DEPARTMENT OF HEALTH AND HUMAN SERVICES 2012 LIFE SAFETY CODE

CENTERS FOR MEDICARE & MEDICAID SERVICE Form Approved OMB Exempt

FIRE SAFETY SURVEY REPORT – 2012 LIFE SAFETY CODE 1. (A) PROVIDER NUMBER 1. (B) MEDICAID I.D. NO.

AMBULATORY HEALTH CARE

K1 K2

PART I — Life Safety Code, New and Existing

PART II — Health Care Facilities Code, New and Existing
PART III — Recommendation for Waiver
PART IV – Crucial Data Extract
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 (STATE, CITY, ZIP A. Fully Sprinklered
CODE) (All required areas are sprinklered)
A. BUILDING _________________
B. Partially Sprinklered
B. WING _________________
(Not all required areas are
C. FLOOR _________________
sprinklered)
C. None (No sprinkler system)
K3 K0180
Date of Survey

Initial Survey Resurvey New Existing Number of Stations in ESRD

K4
CHECK ONE DATE OF BLDG. PERMIT OR PLAN APPROVAL DATE FIRST OCCUPIED AS AMBULATORY SURGICAL
Facility is: CTR.
Physically located in a hospital
K6
Free-standing: only occupancy in building If facility is located in a hospital or hospital owned/operated, was facility surveyed as part of Hospital LSC Survey?
Located in an Office Occupancy
Located in a Mercantile/Business Occupancy Yes No
Indicate Occupancy ____________________
Other (specify) ________________________ A The facility MEETS based upon: B The facility DOES NOT MEET THE STANDARD
Accredited by __________________________ 1. Compliance with all provisions
Non Accredited 2. Acceptance of a Plan of Correction
3. Recommended waivers
4. Performance Based Design

K9

SURVEYOR (Signature) TITLE OFFICE DATE

SURVEYOR ID
K10

REVIEW AUTHORITY OFFICIAL (Signature) TITLE OFFICE DATE

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

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PART I – NFPA 101 LSC REQUIREMENTS
(Items in italics relate to the FSES)
SECTION 1 – GENERAL REQUIREMENTS

K100 General Requirements – Other

List in the REMARKS section any LSC Section 20.1 and 20.1 General
Requirements that are not addressed by the provided K-tags, but are
deficient. This information, along with the applicable Life Safety Code or
NFPA standard citation, should be included on Form CMS-2567.
K111 Building Rehabilitation
Repair, Renovation, Modification, or Reconstruction
Any building undergoing repair, renovation, modification, or reconstruction
complies with both of the following:
• Requirements of Chapter 21
• Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6
20.1.1.4.3, 21.1.1.4.3, 4.6.7, 43.1.2.1
Change of Use or Change of Occupancy
Any building undergoing change of use or change of occupancy
classification complies with the requirements of Section 43.7, unless
permitted by 20.1.1.4.2 or 21.1.1.4.2
20.1.1.4.2, 21.1.1.4.2, 43.1.2.2 (43.7)
Additions
Any building undergoing an addition shall comply with the requirements of
Section 43.8. If the building has a common wall with a nonconforming
building, the common wall is a fire barrier having at least a 2 hour fire
resistance rating constructed of materials as required for the addition.
20.1.1.4.1, 21.1.1.4.1, 4.6.5, 4.6.7, 43.1.2.3 (43.8)

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K131 Multiple Occupancies – Sections of Ambulatory Health Care Facilities

Multiple occupancies shall be in accordance with 6.1.14.
Sections of ambulatory health care facilities shall be permitted to be
classified as other occupancies, provided they meet both of the following:
• The occupancy is not intended to serve ambulatory health care
occupants for treatment or customary access
• They are separated from the ambulatory health care occupancy by a 1
hour fire resistance rating
Ambulatory health care facilities shall be separated from other tenants and
occupancies and shall meet all of the following:
• Walls have not less than 1 hour fire resistance rating and extend from
floor slab to roof slab
• Doors are constructed of not less than 1-3/4 inches thick, solid-bonded
wood core or equivalent and is equipped with positive latches.
• Doors are self-closing and are kept in the closed position, except when
in use.
• Windows in the barriers are of fixed fire window assemblies per 8.3.
Per regulation, ASCs are classified as Ambulatory Health Care
Occupancies, regardless of the number of patients served.
20.1.3.2, 21.1.3.3, 20.3.7.1, 21.3.7.1,42 CFR 416.44

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K161 Building Construction Type and Height

Building construction type and stories meet Table 20.1.6.1 or Table
21.1.6.1, respectively.
Construction Type

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

Any number of stories
1 II (111), III (211), IV (2HH),
non-sprinklered or sprinklered
V (111)

One story non-sprinklered

2 II (000), III (200), V (000)
Any number of stories sprinklered

Any level below the level of exit discharge shall be separated by Type II
(111), Type III (211), or Type V (111) construction unless both of the
following are met:
1. Such levels are under the control of the ambulatory health care
occupancy.
2. Hazardous spaces are protected per section 8.7.
Sprinklered stories must be sprinklered throughout by an approved,
supervised automatic system in accordance with section 9.7. (See 20.3.5 or
21.3.5, respectively)
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.
20.1.6.1, 20.1.6.2, 21.1.6.1, 21.1.6.2

K163 Interior Nonbearing Wall Construction

Interior nonbearing walls in Type I or II construction are constructed of
noncombustible or limited-combustible materials.
Interior nonbearing walls required to have a minimum 2 hour fire resistance
rating are permitted to be fire-retardant-treated wood enclosed within
noncombustible or limited-combustible materials, provided they are not
used as shaft enclosures.
20.1.6.3, 20.1.6.4, 21.1.6.3, 21.1.6.4

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SECTION 2 – MEANS OF EGRESS REQUIREMENTS

K200 Means of Egress Requirements – Other

List in the REMARKS section any LSC Section 20.2 and 21.2 Means of
Egress Requirements that are not addressed by the provided K-tags, but
are deficient. This information, along with the applicable Life Safety Code or
NFPA standard citation, should be included on Form CMS-2567.
20.2, 21.2
K211 Means of Egress – General
Aisles, passageways, corridors, exit discharges, exit locations, and
accesses are in accordance with Chapter 7, and the means of egress is
continuously maintained free of all obstructions to full instant use in case of
emergency, unless modified by 20/21.2.2 through 20/21.2.11.
20.2.1, 21.2.1, 7.1.10.1
K222 Egress Doors
Special locking arrangements are in accordance with section 7.2.1.6
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance
with 7.2.1.6.1 shall be permitted on door assemblies serving low and
ordinary hazard contents in buildings protected throughout by an approved,
supervised automatic fire detection system or an approved, supervised
automatic sprinkler system.
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with
7.2.1.6.2 shall be permitted.
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall
be permitted on door assemblies in buildings protected throughout by an
approved, supervised automatic fire detection system and an approved,
supervised automatic sprinkler system.
20.2.2.2, 21.2.2.2, 7.2.1.6.1 through 7.2.1.6.3

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K223 Doors with Self-Closing Devices

Doors required to be self-closing are permitted to be held open by a release
device complying with 7.2.1.8.2 that automatically closes all such doors
throughout the smoke compartment, entire facility, and all stair enclosure
doors upon activation of:
• Required manual fire alarm system, and
• Local smoke detectors designed to detect smoke passing through the
• opening or a required smoke detection system; and
• Automatic sprinkler system, if installed; and
• Loss of power
20.2.2.4, 20.2.2.5, 21.2.2.4, 21.2.2.5
K231 Means of Egress Capacity
The capacity of required means of egress is in accordance with 7.3.
20.2.3.1, 21.2.3.1, 38.2.3, 39.2.3

K232 Aisle, Corridor or Ramp Width

The clear width of any corridor or passageway required for egress shall be
not less than 44 inches wide.
Where a corridor is 6 feet wide, projections of not more than 6 inches from
the corridor wall above the handrail height are permitted for alcohol-based
hand rub dispensers.
20.2.3.2, 20.2.3.3, 21.2.3.2, 21.2.3.3
K233 Clear Width of Exit and Exit Access Doors
2012 EXISTING
Doors in the means of egress from diagnostic or treatment areas, such as
x-ray, surgical, or physical therapy, shall provide a clear width of not less
than 32 inches, unless the doors are existing 34 inch wide doors.
21.2.3.4
2012 NEW
Doors in the means of egress from diagnostic or treatment areas, such as
x-ray, surgical, or physical therapy, shall provide a clear width of not less
than 32 inches.
20.2.3.4

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Number of Exits – Story and Compartment
K241
2012 EXISTING
Single means of egress is allowed from a mezzanine or balcony if one of
the following exist:
1. Common path of travel is under 100 feet if in a sprinklered building.
2. Common path of travel 75 feet if in a non-sprinklered building.
3. Common path of travel is not limited if occupant load is under 30.
Not less than 2 exits, as described in 38.2.2, are remotely located for each
fire section or patient care area of the building and are accessible from
each smoke compartment.
Patient care suites larger than 2500 square feet have 2 exits remotely
located from each other.
Egress from smoke compartments, if installed, shall be permitted through
adjacent compartments provided the egress does not return through the
compartment of fire origin.
21.2.3.1 through 21.2.3.5, 7.4.1.1, 7.4.1.3 through 7.4.1.6
2012 NEW
Meets the requirements of section 7.4.
Not less than 2 exits, as described in 38.2.2, are remotely located for each
fire section or patient care area of the building and are accessible from
each smoke compartment.
Patient care suites larger than 2500 square feet have 2 exits remotely
located from each other.
Egress from smoke compartments, if installed, shall be permitted through
adjacent compartments provided the egress does not return through the
compartment of fire origin.
20.2.4.1 through 20.2.4.5, 7.4
K251 Dead-End Corridors and Common Path of Travel
2012 EXISTING
Dead end corridors shall not exceed 50 feet.
Common path of travel is no more 75 feet, and no more than 100 feet on a
sprinklered story. Common path of travel is not limited in single tenant
space with an occupant load not exceeding 30 persons.
21.2.5, 39.2.5.2

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K251 2012 NEW

Dead-end corridors are no more than 50 feet in sprinklered buildings, and
no more than 20 feet in non-sprinklered buildings.
Common path of travel is no more 75 feet, and no more than 100 feet in
sprinklered buildings or single tenant space with an occupant load not
exceeding 30 persons.
20.2.5, 38.2.5.2, 38.2.5.3
K261 Travel Distance to Exits
Travel distance between any point in a room and an exit is not more than
150 feet or 200 feet in sprinklered buildings.
20.2.6, 21.2.6
K271 Discharge from Exits
Exit discharge is arranged in accordance with 7.7, provides a level walking
surface meeting the provisions of 7.1.7 with respect to changes in elevation
and shall be maintained free of obstructions. Additionally, the exit discharge
shall be a hard packed all-weather travel surface in accordance with CMS
Survey and Certification Letter 07-38.
20.2.7, 21.2.7, 38.2.7, 39.2.7, 7.7
K281 Illumination of Means of Egress
Illumination of means of egress, including exit discharge, is arranged in
accordance with 7.8 and shall be either continuously in operation or
capable of automatic operation without manual intervention.
20.2.8, 21.2.8, 7.8
K291 Emergency Lighting
Emergency lighting of at least 1-1/2 hour duration is provided automatically
in accordance with 7.9.
20.2.9.1, 21.2.9.1, 7.9
K292 Life Support Means of Egress
Where general anesthesia or life-support equipment is used, each
ambulatory health care facility shall be provided with an essential electric
system in accordance with NFPA 99.
(Indicate N/A if life support equipment is for emergency purposes only.)
20.2.9.2, 21.2.9.2

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K293 Exit Signage

Exit and directional signs are displayed in accordance with 7.10 with
continuous illumination also served by the emergency lighting system.
20.2.10, 21.2.10, 7.10

SECTION 3 – PROTECTION
K300 Protection – Other
List in the REMARKS section any LSC Section 20.3 and 21.3 Protection
requirements that are not addressed by the provided K-tags, but are
deficient. This information, along with the applicable Life Safety Code or
NFPA standard citation, should be included on Form CMS-2567.

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K311 Vertical Openings – Enclosure

2012 EXISTING
Vertical openings shall be enclosed or protected per 8.6, unless one of the
following conditions exist:
1. Unenclosed vertical openings per 8.6.9.1 are permitted.
2. Unenclosed openings which do not serve as a required means of
egress are permitted.
3. Exit access stairs may be unenclosed if they meet the following
conditions:
Two stories or less
a. Building is protected throughout by a supervised sprinkler system
per 9.7.1.1(1).
b. Total travel distance to outside does not exceed 100 feet.
Three stories or less
a. Occupant load per story does not exceed 15 people.
b. Building is sprinkler protected throughout per 9.7.1.1(1).
c. Building contains an automatic smoke detection system per 9.6.
d. Activation of the sprinkler system or smoke detection system
notifies all occupants of the building.
e. Total travel distance to outside does not exceed 100 feet.
Floors that are below the street level and are used for storage or any use
other than a business occupancy, shall not have any unprotected openings
to the business occupancy floors.
21.3.1, 39.3.1.1, 39.3.1.2

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K311 2012 NEW

Vertical openings shall be enclosed or protected per 8.6, unless one of the
following conditions exist:
1. Unenclosed vertical openings per 8.6.9.1 are permitted.
2. Exit access stairs may be unenclosed if they meet the 2 conditions:
a. Building is sprinkler protected throughout.
b. Total travel distance to outside does not exceed 100 feet.
Floors that are below the street level and are used for storage or any use
other than a business occupancy, shall not have any unprotected openings
to the business occupancy floors.
20.3.1, 38.3.1.1, 38.3.1.2

K321 Hazardous Areas – Enclosure

Hazardous areas must meet one of the following:
Contain 1 hour rated enclosure when non-sprinklered
Sprinkler protected with smoke resistive separation
Severe Hazard locations contain sprinkler protection and 1 hour
separation with 3/4 hour rated self-closing doors
20.3.2, 21.3.2, 38.3.2, 38.3.2.2, 39.3.2.1, 39.3.2.2, 8.7

K322 Laboratories
Laboratories employing quantities of flammable, combustible, or hazardous
materials that are considered a severe hazard are protected by 1-hour fire
resistance-rated separation, automatic sprinkler system, and are in
accordance with 8.7 and with NFPA 99.
Laboratories not considered a severe hazard are protected as hazardous
areas (see K321).
Laboratories using chemicals are in accordance with NFPA 45.
Gas appliances are of appropriate design and installed in accordance with
NFPA 54. Shutoff valves are marked to identify material they control.
Devices requiring medical grade oxygen from the piped distribution system
meet the requirements under 11.4.2.2 (NFPA 99).
20.3.2.2, 21.3.2.2
9.3.1.2, 11.4.3.2, 15.4 (NFPA 99)

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K323 Anesthetizing Locations

Areas designated for administration of general anesthesia (i.e., inhalation
anesthetics) are in accordance with 8.7 and NFPA 99.
Zone valves are located immediately outside each life-support, critical care,
and anesthetizing location of moderate sedation, deep sedation, or general
anesthesia for medical gas or vacuum; readily accessible in an emergency;
and arranged so shutting off any one anesthetizing location will not affect
others.
Area alarm panels are provided to monitor all medical gas, medical-surgical
vacuum, and piped WAGD systems. Panels are at locations that provide for
surveillance, indicate medical gas pressure decreases of 20 percent and
vacuum decreases of 12 inch gauge HgV, and provide visual and audible
indication. Alarm sensors are installed either on the source side of individual
room zone valve box assemblies or on the patient/use side of each of the
individual zone box valve assemblies.
The EES critical branch supplies power for task illumination, fixed
equipment, select receptacles, and select power circuits, and EES
equipment system supplies power to ventilation system.
Heating, cooling, and ventilation are in accordance with ASHRAE 170.
Medical supply and equipment manufacturer’s instructions for use are
considered before reducing humidity levels to those allowed by ASHRAE,
per S&C 13-58.
20.3.2.3, 21.3.2.3, NFPA 99 5.1.4.8.7, 5.1.4.8.7.2, 5.1.9.3.4, 6.4.2.2.4.2

K324 Cooking Facilities

Commercial cooking equipment shall be installed per NFPA 96 unless used
for food warming or limited cooking.
20.3.2.4, 20.3.2.5, 21.3.2.4, 21.3.2.5, 9.2.3

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K325 Alcohol Based Hand Rub Dispenser (ABHR)

ABHRs are protected in accordance with 8.7.3.1, unless all conditions are
met:
• Corridor is at least 6 feet wide.
• Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in
suites) of fluid and 18 ounces of Level 1 aerosols.
• Dispensers shall have a minimum of 4-foot horizontal spacing.
• Not more than an aggregate of 10 gallons of fluid or 1135 ounces of
aerosol are used in a single smoke compartment outside a storage
cabinet, excluding one individual dispenser per room.
• Storage in a single smoke compartment greater than 5 gallons complies
with NFPA 30.
• Dispensers are not installed within 1 inch of an ignition source.
• If floor is carpeted, the building is fully sprinkler protected.
• ABHR does not exceed 95% alcohol.
• Operation of the dispenser shall comply with Section 20.3.2.6(11) or
21.3.2.6(11).
• ABHR is protected against inappropriate access.
20.3.2.6, 21.3.2.6, 8.7.3.1, CFR 416.44

K331 Interior Wall and Ceiling Finish

Interior wall and ceiling finishes in exits and exit access corridors shall have
a flame spread rating of Class A or Class B. The reduction in class of
interior finish for a sprinkler system as prescribed in 10.2.8.1 is permitted.
All other areas may be class C rated material.
Indicate flame spread rating(s) walls. _____________________
20.3.3, 21.3.3, 38.3.3, 39.3.3, 10.2

K332 Interior Floor Finish

2012 NEW (Indicate N/A for 2012 EXISTING)
Interior floor finish in exit enclosures must meet 10.2 and be Class I or
Class II. All other areas must meet 10.2.7.1 or 10.2.7.2.
Indicate rating(s) for floors_____________________
20.3.3, 21.3.3, 38.3.3, 39.3.3, 10.2

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K341 Fire Alarm - Installation

A fire alarm system is installed with systems and components approved for
the purpose in accordance with NFPA 70, National Electric Code, and
NFPA 72, National Fire Alarm Code to provide effective warning of fire in
any part of the building. In areas not continuously occupied, detection is
installed at each fire alarm control unit. In new occupancy, detection is also
installed at notification appliance circuit power extenders, and supervising
station transmitting equipment. Fire alarm system wiring or other
transmission paths are monitored for integrity.
20.3.4.2.1, 21.3.4.1, 9.6
K342 Fire Alarm - Initiation
Initiation of the fire alarm system is by manual means and by any required
sprinkler system alarm, detection device, or detection system. Manual alarm
boxes are provided in the path of egress near each required exit and 200
feet travel distance is not exceeded.
20.3.4.2, 21.3.4.2, 9.6.2
K343 Fire Alarm – Notification
2012 EXISTING
A positive alarm sequence in accordance with 9.6.3.4 is permitted.
Occupant notification is provided automatically, without delay, in
accordance with 9.6.3. Fire department notification is accomplished
automatically per 9.6.4. Smoke detection devices or systems equipped with
reconfirmation features shall not be required to automatically notify the fire
department, unless the alarm condition is reconfirmed within 120 seconds
(2 minutes)
21.3.4.3 through 21.3.4.3.2.2, 9.6.3, 9.6.4
2012 NEW
A positive alarm sequence in accordance with 9.6.3.4 is permitted.
Occupant notification is provided automatically, without delay, in
accordance with 9.6.3. Fire department notification is accomplished
automatically per 9.6.4.
20.3.4.3 through 20.3.4.3.2.1, 9.6.3, 9.6.4
K344 Fire Alarm – Control Functions
The fire alarm automatically activates required control functions and is
provided with an alternative power supply in accordance with NFPA 72.
20.3.4.4, 21.3.4.4

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K345 Fire Alarm Systems – Testing and Maintenance

A fire alarm system is tested and maintained in accordance with an
approved program complying with the requirements of NFPA 70, National
Electric Code, and NFPA 72, National Fire Alarm and Signaling Code.
Records of system acceptance, maintenance and testing are readily
available.
9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72
K346 Fire Alarm – Out of Service
Fire alarms that are out of service for 4 hours in a 24 hour period, the
authority having jurisdiction shall be notified, and the building shall be
evacuated or an approved fire watch shall be provided for all parties left
unprotected by the shutdown until the fire alarm system has been returned
to service.
9.6.1.6
K351 Sprinkler System – Installation
Sprinkler systems (if installed) are installed per NFPA 13.
Where more than two sprinklers are installed in a single area for protection,
waterflow devices shall be provided to sound the building fire alarm system
or to notify a constantly attended location such as a PBX, security office, or
emergency room.
20.3.5.1, 20.3.5.2, 21.3.5.1, 21.3.5.2, 9.7.1.2, 9.7, NFPA 13
K353 Sprinkler System – Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and
maintained in accordance with NFPA 25, Standard for the Inspection,
Testing, and Maintaining of Water-based Fire Protection Systems. Records
of system design, maintenance, inspection and testing are maintained in a
secure location and readily available.
a) Date sprinkler system last checked. _____________________
b) Who provided system test. ____________________________
c) Water system supply source. __________________________
Provide in REMARKS information on coverage for any non-required or
partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

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K354 Sprinkler System – Out of Service

Where the sprinkler system is impaired, the extent and duration of the
impairment has been determined, areas or buildings involved are inspected
and risks are determined, recommendations are submitted to management
or designated representative, and the fire department and other authorities
having jurisdiction have been notified. Where the sprinkler system is out of
service for more than 10 hours in a 24 hour period, the building or portion of
the building affected are evacuated or an approved fire watch is provided
until the sprinkler system has been returned to service.
9.7.5, 15.5.2 (NFPA 25)
K355 Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and
maintained in accordance with NFPA 10, Standard for Portable Fire
Extinguishers.
20.3.5.3, 21.3.5.3, 9.7.4.1, NFPA 10
K362 Corridors – Construction of Corridor Walls
2012 NEW (Indicate N/A for 2012 EXISTING)
Where access to exits is provided by corridors, such corridors shall be
separated from use areas by a minimum 1 hour fire barrier constructed per
section 8.3, unless one of the following exists:
1. Where exits are available from an open floor area
2. Where the entire space is a single tenant
3. Where the building is protected throughout by an approved automatic
sprinkler system installed per 9.7.1.1(1)
If the walls have a fire resistance rating, give the rating. _____________
20.3.6.1, 38.3.6.1, 38.3.6.2

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K364 Corridor – Openings

2012 NEW (Indicate N/A for 2012 EXISTING)
Miscellaneous openings, such as mail slots, pharmacy/laboratory/cashier
pass-through windows, shall be permitted to be installed in vision panels or
doors without special protection provided that they meet both of the
following:
1) The aggregate opening does not exceed 20 square inches.
2) The opening is installed at or below half the distance from the floor to
the ceiling.
If the room is protected throughout by an automatic sprinkler system. The
aggregate opening shall not exceed 80 square inches.
20.3.6.2.1, 20.3.6.2.2

K371 Subdivision of Building Spaces - Smoke Compartments

Smoke compartments do not exceed 25,000 square feet in size.
Every story shall be divided into not less than 2 smoke compartments
unless one of the following conditions occur:
Facility is less than 5,000 square feet protected by an approved smoke
detection system.
Facility is less than 10,000 square feet protected by an approved,
supervised sprinkler system per 9.7.
Adjoining occupancy is used as a smoke compartment if all of the
following are met:
a. Separating wall is 1 hour fire resistive rated.
b. Doors in the 1 hour rated wall at 1-3/4 inches thick.
c. Doors in the 1 hour rated wall are self-closing.
d. Windows in the 1 hour rated wall are fixed fire window assemblies per
8.3.
e. The ambulatory health care facility is less than 22,500 square feet.
f. Access from the ambulatory health care facility is unrestricted to
another occupancy.
20.3.7.2, 21.3.7.2

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K372 Subdivision of Building Spaces – Smoke Barrier Construction

2012 EXISTING
Smoke barriers shall be constructed to a 1/2 hour fire resistance rating per
8.5. Smoke barriers shall be permitted to terminate at an atrium wall.
Smoke dampers are not required in duct penetrations in fully ducted HVAC
systems where an approved sprinkler system is installed for smoke
compartments adjacent to the smoke barrier.
21.3.7.5, 21.3.7.6, 8.5
2012 NEW
Smoke barriers shall be constructed to provide at least a 1 hour fire
resistance rating and constructed in accordance with 8.5. Smoke barriers
shall be permitted to terminate at an atrium wall. Smoke dampers are not
required in duct penetrations of fully ducted HVAC systems.
20.3.7.5, 20.3.7.6, 8.5

K374 Subdivision of Building Spaces – Smoke Barrier Doors

2012 EXISTING
Smoke barrier doors shall be a minimum of 1-3/4 inches thick, solid-bonded
wood core or equivalent with self-closing or automatic-closing devices in
accordance with 21.2.2.4. Latching hardware is not required. Doors are not
required to swing in the direction of egress travel.
21.3.7.9, 21.3.7.10
2012 NEW
Smoke barrier doors shall be a minimum of 1-3/4 inches thick, solid-bonded
wood core or equivalent with self-closing or automatic-closing devices in
accordance with 21.2.2.4. Latching hardware is not required. Doors are
required to swing in the direction of egress travel. Rabbets, bevels, or
astragals are at meeting edges, and stops are at the head and sides of door
frames. Center mullions are prohibited in smoke barrier door openings.
20.3.7.9, 20.3.7.10, 20.3.7.13, 20.3.7.14

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K379 Smoke Barrier Door Glazing

2012 NEW (Indicate N/A for 2012 EXISTING)
Cross-corridor swinging doors or cross corridor horizontal-sliding doors,
contain a vision panel consisting of fire-rated glazing in approved frames in
each door.
Vision panels in any other door in the smoke barrier, if provided, shall be
fire-rated glazing in approved frames.
20.3.7.11, 20.3.7.12, 21.3.7.7, 8.3
SECTION 4 – SPECIAL PROVISIONS

K400 Special Provisions – Other

List in the REMARKS section any LSC Section 20.4 and 21.4 Special
Provisions requirements that are not addressed by the provided K-tags, but
are deficient. This information, along with the applicable Life Safety Code or
NFPA standard citation, should be included on Form CMS-2567.
High-Rise Buildings
K421
2012 EXISTING
High-rise buildings are protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.1.1(1), or an
engineered life safety system complying with 39.4.2.1(2).
21.4, 39.4.2
2012 NEW
High-rise buildings comply with section 11.8.
20.4, 38.4.2
SECTION 5 – BUILDING SERVICES

K500 Building Services – Other

List in the REMARKS section any LSC Section 20.5 and 21.5 Building
Services requirements that are not addressed by the provided K-tags, but
are deficient. This information, along with the applicable Life Safety Code or
NFPA standard citation, should be included on Form CMS-2567.
K511 Utilities – Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National
Fuel Gas Code, electrical wiring and equipment complies with NFPA 70,
National Electric Code. Existing installations can continue in service
provided no hazard to life.
20.5.1, 21.5.1, 21.5.1.2, 9.1.1, 9.1.2

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K521 HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be
installed in accordance with the manufacturer’s specifications.
20.5.2.1, 21.5.2.1, 9.2
K522 HVAC – Any Heating Device
Any heating device, other than a central heating plant, is designed and
installed so combustible materials cannot be ignited by device, and has a
safety features to stop fuel and shut down equipment if there is excessive
temperature or ignition failure. If fuel fired, the device also:
• is chimney or vent connected.
• takes air for combustion from outside.
• provides for a combustion system separate from occupied area
atmosphere.
20.5.2.2, 20.5.2.2.1, 21.5.2.2, 21.5.2.2.1
K523 HVAC – Suspended Unit Heaters
Suspended unit heaters are permitted provided the following are met:
• Not located in means of egress or in patient rooms.
• Located high enough to be out of reach of people in the area.
• Has the safety features to stop fuel and shut down equipment if there is
excessive temperature or ignition failure.
20.5.2.2.2, 21.5.2.2.2
K531 Elevators
2012 EXISTING
Elevators comply with the provision of 9.4. Elevators are inspected and
tested as specified in ASME A17.1, Safety Code for Elevators and
Escalators. Firefighter’s Service is operated monthly with a written record.
Existing elevators conform to ASME/ANSI A17.3, Safety Code for Existing
Elevators and Escalators. All existing elevators, having a travel distance of
25 feet or more above or below the level that best serves the needs of
emergency personnel for firefighting purposes, conform with Firefighter’s
Service Requirements of ASME/ANSI A17.3. (Includes firefighter’s service
Phase I key recall and smoke detector automatic recall, firefighter’s service
Phase II emergency in-car key operation, machine room smoke detectors,
and elevator lobby smoke detectors.)
21.5.3, 9.4.2, 9.4.3

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K531 2012 NEW

Elevators comply with the provision of 9.4. Elevators are inspected and
tested as specified in ASME A17.1, Safety Code for Elevators and
Escalators. Firefighter’s Service is operated monthly with a written record.
New elevators conform to ASME/ANSI A17.1, Safety Code for Elevators
and Escalators, including Firefighter’s Service Requirements. (Includes
firefighter’s Phase I key recall and smoke detector automatic recall,
firefighter’s service Phase II emergency in-car key operation, machine room
smoke detectors, and elevator lobby smoke detectors.)
20.5.3, 9.4.2, 9.4.3
K532 Escalators, Dumbwaiters, and Moving Walks
Escalators, dumbwaiters, and moving walks comply with the provisions of
9.4.
All existing escalators, dumbwaiters, and moving walks conform to the
requirements of ASME/ANSI A17.3, Safety Code for Existing Elevators and
Escalators.
(Includes escalator emergency stop buttons and automatic skirt obstruction
stop. For power dumbwaiters, includes hoistway door locking to keep doors
closed except for floor where car is being loaded or unloaded.)
20.5.3, 21.5.3, 9.4

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K541 Rubbish Chutes, Incinerators, and Laundry Chutes

2012 EXISTING
Rubbish chutes are installed per section 9.5:
Walls, partitions, and inlet openings meet the requirements of 8.3.
Doors of chutes open to a room designed exclusively for accessing the
chute opening.
Room used for accessing the chute opening(s) are separated from other
spaces per 8.7.
Chutes shall be permitted to open into rooms not exceeding 400 cubic
feet in size if the room is sprinkler protected and the room is not used for
storage.
OR
Existing installations having properly enclosed and maintained chute
openings shall be permitted to have inlets open to a corridor or normally
occupied space.
21.5.4, 9.5, NFPA 82
2012 NEW
Rubbish chutes are installed per section 9.5:
Walls, partitions, and inlet openings meet the requirements of 8.3.
Doors of chutes open to a room designed exclusively for accessing the
chute opening.
Room used for accessing the chute opening(s) are separated from other
spaces per 8.7.
Chutes shall be permitted to open into rooms not exceeding 400 cubic
feet in size if the room is sprinkler protected and the room is not used for
storage.
Maintenance and installation are per NFPA 82.
20.5.4, 9.5, NFPA 82

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SECTION 6 – RESERVED
SECTION 7 – OPERATING FEATURES
K700 Operating Features – Other
List in the REMARKS section any LSC Section 20.7 and 21.7 Operating
Features requirements that are not addressed by the provided K-tags, but
are deficient. This information, along with the applicable Life Safety Code or
NFPA standard citation, should be included in Form CMS-2567.
K711 Evacuation and Relocation Plan
There is a written plan for the protection of all patients and for their
evacuation in the event of an emergency.
Employees are periodically instructed and kept informed with their duties
under the plan, and a copy of the plan is readily available with telephone
operator or with security. The plan addresses the basic response required
of staff per 20/21.7.2.1.2 and provides for all of the fire safety plan
components per 20/21.7.2.2.
20.7.1.1 through 20.7.1.3, 20.7.1.8 through 20.7.2.3.3
21.7.1.1 through 20.7.1.3, 21.7.1.8 through 20.7.2.3.3
K712 Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of
emergency fire conditions. Fire drills are held at expected and unexpected
times under varying conditions, at least quarterly on each shift. The staff is
familiar with procedures and is aware that drills are part of established
routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded
announcement may be used instead of audible alarms.
20.7.1.4 through 20.7.1.7, 21.7.1.4 through 21.7.1.7

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K741 Smoking Regulations

Smoking regulations shall be adopted and shall include not less than the
following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where
flammable liquids, combustible gases, or oxygen is used or stored and
in any other hazardous location, and such area shall be posted with
signs that read NO SMOKING or shall be posted with the international
symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are
prominently placed at all major entrances, secondary signs with
language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under
direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided
in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can
be emptied shall be readily available to all areas where smoking is
permitted.
20.7.4, 21.7.4
K751 Draperies, Curtains, and Loosely Hanging Fabrics
Draperies, curtains including cubicle curtains and loosely hanging fabric or
films shall be in accordance with 10.3.1. Excluding curtains and draperies at
showers and baths.
20.7.5.1 through 20.7.5.3, 21.7.5.1 through 21.7.5.3

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K752 Upholstered Furniture and Mattresses

Newly introduced upholstered furniture meets Class I or char length, and
heat release criteria in accordance with 10.3.2.1 and 10.3.3, unless the
building is fully sprinklered.
Newly introduced mattresses shall meet char length and heat release
criteria in accordance with 10.3.2.2 and 10.3.4, unless the building is fully
sprinklered.
Upholstered furniture and mattresses belonging to nursing home residents
do not have to meet these requirements as all nursing homes are required
to be fully sprinklered.
Newly introduced upholstered furniture and mattresses means purchased
on or after the LSC final rule effective date.
20.7.5.2, 20.7.5.3, 21.7.5.2, 21.7.5.3
K753 Combustible Decorations
Combustible decorations shall be prohibited unless one of the following is
met:
• Flame retardant or treated with approved fire-retardant coating that is
listed and labeled for product.
• Decorations meet NFPA 701.
• Decorations exhibit heat release less than 100 kilowatts in accordance
with NFPA 289.
• The decorations in existing occupancies are in such limited quantities
that a hazard of fire is not present.
20.7.5.4, 21.7.5.4
K754 Soiled Linen and Trash Containers
Soiled linen or trash collection receptacles shall not exceed 32 gallons in
capacity. The average density of container capacity in a room or space shall
not exceed 0.5 gallons/square feet. A total container capacity of 32 gallons
shall not be exceeded within any 64 square feet area. Mobile soiled linen or
trash collection receptacles with capacities greater than 32 gallons shall be
located in a room protected as a hazardous area when not attended.
20.7.5.5, 21.7.5.5
K761 Maintenance, Inspection & Testing - Doors
Fire doors assemblies are inspected and tested annually in accordance with NFPA
80 Standard for Fire Doors and Other Opening Protectives. Fire doors that are not
located in required fire barriers, including corridor doors to patient rooms and
smoke barrier doors, are routinely inspected as part of the facility maintenance
program. Individuals performing the door inspections and testing possess
knowledge, training or experience that demonstrates ability. Written records of
inspection and testing are maintained and are available for review.
20.7.6, 21.7.6, 8.3.3.1 (LSC), 5.2. 5.2.3 (NFPA 80)
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K771 Engineered Smoke Control Systems

When installed, engineered smoke control systems are tested in
accordance with established engineering principles. Test documentation is
maintained on the premises.
20.7.7.1 through 20.7.7.3, 21.7.7.1 through 21.7.7.3
K781 Portable Space Heaters
Portable space heating devices shall be prohibited in all health care
occupancies. Except, when used in nonsleeping staff and employee areas
where the heating elements do not exceed 212 degrees Fahrenheit (100
degrees Celsius).
20.7.8, 21.7.8
K791 Construction, Repair, and Improvement Operations
Construction, repair, and improvement operations shall comply with 4.6.10.
Any means of egress in any area undergoing construction, repair, or
improvements shall be inspected daily to ensure its ability to be used
instantly in case of emergency and compliance with NFPA 241.
20.7.9.1, 20.7.9.2, 21.7.9.1, 21.7.9.2
PART II – HEALTH CARE FACILITIES CODE REQUIREMENTS

K900 Health Care Facilities Code – Other

List in the REMARKS section, any NFPA 99 requirements (excluding
Chapter 7, 8, 12, and 13) that are not addressed by the provided K-Tags,
but are deficient. This information, along with the applicable Health Care
Facilities Code or NFPA standard citation, should be included on Form
CMS-2567.
K901 Fundamentals – Building System Categories
Building systems are designed to meet Category 1 through 4 requirements
as detailed in NFPA 99. Categories are determined by a formal and
documented risk assessment procedure performed by qualified personnel.
Chapter 4 (NFPA 99)
K902 Gas and Vacuum Piped Systems – Other
List in the REMARKS section, any NFPA 99 Chapter 5 Gas and Vacuum
Systems requirements that are not addressed by the provided K-Tags, but
are deficient. This information, along with the applicable Life Safety Code or
NFPA standard citation, should be included on Form CMS-2567.
Chapter 5 (NFPA 99)

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K903 Gas and Vacuum Piped Systems – Categories

Medical gas, medical air, surgical vacuum, WAGD, and air supply systems
are designated:
☐ Category 1. Systems in which failure is likely to cause major injury or
death.
☐ Category 2. Systems in which failure is likely to cause minor injury.
☐ Category 3. Systems in which failure is not likely to cause injury, but can
cause discomfort.
Deep sedation and general anesthesia are not to be administered using a
Category 3 medical gas system.
5.1.1.1, 5.2.1, 5.3.1.1, 5.3.1.5 (NFPA 99)

K904 Gas and Vacuum Piped Systems – Warning Systems

All master, area, and local alarm systems used for medical gas and vacuum
systems comply with appropriate Category warning system requirements,
as applicable.
5.1.9, 5.2.9, 5.3.6.2.2 (NFPA 99)

K905 Gas and Vacuum Piped Systems – Central Supply System

Identification and Labeling
Containers, cylinders and tanks are designed, fabricated, tested, and
marked in accordance with 5.1.3.1.1 through 5.1.3.1.7. Locations
containing only oxygen or medical air have doors labeled with "Medical
Gases, NO Smoking or Open Flame". Locations containing other gases
have doors labeled "Positive Pressure Gases, NO Smoking or Open Flame,
Room May Have Insufficient Oxygen, Open Door and Allow Room to
Ventilate Before Opening.
5.1.3.1, 5.2.3.1, 5.3.10 (NFPA 99)

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K906 Gas and Vacuum Piped Systems – Central Supply System Operations
Adaptors or conversion fittings are prohibited. Cylinders are handled in
accordance with 11.6.2. Only cylinders, reusable shipping containers, and
their accessories are stored in rooms containing central supply systems or
cylinders. No flammable materials are stored with cylinders. Cryogenic
liquid storage units intended to supply the facility are not used to transfill.
Cylinders are kept away from sources of heat. Valve protection caps are
secured in place, if supplied, unless cylinder is in use. Cylinders are not
stored in tightly closed spaces. Cylinders in use and storage are prevented
from exceeding 130 degrees Fahrenheit, and nitrous oxide and carbon
dioxide cylinders are prevented from reaching temperatures lower than
manufacture recommendations or 20 degrees Fahrenheit. Full or empty
cylinders, when not connected, are stored in locations complying with
5.1.3.3.2 through 5.1.3.3.3, and are not stored in enclosures containing
motor-driven machinery, unless for instrument air reserve headers.
5.1.3.2, 5.1.3.3.17, 5.1.3.3.1.8, 5.1.3.3.4, 5.2.3.2, 5.2.3.3, 5.3.6.20.4,
5.6.20.5, 5.3.6.20.7, 5.3.6.20.8, 5.3.6.20.9 (NFPA 99)
K907 Gas and Vacuum Piped Systems – Maintenance Program
Medical gas, vacuum, WAGD, or support gas systems have documented
maintenance programs. The program includes an inventory of all source
systems, control valves, alarms, manufactured assemblies, and outlets.
Inspection and maintenance schedules are established through risk
assessment considering manufacturer recommendations. Inspection
procedures and testing methods are established through risk assessment.
Persons maintaining systems are qualified as demonstrated by training and
certification or credentialing to the requirements of AASE 6030 or 6040.
5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99)
K908 Gas and Vacuum Piped Systems – Inspection and Testing Operations
The gas and vacuum systems are inspected and tested as part of a
maintenance program and include the required elements. Records of the
inspections and testing are maintained as required.
5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99)

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K909 Gas and Vacuum Piped Systems – Information and Warning Signs
Piping is labeled by stencil or adhesive markers identifying the gas or
vacuum system, including the name of system or chemical symbol, color
code (Table 5.1.11), and operating pressure if other than standard. Labels
are at intervals not more than 20 feet, are in every room, at both sides of
wall penetrations, and on every story traversed by riser. Piping is not
painted. Shutoff valves are identified with the name or chemical symbol of
the gas or vacuum system, room or area served, and caution to not use the
valve except in emergency.
5.1.14.3, 5.1.11.1, 5.1.11.2, 5.2.11, 5.3.13.3, 5.3.11 (NFPA 99)
K910 Gas and Vacuum Piped Systems – Modifications
Whenever modifications are made that breach the pipeline, any necessary
installer and verification test specified in 5.1.2 is conducted on the
downstream portion of the medical gas piping system. Permanent records
of all tests required by system verification tests are maintained.
5.1.14.4.1, 5.1.14.4.6, 5.2.13, 5.3.13.4.3 (NFPA 99)
K911 Electrical Systems – Other
List in the REMARKS section, any NFPA 99 Chapter 6 Electrical Systems
requirements that are not addressed by the provided K-Tags, but are
deficient. This information, along with the applicable Life Safety Code or
NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)
K912 Electrical Systems – Receptacles
Power receptacles have at least one, separate, highly dependable
grounding pole capable of maintaining low-contact resistance with its
mating plug. In pediatric locations, receptacles in patient rooms,
bathrooms, play rooms, and activity rooms, other than nurseries, are listed
tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are
listed.
6.3.2.2.6.2 (F), 6.3.2.2.4.2 (NFPA 99)

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K913 Electrical Systems – Wet Procedure Locations

Operating rooms are considered wet procedure locations, unless otherwise
determined by a risk assessment conducted by the facility governing body.
Operating rooms defined as wet locations are protected by either isolated
power or ground-fault circuit interrupters. A written record of the risk
assessment is maintained and available for inspection.
6.3.2.2.8.4, 6.3.2.2.8.7, 6.4.4.2
K914 Electrical Systems – Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep
sedation or general anesthesia is administered, are tested after initial
installation, replacement or servicing. Additional testing is performed at
intervals defined by documented performance data. Receptacles not listed
as hospital-grade at these locations are tested at intervals not exceeding 12
months. Line isolation monitors (LIM), if installed, are tested at intervals of
less than or equal to 1 month by actuating the LIM test switch per
6.3.2.6.3.6, which activates both visual and audible alarm. For, LIM circuits
with automated self-testing, this manual test is performed at intervals less
than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any
repair or renovation to the electric distribution system. Records are
maintained of required tests and associated repairs or modifications,
containing date, room or area tested, and results.
6.3.4 (NFPA 99)
K915 Electrical Systems – Essential Electric System Categories
☐ Critical care rooms (Category 1) in which electrical system failure is likely
to cause major injury or death of patients, including all rooms where electric
life support equipment is required, are served by a Type 1 EES.
☐ General care rooms (Category 2) in which electrical system failure is
likely to cause minor injury to patients (Category 2) are served by a Type 1
or Type 2 EES.
☐ Basic care rooms (Category 3) in which electrical system failure is not
likely to cause injury to patients and rooms other than patient care rooms
are not required to be served by an EES. Type 3 EES life safety branch has
an alternate source of power that will be effective for 1-1/2 hours.
3.3.138, 6.3.2.2.10, 6.6.2.2.2, 6.6.3.1.1 (NFPA 99), TIA 12-3

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K916 Electrical Systems – Essential Electric System Alarm Annunciator

A remote annunciator that is storage battery powered is provided to operate
outside of the generating room in a location readily observed by operating
personnel. The annunciator is hard-wired to indicate alarm conditions of the
emergency power source. A centralized computer system (e.g., building
information system) is not to be substituted for the alarm annunciator.
6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99)
K917 Electrical Systems – Essential Electric System Receptacles
Electrical receptacles or cover plates supplied from the life safety and
critical branches have a distinctive color or marking.
6.4.2.2.6, 6.5.2.2.4.2, 6.6.2.2.3.2 (NFPA 99)
K918 Electrical Systems – Essential Electric System Maintenance and
Testing
The generator or other alternate power source and associated equipment is
capable of supplying service within 10-seconds. If the 10-second criterion is
not met during the monthly test, a process shall be provided to annually
confirm this capability for the life safety and critical branches. Maintenance
and testing of the generator and transfer switches are performed in
accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12
times a year in 20-40 day intervals, and exercised once every 36 months for
four continuous hours. Scheduled test under load conditions include a
complete simulated cold start and automatic or manual transfer of all EES
loads, and are conducted by competent personnel. Maintenance and
testing of stored energy power sources (Type 3 EES) are in accordance
with NFPA 111. Main and feeder circuit breakers are inspected annually,
and a program for periodically exercising the components is established
according to manufacturer requirements. Written records of maintenance
and testing are maintained and readily available. EES electrical panels and
circuits are marked and readily identifiable. Minimizing the possibility of
damage of the emergency power source is a design consideration for new
installations.
6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

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K919 Electrical Equipment – Other

List in the REMARKS section, any NFPA 99 Chapter 10, Electrical
Equipment, requirements that are not addressed by the provided K-Tags,
but are deficient. This information, along with the applicable Life Safety
Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 10 (NFPA 99)
K920 Electrical Equipment – Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of
movable patient-care-related electrical equipment (PCREE) assembles that
have been assembled by qualified personnel and meet the conditions of
10.2.3.6. Power strips in the patient care vicinity may not be used for non-
PCREE (e.g., personal electronics), except in long-term care resident
rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or
UL 60601-1. Power strips for non-PCREE in the patient care rooms
(outside of vicinity) meet UL 1363. In non-patient care rooms, power strips
meet other UL standards. All power strips are used with general
precautions. Extension cords are not used as a substitute for fixed wiring of
a structure. Extension cords used temporarily are removed immediately
upon completion of the purpose for which it was installed and meets the
conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA
70), TIA 12-5

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K921 Electrical Equipment – Testing and Maintenance Requirements

The physical integrity, resistance, leakage current, and touch current tests
for fixed and portable patient-care related electrical equipment (PCREE) is
performed as required in 10.3. Testing intervals are established with
policies and protocols. All PCREE used in patient care rooms is tested in
accordance with 10.3.5.4 or 10.3.6 before being put into service and after
any repair or modification. Any system consisting of several electrical
appliances demonstrates compliance with NFPA 99 as a complete system.
Service manuals, instructions, and procedures provided by the
manufacturer include information as required by 10.5.3.1.1 and are
considered in the development of a program for electrical equipment
maintenance. Electrical equipment instructions and maintenance manuals
are readily available, and safety labels and condensed operating
instructions on the appliance are legible. A record of electrical equipment
tests, repairs, and modifications is maintained for a period of time to
demonstrate compliance in accordance with the facility's policy. Personnel
responsible for the testing, maintenance and use of electrical appliances
receive continuous training.
10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8
K922 Gas Equipment – Other
List in the REMARKS section, any NFPA 99 Chapter 11 Gas Equipment
requirements that are not addressed by the provided K-Tags, but are
deficient. This information, along with the applicable Life Safety Code or
NFPA standard citation, should be included on Form CMS-2567.
Chapter 11 (NFPA 99)

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K923 Gas Equipment – Cylinder and Container Storage

Greater than or equal to 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance
with 5.1.3.3.2 and 5.1.3.3.3.
Greater than 300 but less than 3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed
interior space of non- or limited- combustible construction, with door (or
gates outdoors) that can be secured. Oxidizing gases are not stored with
flammables, and are separated from combustibles by 20 feet (5 feet if
sprinklered) or enclosed in a cabinet of noncombustible construction having
a minimum 1/2 hr. fire protection rating.
Less than or equal to 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate
use in patient care areas with an aggregate volume of ≤ 300 cubic feet are
not required to be stored in an enclosure. Cylinders must be handled with
precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a
cylinder storage room, where the sign includes the wording as a minimum
"CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING."
Storage is planned so cylinders are used in order of which they are received
from the supplier. Empty cylinders are segregated from full cylinders.
When facility employs cylinders with integral pressure gauge, a threshold
pressure considered empty is established. Empty cylinders are marked to
avoid confusion. Cylinders stored in the open are protected from weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
K924 Gas Equipment – Testing and Maintenance Requirements
Anesthesia apparatus are tested at the final path to patient after any
adjustment, modification or repair. Before the apparatus is returned to
service, each connection is checked to verify proper gas and an oxygen
analyzer is used to verify oxygen concentration. Defective equipment is
immediately removed from service. Areas designated for servicing of
oxygen equipment are clean and free of oil, grease, or other flammables.
Manufacturer service manuals are used to maintain equipment and a
scheduled maintenance program is followed.
11.4.1.3, 11.5.1.3, 11.6.2.5, 11.6.2.6 (NFPA 99)

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K925 Gas Equipment – Respiratory Therapy Sources of Ignition

Smoking materials are removed from patients receiving respiratory therapy.
When a nasal cannula is delivering oxygen outside of a patient’s room, no
sources of ignition are within in the site of intentional expulsion (1-foot).
When other oxygen deliver equipment is used or oxygen is delivered inside
a patient’s room, no sources of ignition are within the area are of
administration (15-feet). Solid fuel-burning appliances is not in the area of
administration. Nonmedical appliances with hot surfaces or sparking
mechanisms are not within oxygen-delivery equipment or site of intentional
expulsion.
11.5.1.1, TIA 12-6 (NFPA 99)
K926 Gas Equipment – Qualifications and Training of Personnel
Personnel concerned with the application, maintenance and handling of
medical gases and cylinders are trained on the risk. Facilities provide
continuing education, including safety guidelines and usage requirements.
Equipment is serviced only by personnel trained in the maintenance and
operation of equipment.
11.5.2.1 (NFPA 99)
K927 Gas Equipment – Transfilling Cylinders
Transfilling of oxygen from one cylinder to another is in accordance with
CGA P-2.5, Transfilling of High Pressure Gaseous Oxygen Used for
Respiration. Transfilling of any gas from one cylinder to another is
prohibited in patient care rooms. Transfilling to liquid oxygen containers or
to portable containers over 50 psi comply with conditions under 11.5.2.3.1
(NFPA 99). Transfilling to liquid oxygen containers or to portable containers
under 50 psi comply with conditions under 11.5.2.3.2 (NFPA 99).
11.5.2.2 (NFPA 99)

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K928 Gas Equipment – Labeling Equipment and Cylinders

Equipment listed for use in oxygen-enriched atmospheres are so labeled.
Oxygen metering equipment and pressure reducing regulators are labeled
"OXYGEN-USE NO OIL". Flowmeters, pressure reducing regulators, and
oxygen-dispensing apparatus are clearly and permanently labeled
designating the gases for which they are intended. Oxygen-metering
equipment, pressure reducing regulators, humidifiers, and nebulizers are
labeled with name of manufacturer or supplier. Cylinders and containers
are labeled in accordance with CGA C-7. Color coding is not utilized as the
primary method of determining cylinder or container contents. All labeling is
durable and withstands cleaning or disinfecting.
11.5.3.1 (NFPA 99)
K929 Gas Equipment – Precautions for Handling Oxygen Cylinders and
Manifolds
Handling of oxygen cylinders and manifolds is based on CGA G-4, Oxygen.
Oxygen cylinders, containers, and associated equipment are protected from
contact with oil and grease, from contamination, protected from damage,
and handled with care in accordance with precautions provided under
11.6.2.1 through 11.6.2.4 (NFPA 99).
11.6.2 (NFPA 99)
K930 Gas Equipment – Liquid Oxygen Equipment
The storage and use of liquid oxygen in base reservoir containers and
portable containers comply with sections 11.7.2 through 11.7.4 (NFPA 99).
11.7 (NFPA 99)
K931 Hyperbaric Facilities
All occupancies containing hyperbaric facilities comply with construction,
equipment, administration, and maintenance requirements of NFPA 99.
Chapter 14 (NFPA 99)
K932 Features of Fire Protection – Other
List in the REMARKS section, any NFPA 99 Chapter 15 Features of Fire
Protection requirements that are not addressed by the provided K-Tags, but
are deficient. This information, along with the applicable Life Safety Code or
NFPA standard citation, should be included on Form CMS-2567.
Chapter 15 (NFPA 99)

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K933 Features of Fire Protection – Fire Loss Prevention in Operating Rooms

Periodic evaluations are made of hazards that could be encountered during
surgical procedures, and fire prevention procedures are established. When
flammable germicides or antiseptics are employed during surgeries utilizing
electrosurgery, cautery or lasers:
• packaging is non-flammable.
• applicators are in unit doses.
• Preoperative "time-out" is conducted prior the initiation of any surgical
procedure to verify:
o application site is dry prior to draping and use of surgical
equipment.
o pooling of solution has not occurred or has been corrected.
o solution-soaked materials have been removed from the OR prior to
draping and use of surgical devices.
o policies and procedures are established outlining safety precautions
related to the use of flammable germicide or antiseptic use.
Procedures are established for operating room emergencies including alarm
activation, evacuation, equipment shutdown, and control operations.
Emergency procedures include the control of chemical spills, and
extinguishment of drapery, clothing and equipment fires. Training is
provided to new OR personnel (including surgeons), continuing education is
provided, incidents are reviewed monthly, and procedures are reviewed
annually.
15.13 (NFPA 99)

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PART III - 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

Surveyor (Signature) Title Office Date

Fire Authority Official (Signature) Title Office Date

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 PART IV - FIRE SAFETY SURVEY REPORT
CRUCIAL DATA EXTRACT
(TO BE USED WITH CMS 2786 FORMS)
Provider Number Facility Name Survey Date

K1 *K4

K6 DATE OF PLAN K3 MULTIPLE CONSTRUCTION A. BUILDING

APPROVAL
TOTAL NUMBER OF BUILDINGS ______ B. WING
C. FLOOR
NUMBER OF THIS BUILDING _______ D. APARTMENT UNIT
LSC FORM INDICATOR COMPLETE IF ICF/IID IS SURVEYED UNDER CHAPTER 33,
EXISTING
HEALTH CARE FORM
12 2786R 2012 EXISTING SMALL (16 BEDS OR LESS)
1. PROMPT
13 2786R 2012 NEW
K8 󠇃 2. SLOW
3. IMPRACTICAL
AHCO FORM LARGE
14 2786U 2012 EXISTING
4. PROMPT
15 2786U 2012 NEW
K8 󠇃 5. SLOW
6. IMPRACTICAL
ICF/IID FORM
APARTMENT HOUSE
16 2786V, W, X 2012 EXISTING
7. PROMPT
17 2786V, W, X 2012 NEW K8 󠇃 8. SLOW
9. IMPRACTICAL

*K7
󠇃SELECT NUMBER OF FORM USED FROM ABOVE
COMPLETE IF ICF/IID IS SURVEYED UNDER CHAPTER 33,
(Check if K321 or K351 are marked as not applicable EXISTING
in the 2786 M, R, T, U, V, W, X, and Y.) ENTER E – SCORE

K321:
󠇃 K351:
󠇃 K5: 󠇃 e.g. 2.5

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

A1.
󠇃 A2.
󠇃 A3.
󠇃 A4.
󠇃 A5.
󠇃
(COMP. WITH ALL (ACCEPTABLE POC) (WAIVERS) (FSES) (PERFORMANCE
PROVISIONS) BASED DESIGN)
FACILITY DOES NOT MEET LSC K0180

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

*MANDATORY

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