-2786R (06/07) EF 06/2007 Page 22 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility 2000 CODE ID PREFIX K75 MET NOT MET N/A REMARKS 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. Form CMS-2786R (06/07) EF 06/2007 Page 23 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility ID PREFIX K135 2000 CODE MET NOT MET N/A REMARKS 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. Form CMS-2786R (06/07) EF 06/2007 Page 24 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility 2000 CODE ID PREFIX K143 MET NOT MET N/A REMARKS 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 American LegalNet, Inc. www.FormsWorkflow.com 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) JUSTIFICATION K84 Surveyor Title (Signature) Fire Authority Official (Signature) Form CMS-2786R (06/07) EF 06/2007 Office Date Title Office Date Page 26 American LegalNet, Inc. www.FormsWorkflow.com FIRE SAFETY SURVEY REPORT CRUCIAL DATA EXTRACT (TO BE USED WITH CMS-2786 FORMS) PROVIDER NUMBER FACILITY NAME SURVEY DATE K1 K6 * K4 K3 DATE OF PLAN APPROVAL MULTIPLE CONSTRUCTION TOTAL NUMBER OF BUILDINGS ____________ NUMBER OF THIS BUILDING LSC FORM INDICATOR ____________ 12 13 14 15 SMALL (16 BEDS OR LESS) K8: ASC Form 2000 EXISTING 2000 NEW 1 PROMPT 2 SLOW 3 IMPRACTICAL LARGE K8: ICF/MR Form 2786V, W, X 2000 EXISTING 2786V, W, X 2000 NEW 16 17 SELECT NUMBER OF FORM USED FROM ABOVE *K9: 7 PROMPT 8 SLOW 9 IMPRACTICAL ENTER E – SCORE HERE (Check if K29 or K56 are marked as not applicable in the 2786 M, R, T, U, V, W, X and Y.) K29: 4 PROMPT 5 SLOW 6 IMPRACTICAL APARTMENT HOUSE K8: * K7 BUILDING WING FLOOR APARTMENT UNIT COMPLETE IF ICF/MR IS SURVEYED UNDER CHAPTER 21 Health Care Form 2786R 2000 EXISTING 2786R 2000 NEW 2786U 2786U A B C D K5: K56: e.g. 2.5 FACILITY MEETS LSC BASED ON (Check all that apply) A1. (COMP. WITH ALL PROVISIONS) A2. A3. (ACCEPTABLE POC) FACILITY DOES NOT MEET LSC (WAIVERS) A5. (FSES) (PERFORMANCE BASED DESIGN) K0180 A. B. A4. FULLY SPRINKLERED B. PARTIALLY SPRINKLERED (All required areas are sprinklered) (Not all required areas are sprinklered) C. NONE (No sprinkler system) * MANDATORY Form CMS-2786R (06/07) EF 06/2007 Page 27 American LegalNet, Inc. www.FormsWorkflow.com