SECT 2 Life Safety Codes PDF

Life Safety Codes
LONG-TERM CARE SURVEY MANUAL

PREPARED BY MU NHA CONSULTANT
SECTION 2 - LIFE SAFETY CODES
Life Safety Codes - This section can be used as a reference for possible K-tag citations and
includes checklists for self-assessment.
SECTION PAGE #
K-Tags and Definitions 3-5
Life Safety Code Check List TBA 6-8
Fire Safety Survey 2012 Code (CMS-2786R) 9-56
Fire Safety Evaluation System for Health Care Facilities (CMS-2786T) 59-65
Fire Safety Survey Report - Intermediate Care Facilities for Individuals with 66-106
Intellectual Disabilities (small) (CMS-2786V)
Fire Safety Survey Report - Intermediate Care Facilities for Individuals with 107-137
Intellectual Disabilities (large) (CMS-2786W)
S&C: 16-29-LSC Adoption of the 2012 NFPA 101/99 138-140
S&C: Categorical Waiver for Power Strips Use in Patient Care Areas 141-145
Fire Safety Information (provided by CMS for distribution to surveyors and 146-157
Providers)
K-Tags and Definitions
K100 General Requirements – Other

K111 Building Rehabilitation
K112 Sprinkler Requirements for Major Rehabilitation
K131 Multiple Occupancies – Sections of Health Care Facilities
K132 Multiple Occupancies – Contiguous Non-Health Care Occupancies
K133 Multiple Occupancies – Construction Type
K161 Building Construction Type and Height
K162 Roofing Systems Involving Combustibles
K163 Interior Nonbearing Wall Construction
K200 Means of Egress Requirements – Other
K211 Means of Egress – General
K221 Patient Sleeping Room Doors
K222 Egress Doors
K223 Doors with Self-Closing Devices
K224 Horizontal-Sliding Doors
K225 Stairways and Smoke proof Enclosures
K226 Horizontal Exits
K227 Ramps and Other Exits
K231 Means of Egress Capacity
K232 Aisle, Corridor or Ramp Width
K233 Clear Width of Exit and Exit Access Doors
K241 Number of Exits – Story and Compartment
K251 Dead-End Corridors and Common Path of Travel
K252 Number of Exits – Corridors
K253 Number of Exits – Patient Sleeping and Non-Sleeping Rooms
K254 Corridor Access
K255 Suite Separation, Hazardous Content, and Subdivision
K256 Sleeping Suites
K257 Non-Sleeping Suites
K261 Travel Distance to Exits
K271 Discharge from Exits
K281 Illumination of Means of Egress
K291 Emergency Lighting
K292 Life Support Means of Egress
K293 Exit Signage
K300 Protection – Other
K311 Vertical Openings – Enclosure
K321 Hazardous Areas – Enclosure
K322 Laboratories
K323 Anesthetizing Locations
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K324 Cooking Facilities
K325 Alcohol Based Hand Rub Dispenser (ABHR)
K331 Interior Wall and Ceiling Finish
K332 Interior Floor Finish
K341 Fire Alarm System – Installation
K342 Fire Alarm System – Initiation
K343 Fire Alarm – Notification
K344 Fire Alarm – Control Functions
K345 Fire Alarm System – Testing and Maintenance
K346 Fire Alarm – Out of Service
K347 Smoke Detection
K351 Sprinkler System – Installation
K352 Sprinkler System – Supervisory Signals
K353 Sprinkler System – Maintenance and Testing
K354 Sprinkler System – Out of Service
K355 Portable Fire Extinguishers
K361 Corridors – Areas Open to Corridor
K362 Corridors – Construction of Walls
K363 Corridor – Doors
K364 Corridor – Openings
K371 Subdivision of Building Spaces – Smoke Compartments
K372 Subdivision of Building Spaces – Smoke Barrier Construction
K374 Subdivision of Building Spaces – Smoke Barrier Doors373 Subdivision of Building Spaces –
Accumulation Space
K379 Smoke Barrier Door Glazing
K381 Sleeping Room Outside Windows and Doors
K400 Special Provisions – Other
K421 High-Rise Buildings
K500 Building Services – Other
K511 Utilities – Gas and Electric
K521 HVAC
K522 HVAC – Any Heating Device
K523 HVAC – Suspended Unit Heaters
K524 HVAC – Direct-Vent Gas Fireplaces
K525 HVAC – Solid Fuel-Burning Fireplaces
K531 Elevators
K532 Escalators, Dumbwaiters, and Moving Walks
K541 Rubbish Chutes, Incinerators, and Laundry Chutes
K700 Operating Features – Other
K711 Evacuation and Relocation Plan
K712 Fire Drills
K741 Smoking Regulations
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K751 Draperies, Curtains, and Loosely Hanging Fabrics
K752 Upholstered Furniture and Mattresses
K753 Combustible Decorations
K754 Soiled Linen and Trash Containers
K771 Engineer Smoke Control Systems
K781 Portable Space Heaters
K791 Construction, Repair, and Improvement Operations
K900 Health Care Facilities Code – Other
K901 Fundamentals – Building System Categories
K902 Gas and Vacuum Piped Systems – Other
K903 Gas and Vacuum Piped Systems – Categories
K904 Gas and Vacuum Piped Systems – Warning Systems
K905 Gas and Vacuum Piped Systems – Central Supply System Identification and Labeling
K906 Gas and Vacuum Piped Systems – Central Supply System Operation
K907 Gas and Vacuum Piped Systems – Maintenance Program
K908 Gas and Vacuum Piped Systems – Inspection and Testing Operations
K909 Gas and Vacuum Piped Systems – Information and Warning Signs
K910 Gas and Vacuum Piped Systems – Modifications
K911 Electrical Systems – Other
K912 Electrical Systems – Receptacles
K913 Electrical Systems – Wet Procedure Locations
K914 Electrical Systems – Maintenance and Testing
K915 Electrical Systems – Essential Electric System Categories
K916 Electrical Systems – Essential Electric System Alarm Annunciator
K917 Electrical Systems – Essential Electric System Receptacles
K918 Electrical Systems – Essential Electric System Maintenance and Testing
K919 Electrical Equipment – Other
K920 Electrical Equipment – Power Cords and Extension Cords
K921 Electrical Equipment – Testing and Maintenance Requirements
K922 Gas Equipment – Other
K923 Gas Equipment – Cylinder and Container Storage
K924 Gas Equipment – Testing and Maintenance Requirements
K925 Gas Equipment – Respiratory Therapy Sources of Ignition
K926 Gas Equipment – Qualifications and Training of Personnel
K927 Gas Equipment – Transfilling Cylinders
K928 Gas Equipment – Labeling Equipment and Cylinders
K929 Gas Equipment – Precautions for Handling Oxygen Cylinders and Manifolds
K930 Gas Equipment – Liquid Oxygen Equipment
K931 Hyperbaric Facilities
K932 Features of Fire Protection – Other
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DEPARTMENT OF HEALTH AND HUMAN SERVICES 2012 LIFE SAFETY CODE
CENTERS FOR MEDICARE & MEDICAID SERVICE Form Approved OMB Exempt
FIRE SAFETY SURVEY REPORT 2012 CODE – HEALTH CARE 1. (A) PROVIDER NUMBER 1. (B) MEDICAID I.D. NO.
Medicare – Medicaid 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

OPTIONAL — Chapter 4 – NFPA 101A - Fire Safety Evaluation System for Health Care Occupancies – CMS-2786T
Identifying information as shown in applicable records. Enter changes, if any, alongside each item, giving date of change.

2. NAME OF FACILITY 2. (A) MULTIPLE CONSTRUCTION (BLDGS) 2. (B) ADDRESS OF FACILITY (STREET, CITY, STATE, ZIP CODE) A. Fully Sprinklered
A. BUILDING _______________ (All required areas are sprinklered)
B. WING _______________ B. Partially Sprinklered

(Not all required areas are
C. FLOOR ________________ sprinklered)
C. None (No sprinkler system)

K3 K0180
3. SURVEY FOR 4. DATE OF SURVEY DATE OF PLAN APPROVAL SURVEY UNDER

MEDICARE MEDICAID 5. 2012 EXISTING 6. 2012 NEW
K4 K6 K7
5. SURVEY FOR CERTIFICATION OF
1. HOSPITAL 2. SKILLED/NURSING FACILITY 4. ICF/IID UNDER HEALTH CARE 5. HOSPICE
IF “2” OR “5” ABOVE IS MARKED, CHECK APPROPRIATE ITEM(S) BELOW 3. IF DISTINCT PART OF HOSPITAL,
IS HOSPITAL ACCREDITED?
1. ENTIRE FACILITY 2. DISTINCT PART OF (SPECIFY) _____________________________________ a. YES b. NO
6. BED COMPOSITION
a. TOTAL NO. OF BEDS IN b. NUMBER OF HOSPITAL BEDS c. NUMBER OF SKILLED BEDS d. NUMBER OF SKILLED BEDS e. NUMBER OF NF or ICF/IID BEDS
THE FACILITY _____ CERTIFIED FOR MEDICARE ____ CERTIFIED FOR MEDICARE ______ CERTIFIED FOR MEDICAID ____ CERTIFIED FOR MEDICAID ____
7. A. THE FACILITY MEETS THE STANDARD, BASED UPON (CHECK ALL APPROPRIATE BOXES)
1. COMPLIANCE WITH ALL PROVISIONS 2. ACCEPTANCE OF A PLAN OF CORRECTION 3. RECOMMENDED WAIVERS . FSES 5. PERFORMANCE BASED DESIGN
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B. THE FACILITY DOES NOT MEET THE STANDARD
K9
SURVEYOR (Signature) TITLE OFFICE DATE
SURVEYOR ID
K10
FIRE AUTHORITY OFFICIAL (Signature) TITLE OFFICE DATE
CMS FORMS SHALL BE COMPLETED AND RETAINED AS PART OF THE SURVEY RECORD.
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PART I – NFPA 101 LSC REQUIREMENTS
(Items in italics relate to the FSES)
SECTION 1 – GENERAL REQUIREMENTS
List in the REMARKS section any LSC Section 18.1 and 19.1 General
Requirements that are not addressed by the provided K-tags, but are
deficient. This information, along with the applicable Life Safety Code or
NFPA standard citation, should be included on Form CMS-2567.
Repair, Renovation, Modification, or Reconstruction
Any building undergoing repair, renovation, modification, or reconstruction
complies with both of the following:
 Requirements of Chapter 18 and 19.
 Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6.
18.1.1.4.3, 19.1.1.4.3, 43.1.2.1
Change of Use or Change of Occupancy
Any building undergoing change of use or change of occupancy
classification complies with the requirements of Section 43.7, unless
permitted by 18.1.1.4.2 or 19.1.1.4.2.
18.1.1.4.2 (4.6.7 and 4.6.11), 19.1.1.4.2 (4.6.7 and 4.6.11), 43.1.2.2 (43.7)
Additions
Any building undergoing an addition shall comply with the requirements of
Section 43.8. If the building has a common wall with a nonconforming
building, the common wall is a fire barrier having at least a two hour fire
resistance rating constructed of materials as required for the addition.
Communicating openings occur only in corridors and are protected by
approved self-closing fire doors with at least a 1-1/2 hour fire resistance
rating. Additions comply with the requirements of Section 43.8.
18.1.1.4.1 (4.6.7 and 4.6.11), 18.1.1.4.1.1 (8.3), 18.1.1.4.1.2, 18.1.1.4.1.3,
19.1.1.4.1 (4.6.7 and 4.6.11), 19.1.1.4.1.1 (8.3), 19.1.1.4.1.2, 19.1.1.4.1.3,
43.1.2.3(43.8)
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K112 Sprinkler Requirements for Major Rehabilitation
If a nonsprinklered smoke compartment has undergone major rehabilitation
the automatic sprinkler requirements of 18.3.5 have been applied to the
smoke compartment.
In cases where the building is not protected throughout by a sprinkler
system, the requirements of 18.4.3.2, 18.4.3.3, and 18.4.3.8 are also met.
Note: Major rehabilitation involves the modification of more than 50 percent,
or more than 4500 ft² of the area of the smoke compartment.
18.1.1.4.3.3, 19.1.1.4.3.3
K131 Multiple Occupancies – Sections of Health Care Facilities
Sections of health care facilities classified as other occupancies meet all of
the following:
 They are not intended to serve four or more inpatients.
 They are separated from areas of health care occupancies by
construction having a minimum two hour fire resistance rating in
accordance with Chapter 8.
 The entire building is protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7.
Hospital outpatient surgical departments are required to be classified as an
Ambulatory Health Care Occupancy regardless of the number of patients
served.
18.1.3.3, 19.1.3.3, 42 CFR 482.41, 42 CFR 485.623
K132 Multiple Occupancies – Contiguous Non-Health Care Occupancies
Non-health care occupancies that are located immediately next to a Health
Care Occupancy, but are primarily intended to provide outpatient services
are permitted to be classified as Business or Ambulatory Health Care
Occupancies, provided the facilities are separated by construction having
not less than two hour fire resistance-rated construction, and are not
intended to provide services simultaneously for four or more inpatients.
Outpatient surgical departments must be classified as Ambulatory Health
Care Occupancy regardless of the number of patients served.
18.1.3.4.1, 19.1.3.4.1
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K133 Multiple Occupancies – Construction Type
Where separated occupancies are in accordance with 18/19.1.3.2 or
18/19.1.3.4, the most stringent construction type is provided throughout the
building, unless a two hour separation is provided in accordance with
8.2.1.3, in which case the construction type is determined as follows:
 The construction type and supporting construction of the health care
occupancy is based on the story in which it is located in the building in
accordance with 18/19.1.6 and Tables 18/19.1.6.1.
 The construction type of the areas of the building enclosing the other
occupancies shall be based on the applicable occupancy chapters.
18.1.3.5, 19.1.3.5, 8.2.1.3
2012 EXISTING
Building construction type and stories meets Table 19.1.6.1, unless
otherwise permitted by 19.1.6.2 through 19.1.6.7
19.1.6.4, 19.1.6.5
Construction Type
Any number of stories
1 I (442), I (332), II (222)
non-sprinklered or sprinklered
One story non-sprinklered
2 II (111)
Maximum 3 stories sprinklered
3 II (000)
4 III (211) Not allowed non-sprinklered
5 IV (2HH) Maximum 2 stories sprinklered
6 V (111)
8 V (000) Maximum 1 story sprinklered
Sprinklered stories must be sprinklered throughout by an approved,

supervised automatic system in accordance with section 9.7. (See 19.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories,
including basements, floors on which patients are located, location of smoke or
fire barriers and dates of approval. Complete sketch or attach small floor
plan of the building as appropriate.
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K161 2012 NEW
Building construction type and stories meets Table 18.1.6.1, unless
otherwise permitted by 18.1.6.2 through 18.1.6.7
18.1.6.4, 18.1.6.5
Construction Type
Not allowed non-sprinklered
1 I (442), I (332), II (222)
Any number of stories sprinklered
II (111)
2 Maximum 3 stories sprinklered
3 II (000)
5 IV (2HH) Maximum 1 story sprinklered
6 V (111)
7 III (200)
8 V (000)
Sprinklered stories must be sprinklered throughout by an approved,
supervised automatic system in accordance with section 9.7. (See 18.3.5)
Give a brief description, in REMARKS, of the construction, the number of stories,
including basements, floors on which patients are located, location of smoke or
fire barriers and dates of approval. Complete sketch or attach small floor
plan of the building as appropriate.
K162 Roofing Systems Involving Combustibles
2012 EXISTING
Buildings of Type I (442), Type I (332), Type II (222), or Type II (111)
having roof systems employing combustible roofing supports, decking or
roofing meet the following:
1. roof covering meets Class C requirements.
2. roof is separated from occupied building portions with 2 hour fire
resistive noncombustible floor assembly using not less than 2½ inches
concrete or gypsum fill.
3. attic or other space is either unoccupied or protected throughout by an
approved automatic sprinkler system.
19.1.6.2*, ASTM E108, ANSI/UL 790
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K162 2012 NEW
Buildings of Type I (442), Type I (332), Type II (222), Type II (111) having
roof systems employing combustible roofing supports, decking or roofing
meet the following:
1. roof covering meets Class A requirements.
2. roof is separated from occupied building portions with 2 hour fire
resistive noncombustible floor assembly using not less than 2½ inches
concrete or gypsum fill.
3. the structural elements supporting the rated floor assembly meet the
required fire resistance rating of the building.
18.1.6.2, ASTM E108, ANSI/UL 790
K163 Interior Nonbearing Wall Construction
Interior nonbearing walls in Type I or II construction are constructed of
noncombustible or limited-combustible materials.
Interior nonbearing walls required to have a minimum 2 hour fire resistance
rating are fire-retardant-treated wood enclosed within noncombustible or
limited-combustible materials, provided they are not used as shaft
enclosures.
18.1.6.4, 18.1.6.5, 19.1.6.4, 19.1.6.5
SECTION 2 – MEANS OF EGRESS REQUIREMENTS

K200 Means of Egress Requirements – Other
List in the REMARKS section any LSC Section 18.2 and 19.2 Means of
Egress requirements that are not addressed by the provided K-tags, but are
18.2, 19.2
Aisles, passageways, corridors, exit discharges, exit locations, and
accesses are in accordance with Chapter 7, and the means of egress is
continuously maintained free of all obstructions to full use in case of
emergency, unless modified by 18/19.2.2 through 18/19.2.11.
18.2.1, 19.2.1, 7.1.10.1
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K221 Patient Sleeping Room Doors
Locks on patient sleeping room doors are not permitted unless the key-
locking device that restricts access from the corridor does not restrict
egress from the patient room, or the locking arrangement is permitted for
patient clinical, security or safety needs in accordance with 18.2.2.2.5 or
19.2.2.2.5.
18.2.2.2, 19.2.2.2, TIA 12-4
K222 Egress Doors

Doors in a required means of egress shall not be equipped with a latch or a
lock that requires the use of a tool or key from the egress side unless using
one of the following special locking arrangements:
☐ CLINICAL NEEDS OR SECURITY THREAT LOCKING
Where special locking arrangements for the clinical security needs of the
patient are used, only one locking device shall be permitted on each door
and provisions shall be made for the rapid removal of occupants by: remote
control of locks; keying of all locks or keys carried by staff at all times; or
other such reliable means available to the staff at all times.
18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6
☐ SPECIAL NEEDS LOCKING ARRANGEMENTS
Where special locking arrangements for the safety needs of the patient are
used, all of the Clinical or Security Locking requirements are being met. In
addition, the locks must be electrical locks that fail safely so as to release
upon loss of power to the device; the building is protected by a supervised
automatic sprinkler system and the locked space is protected by a complete
smoke detection system (or is constantly monitored at an attended location
within the locked space); and both the sprinkler and detection systems are
arranged to unlock the doors upon activation.
18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4
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K222 ☐ DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance
with 7.2.1.6.1 shall be permitted on door assemblies serving low and
ordinary hazard contents in buildings protected throughout by an approved,
supervised automatic fire detection system or an approved, supervised
automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
☐ ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with
7.2.1.6.2 shall be permitted.
18.2.2.2.4, 19.2.2.2.4
☐ ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall
be permitted on door assemblies in buildings protected throughout by an
approved, supervised automatic fire detection system and an approved,
supervised automatic sprinkler system.
18.2.2.2.4, 19.2.2.2.4
K223 Doors with Self-Closing Devices
Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke
barrier, or hazardous area enclosure are self-closing and kept in the closed
position, unless held open by a release device complying with 7.2.1.8.2 that
automatically closes all such doors throughout the smoke compartment or
entire facility upon activation of:
 Required manual fire alarm system; and
 Local smoke detectors designed to detect smoke passing through the
opening or a required smoke detection system; and
 Automatic sprinkler system, if installed; and
 Loss of power.
18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8
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K224 Horizontal-Sliding Doors
Horizontal-sliding doors permitted by 7.2.1.14 that are not automatic-closing
are limited to a single leaf and shall have a latch or other mechanism to
ensure the door will not rebound.
Horizontal-sliding doors serving an occupant load fewer than 10 shall be
permitted, providing all of the following criteria are met:
 Area served by the door has no hazards.
 Door is operable from either side without special knowledge or effort.
 Force required to operate the door in the direction of travel is ≤ 30 lbf to
set the door in motion and ≤ 15 lbf to close or open to the required
width.
 Assembly is appropriately fire rated, and where rated, is self-or
automatic-closing by smoke detection per 7.2.1.8, and installed per
NFPA 80.
 Where required to latch, the door has a latch or other mechanism to
ensure the door will not rebound.
18.2.2.2.10, 19.2.2.2.10
K225 Stairways and Smokeproof Enclosures
Stairways and Smokeproof enclosures used as exits are in accordance with
7.2.
18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2
Horizontal exits, if used, are in accordance with 7.2.4 and the provisions of
18.2.2.5.1 through 18.2.2.5.7, or 19.2.2.5.1 through 19.2.2.5.4.
18.2.2.5, 19.2.2.5
Ramps, exit passageways, fire escape ladders, alternating tread devices,
and areas of refuge are in accordance with the provisions 7.2.5 through
7.2.12.
18.2.2.6 to 18.2.2.10 or 19.2.2.6 to 19.2.2.10

The capacity of required means of egress is in accordance with 7.3.
18.2.3.1, 19.2.3.1
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K232 Aisle, Corridor or Ramp Width
2012 EXISTING
The width of aisles or corridors (clear or unobstructed) serving as exit
access shall be at least 4 feet and maintained to provide the convenient
removal of nonambulatory patients on stretchers, except as modified by
19.2.3.4, exceptions 1-5.
19.2.3.4, 19.2.3.5
2012 NEW
The width of aisles or corridors (clear and unobstructed) serving as exit
access in hospitals and nursing homes shall be at least 8 feet. In limited
care facility and psychiatric hospitals, width of aisles or corridors shall be at
least 6 feet, except as modified by the 18.2.3.4 or 18.2.3.5 exceptions.
18.2.3.4, 18.2.3.5
K233 Clear Width of Exit and Exit Access Doors
2012 EXISTING
Exit access doors and exit doors are of the swinging type and are at least
32 inches in clear width. Exceptions are provided for existing 34-inch doors
and for existing 28-inch doors where the fire plan does not require
evacuation by bed, gurney, or wheelchair.
19.2.3.6, 19.2.3.7
2012 NEW
Exit access doors and exit doors are of the swinging type and are at least
41.5 inches in clear width. In psychiatric hospitals or limited care facilities,
doors are at least 32 inches wide. Doors not subject to patient use, in exit
stairway enclosures, or serving newborn nurseries shall be no less than 32
inches in clear width. If using a pair of doors, the doors shall be provided
with a rabbet, bevel, or astragal at the meeting edge, at least one of the
doors shall provide 32 inches in clear width, and the inactive leaf of the pair
shall be secured with automatic flush bolts.
18.2.3.6, 18.2.3.7
Not less than two exits, remote from each other, and accessible from every
part of every story are provided for each story. Each smoke compartment
shall likewise be provided with two distinct egress paths to exits that do not
require the entry into the same adjacent smoke compartment.
18.2.4.1-18.2.4.4, 19.2.4.1-19.2.4.4
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K251 Dead-End Corridors and Common Path of Travel
2012 EXISTING
Dead-end corridors shall not exceed 30 feet. Existing dead-end corridors
greater than 30 feet shall be permitted to be continued to be used if it is
impractical and unfeasible to alter them.
19.2.5.2
K251 2012 NEW
Dead-end corridors shall not exceed 30 feet. Common path of travel shall
not exceed 100 feet.
18.2.5.2, 18.2.5.3
K252 Number of Exits – Corridors
Every corridor shall provide access to not less than two approved exits in
accordance with Sections 7.4 and 7.5 without passing through any
intervening rooms or spaces other than corridors or lobbies.
18.2.5.4, 19.2.5.4
Patient sleeping rooms of more than 1,000 square feet or nonsleeping
rooms of more than 2,500 square feet have at least two exit access doors
remotely located from each other.
18.2.5.5.1, 18.2.5.5.2, 19.2.5.5.1, 19.2.5.5.2
K254 Corridor Access
All habitable rooms not within suites have a door leading directly outside to
grade or have a door leading to an exit access corridor. Patient sleeping
rooms with less than eight patient beds may have one room intervening to
reach an exit access corridor provided the intervening room is equipped
with an approved automatic smoke detection system.
18.2.5.6.1 through 18.2.5.6.4, 19.2.5.6.1 through 19.2.5.6.4
K255 Suite Separation, Hazardous Content, and Subdivision
All suites are separated from the remainder of the building (including from
other suites) by construction meeting the separation provisions for corridor
construction (18.3.6.2-18.3.6.5 or 19.3.6.2-19.3.6.5). Existing approved
barriers shall be allowed to continue to be used provided they limit the
transfer of smoke. Intervening rooms have no hazardous areas and
hazardous areas within suites comply with 18/19.2.5.7.1.3. Subdivision of
suites shall be by noncombustible or limited-combustible construction.
18.2.5.7.1.2 through 18.2.5.7.1.4, 19.2.5.7.1.2, 19.2.5.7.1.3, 19.2.5.7.1.4
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K256 Sleeping Suites
Occupants shall have exit access to a corridor or direct access to a
horizontal exit. Where ≥ 2 exits are required, one exit access door may be
to a stairway, passageway or to the exterior. Suites shall be provided with
constant staff supervision. Staff shall have direct visual supervision of
patient sleeping rooms, from a constantly attended location or the room
shall be provided with an automatic smoke detection system.
Suites more than 1,000 ft² shall have 2 or more remote exits. One means of
egress from the suite shall be to a corridor and one may be into an adjacent
suite separated in accordance with corridor requirements.
Suites shall not exceed the following size limitations:
 5,000 square feet if the suite is not fully smoke detected or fully
sprinklered.
 7,500 square feet if the suite is either fully smoke detected or fully
sprinklered.
 10,000 square feet if the suite is both fully smoke detected and fully
sprinklered and the sleeping rooms have direct supervision from a
constantly attended location.
Travel distance between any point in a suite to exit access shall not exceed
100 feet and distance to an exit shall not exceed 150 feet (200 feet if
building is fully sprinklered).
18.2.5.7.2, 19.2.5.7.2
K257 Non-Sleeping Suites
Occupants shall have exit access to a corridor or direct access to a
horizontal exit. Where ≥ 2 exits are required, one exit access door may be
to a stairway, passageway or to the exterior.
Suites more than 2,500 ft² shall have 2 or more remote exits. One means of
egress from the suite shall be to a corridor and one may be into an adjacent
suite separated in accordance with corridor requirements.
Suites shall not exceed 10,000 ft².
Travel distance between any point in a suite to exit access shall not exceed
100 feet and distance to an exit shall not exceed 150 feet (200 feet if
building is fully sprinklered).
18.2.5.7.3, 19.2.5.7.3
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Travel distance (excluding suites) to exits are measured in accordance with
7.6.
 From any point in the room or suite to exit less than or equal to 150
feet (less than or equal to 200 feet if the building is fully
sprinklered).
 Point in a room to room door less than or equal to 50 feet.
18.2.6, 19.2.6
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 05-38.
18.2.7, 19.2.7, S&C 05-38
Illumination of means of egress, including exit discharge, is arranged in
accordance with 7.8 and shall be either continuously in operation or
capable of automatic operation without manual intervention.
18.2.8, 19.2.8
Emergency lighting of at least 1-1/2 hour duration is provided automatically
in accordance with 7.9.
18.2.9.1, 19.2.9.1
K292 Life Support Means of Egress
2012 NEW (INDICATE N/A FOR EXISTING)
Buildings equipped with or requiring the use of life support systems (electro-
mechanical or inhalation anesthetics) have illumination of means of egress,
emergency lighting equipment, exit, and directional signs supplied by the
life safety branch of the electrical system described in NFPA 99.
(Indicate N/A if life support equipment is for emergency purposes only.)
18.2.9.2, 18.2.10.5
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K293 Exit Signage
2012 EXISTING
Exit and directional signs are displayed in accordance with 7.10 with
continuous illumination also served by the emergency lighting system.
19.2.10.1
(Indicate N/A in one-story existing occupancies with less than 30 occupants
where the line of exit travel is obvious.)
2012 NEW
Exit and directional signs are displayed in accordance with 7.10 with
continuous illumination also served by the emergency lighting system.
18.2.10.1
SECTION 3 – PROTECTION
List in the REMARKS section any LSC Section 18.3 and 19.3 Protection
requirements that are not addressed by the provided K-tags, but are
2012 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes, and other
vertical openings between floors are enclosed with construction having a
fire resistance rating of at least 1-hour. An atrium may be used in
accordance with 8.6.
19.3.1.1 through 19.3.1.6
If all vertical openings are properly enclosed with construction providing at
least a 2 hour fire resistance rating, also check this
box. ☐
2012 NEW
Stairways, elevator shafts, light and ventilation shafts, chutes, and other
vertical openings between floors are enclosed with construction having a
fire resistance rating of at least 2 hours connecting four or more stories. (1-
hour for single story building and buildings up to three stories in height.) An
atrium may be used in accordance with 8.6.7.
18.3.1 through 18.3.1.5
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Hazardous areas are protected by a fire barrier having 1-hour fire
resistance rating (with ¾ hour fire rated doors) or an automatic fire
extinguishing system in accordance with 8.7.1. When the approved
automatic fire extinguishing system option is used, the areas shall be
separated from other spaces by smoke resisting partitions and doors in
accordance with 8.4. Doors shall be self-closing or automatic-closing and
permitted to have nonrated or field-applied protective plates that do not
exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient
in REMARKS.
19.3.2.1
Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 sq. ft.)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms

(exceeding 64 gal.)
e. Trash Collection Rooms
(exceeding 64 gal.)
f. Combustible Storage Rooms/Spaces
(over 50 sq. ft.)
g. Laboratories (if classified as Severe
Hazard - see K322)
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K321 2012 NEW
Hazardous areas are protected in accordance with 18.3.2.1. The areas
shall be enclosed with a 1-hour fire-rated barrier, with a ¾ hour fire-rated
door without windows (in accordance with 8.7.1.1). Doors shall be self-
closing or automatic-closing in accordance with 7.2.1.8. Hazardous areas
are protected by a sprinkler system in accordance with 9.7, 18.3.2.1, and
8.4.
Describe the floor and zone locations of hazardous areas that are deficient
in REMARKS.
18.3.2.1, 7.2.1.8, 8.4, 8.7, 9.7
Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 sq. ft.)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms

(exceeding 64 gal.)
e. Trash Collection Rooms
(exceeding 64 gal.)
f. Combustible Storage Rooms/Spaces
(over 50 and less than 100 sq. ft.)
g. Combustible Storage Rooms/Spaces
(over 100 sq. ft.)
h. Laboratories (if classified as Severe
Hazard - see K322)
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K322 Laboratories
Laboratories employing quantities of flammable, combustible, or hazardous
materials that are considered a severe hazard are protected by 1-hour fire
resistance-rated separation, automatic sprinkler system, and are in
accordance with 8.7 and with NFPA 99.
Laboratories not considered a severe hazard are protected as hazardous
areas (see K321).
Laboratories using chemicals are in accordance with NFPA 45.
Gas appliances are of appropriate design and installed in accordance with
NFPA 54. Shutoff valves are marked to identify material they control.
Devices requiring medical grade oxygen from the piped distribution system
meet the requirements under 11.4.2.2 (NFPA 99).
18.3.2.2, 19.3.2.2, 8.7, 8.7.4.1 (LSC)
9.3.1.2, 11.4.3.2, 15.4 (NFPA 99)
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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 anesthetizing location
for medical gas or vacuum; readily accessible in an emergency; and
arranged so shutting off any one anesthetizing location will not affect
others.
Area alarm panels are provided to monitor all medical gas, medical-surgical
vacuum, and piped WAGD systems. Panels are at locations that provide for
surveillance, indicate medical gas pressure decreases of 20 percent and
vacuum decreases of 12 inch gauge HgV, and provide visual and audible
indication. Alarm sensors are installed either on the source side of
individual room zone valve box assemblies or on the patient/use side of
each of the individual zone box valve assemblies.
The EES critical branch supplies power for task illumination, fixed
equipment, select receptacles, and select power circuits, and EES
equipment system supplies power to ventilation system.
Heating, cooling, and ventilation are in accordance with ASHRAE 170.
Medical supply and equipment manufacturer’s instructions for use are
considered before reducing humidity levels to those allowed by ASHRAE,
per S&C 13-58.
18.3.2.3, 19.3.2.3 (LSC)
5.1.4.8.7, 5.1.4.8.7.2, 5.1.9.3, 5.1.9.3.4, 6.4.2.2.4.2 (NFPA 99)
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Cooking equipment is protected in accordance with NFPA 96, Standard for
Ventilation Control and Fire Protection of Commercial Cooking Operations,
unless:
 residential cooking equipment (i.e., small appliances such as
microwaves, hot plates, toasters) are used for food warming or limited
cooking in accordance with 18.3.2.5.2, 19.3.2.5.2.
 cooking facilities open to the corridor in smoke compartments with 30 or
fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3,
or
 cooking facilities in smoke compartments with 30 or fewer patients
comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required
to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2
K325 Alcohol Based Hand Rub Dispenser (ABHR)
ABHRs are protected in accordance with 8.7.3.1, unless all conditions are
met:
 Corridor is at least 6 feet wide.
 Maximum individual dispenser capacity is 0.32 gallons (0.53 gallons in
suites) of fluid and 18 ounces of Level 1 aerosols.
 Dispensers shall have a minimum of four foot horizontal spacing.
 Not more than an aggregate of 10 gallons of fluid or 1135 ounces of
aerosol are used in a single smoke compartment outside a storage
cabinet, excluding one individual dispenser per room.
 Storage in a single smoke compartment greater than 5 gallons complies
with NFPA 30.
 Dispensers are not installed within 1 inch of an ignition source.
 Dispensers over carpeted floors are in sprinklered smoke
compartments.
 ABHR does not exceed 95 percent alcohol.
 Operation of the dispenser shall comply with Section 18.3.2.6(11) or
19.3.2.6(11).
 ABHR is protected against inappropriate access.
18.3.2.6, 19.3.2.6, 42 CFR Parts 403, 418, 460, 482, 483, and 485
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Interior wall and ceiling finishes, including exposed interior surfaces of
buildings such as fixed or movable walls, partitions, columns, and have a
flame spread rating of Class A or Class B. The reduction in class of interior
finish for a sprinkler system as prescribed in 10.2.8.1 is permitted.
10.2, 19.3.3.1, 19.3.3.2
Indicate flame spread rating(s). _____________________
2012 NEW
Interior wall and ceiling finishes, including exposed interior surfaces of
buildings such as fixed or movable walls, partitions and columns have a
flame spread rating of Class A. The reduction in class of interior finish for a
sprinkler system as prescribed in 10.2.8.1 is permitted.
Individual rooms not exceeding four persons may have a Class A or B
finish.
Lower half of corridor walls, not exceeding 4 feet in height, may have a
Class A or B flame spread rating.
10.2, 18.3.3.1, 18.3.3.2
Indicate flame spread rating(s). _____________________

2012 NEW (Indicate N/A for 2012 EXISTING)
Interior finishes shall comply with 10.2. Floor finishes in exit enclosures and
exit access corridors and spaces not separated by walls that resist the
passage of smoke shall be Class I or II.
18.3.3.3.1, 18.3.3.3.2, 18.3.3.3.3, 10.2, 10.2.7.1, 10.2.7.2
A fire alarm system is installed with systems and components approved for
the purpose in accordance with NFPA 70, National Electric Code, and
NFPA 72, National Fire Alarm Code to provide effective warning of fire in
any part of the building. In areas not continuously occupied, detection is
installed at each fire alarm control unit. In new occupancy, detection is also
installed at notification appliance circuit power extenders, and supervising
station transmitting equipment. Fire alarm system wiring or other
transmission paths are monitored for integrity.
18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8
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Initiation of the fire alarm system is by manual means and by any required
sprinkler system alarm, detection device, or detection system. Manual
alarm boxes are provided in the path of egress near each required exit.
Manual alarm boxes in patient sleeping areas shall not be required at exits
if manual alarm boxes are located at all nurse’s stations or other
continuously attended staff location, provided alarm boxes are visible,
continuously accessible, and 200’ travel distance is not exceeded.
18.3.4.2.1, 18.3.4.2.2, 19.3.4.2.1, 19.3.4.2.2, 9.6.2.5
2012 EXISTING
Positive alarm sequence in accordance with 9.6.3.4 are permitted in
buildings protected throughout by a sprinkler system. Occupant notification
is provided automatically in accordance with 9.6.3 by audible and visual
signals.
In critical care areas, visual alarms are sufficient. The fire alarm system
transmits the alarm automatically to notify emergency forces in the event of
a fire.
19.3.4.3, 19.3.4.3.1, 19.3.4.3.2, 9.6.4, 9.7.1.1(1)
2012 NEW
Positive alarm sequence in accordance with 9.6.3.4 are permitted.
Occupant notification is provided automatically in accordance with 9.6.3 by
audible and visual signals.
In critical care areas, visual alarms are sufficient. The fire alarm system
transmits the alarm automatically to notify emergency forces in the event of
a fire.
Annunciation and annunciation zoning for fire alarm and sprinklers shall be
provided by audible and visual indicators and zones shall not be larger than
22,500 square feet per zone.
18.3.4.3 through 18.3.4.3.3, 9.6.4
K344 Fire Alarm – Control Functions
The fire alarm automatically activates required control functions and is
provided with an alternative power supply in accordance with NFPA 72.
18.3.4.4, 19.3.4.4, 9.6.1, 9.6.5, NFPA 72
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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.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
K346 Fire Alarm – Out of Service
Where required fire alarm system is out of services for more than 4 hours in
a 24 hour period, the authority having jurisdiction shall be notified, and the
building shall be evacuated or an approved fire watch shall be provided for
all parties left unprotected by the shutdown until the fire alarm system has
been returned to service.
9.6.1.6
K347 Smoke Detection
2012 EXISTING
Smoke detection systems are provided in spaces open to corridors as
required by 19.3.6.1.
19.3.4.5.2
2012 NEW
Smoke detection systems are provided in spaces open to corridors as
required by 18.3.6.1
In nursing homes, an automatic smoke detection system is installed in the
corridors of all smoke compartments containing resident sleeping rooms,
unless the resident sleeping rooms have:
 smoke detection, or
 automatic door closing devices with integral smoke detectors on the
room side that provide occupant notification.
Such detectors are electrically interconnected to the fire alarm system.
18.3.4.5.2, 18.3.4.5.3
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Nursing homes, and hospitals where required by construction type, are
protected throughout by an approved automatic sprinkler system in
accordance with NFPA 13, Standard for the Installation of Sprinkler
Systems.
In Type I and II construction, alternative protection measures are permitted
to be substituted for sprinkler protection in specific areas where state or
local regulations prohibit sprinklers.
In hospitals, sprinklers are not required in clothes closets of patient sleeping
rooms where the area of the closet does not exceed 6 ft² and sprinkler
coverage covers the closet footprint as required by NFPA 13, Standard for
Installation of Sprinkler Systems.
19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7,
9.7.1.1(1)
2012 NEW
Buildings are to be protected throughout by an approved automatic
sprinkler system in accordance with NFPA 13, Standard for the Installation
of Sprinkler Systems.
In Type I and II construction, alternative protection measures are permitted
to be substituted for sprinkler protection in specific areas where State and
local regulations prohibit sprinklers.
Listed quick-response or listed residential sprinklers are used throughout
smoke compartments with patient sleeping rooms.
In hospitals, sprinklers are not required in clothes closets of patient sleeping
rooms where the area of the closet does not exceed 6 ft² and sprinkler
coverage covers the closet footprint as required by NFPA 13, Standard for
Installation of Sprinkler Systems.
18.3.5.1, 18.3.5.4, 18.3.5.5, 18.3.5.6, 9.7, 9.7.1.1(1), 18.3.5.10

Automatic sprinkler system supervisory attachments are installed and
monitored for integrity in accordance with NFPA 72, National Fire Alarm
and Signaling Code, and provide a signal that sounds and is displayed at a
continuously attended location or approved remote facility when sprinkler
operation is impaired.
9.7.2.1, NFPA 72
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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
Where the sprinkler system is impaired, the extent and duration of the
impairment has been determined, areas or buildings involved are inspected
and risks are determined, recommendations are submitted to management
or designated representative, and the fire department and other authorities
having jurisdiction have been notified. Where the sprinkler system is out of
service for more than 10 hours in a 24 hour period, the building or portion of
the building affected are evacuated or an approved fire watch is provided
until the sprinkler system has been returned to service.
18.3.5.1, 19.3.5.1, 9.7.5, 15.5.2 (NFPA 25)
Portable fire extinguishers are selected, installed, inspected, and
maintained in accordance with NFPA 10, Standard for Portable Fire
Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
K361 Corridors – Areas Open to Corridor
Spaces (other than patient sleeping rooms, treatment rooms and hazardous
areas), waiting areas, nurse’s stations, gift shops, and cooking facilities,
open to the corridor are in accordance with the criteria under 18.3.6.1 and
19.3.6.1.
18.3.6.1, 19.3.6.1
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Corridors are separated from use areas by walls constructed with at least ½
hour fire resistance rating. In fully sprinklered smoke compartments,
partitions are only required to resist the transfer of smoke. In nonsprinklered
buildings, walls extend to the underside of the floor or roof deck above the
ceiling. Corridor walls may terminate at the underside of ceilings where
specifically permitted by Code.
Fixed fire window assemblies in corridor walls are in accordance with
Section 8.3, but in sprinklered compartments there are no restrictions in
area or fire resistance of glass or frames.
If the walls have a fire resistance rating, give the rating _____________ if
the walls terminate at the underside of the ceiling, give brief description in
REMARKS, describing the ceiling throughout the floor area.
19.3.6.2, 19.3.6.2.7
2012 NEW
Corridor walls shall form a barrier to limit the transfer of smoke. Such walls
shall be permitted to terminate at the ceiling where the ceiling is constructed
to limit the transfer of smoke. No fire resistance rating is required for the
corridor walls.
18.3.6.2
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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 1¾ 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. Doors shall
be provided with a means suitable for keeping the door closed.
There is no impediment to the closing of the doors. Clearance between
bottom of door and floor covering is not exceeding 1 inch. Roller latches are
prohibited by CMS regulations on corridor doors and rooms containing
flammable or combustible materials. Powered doors complying with 7.2.1.9
are permissible. Hold open devices that release when the door is pushed or
pulled are permitted. Nonrated protective plates of unlimited height are
permitted. Dutch doors meeting 19.3.6.3.6 are permitted.
Door frames shall be labeled and made of steel or other materials in
compliance with 8.3, unless the smoke compartment is sprinklered. Fixed
fire window assemblies are allowed per 8.3. In sprinklered compartments
there are no restrictions in area or fire resistance of glass or frames in
window assemblies.
19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings,
automatics closing devices, etc.
2012 NEW
Doors protecting corridor openings shall be constructed to resist the
passage of smoke. Clearance between bottom of door and floor covering is
not exceeding 1 inch. There is no impediment to the closing of the doors.
Hold open devices that release when the door is pushed or pulled are
permitted.
Doors shall be provided with self-latching and positive latching hardware.
Nonrated protective plates of unlimited height are permitted. Dutch doors
meeting 18.3.6.3.6 are permitted. Roller latches are prohibited by CMS
regulations on corridor doors and rooms containing flammable or
combustible materials.
18.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings,
automatic closing devices, etc.
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Transfer grilles are not used in corridor walls or doors. Auxiliary spaces
that do not contain flammable or combustible materials are permitted to
have louvers or be undercut.
In other than smoke compartments containing patient sleeping rooms,
miscellaneous openings are permitted in vision panels or doors, provided
the openings per room do not exceed 20 in² and are at or below half the
distance from floor to ceiling. In sprinklered rooms, the openings per room
do not exceed 80 in².
Vision panels in corridor walls or doors shall be fixed window assemblies in
approved frames. (In fully sprinklered smoke compartments, there are no
restrictions in the area and fire resistance of glass and frames.)
18.3.6.5.1, 19.3.6.5.2, 8.3
2012 EXISTING
Smoke barriers shall be provided to form at least two smoke compartments
on every sleeping floor with a 30 or more patient bed capacity. Size of
compartments cannot exceed 22,500 square feet or a 200-foot travel
distance from any point in the compartment to a door in the smoke barrier.
19.3.7.1, 19.3.7.2
Detail in REMARKS zone dimensions including length of zones and dead-
end corridors.
2012 NEW
Smoke barriers shall be provided to form at least two smoke compartments
on every floor used by inpatients for sleeping or treatment, and on every
floor with an occupant load of 50 or more persons, regardless of use.
Size of compartments cannot exceed 22,500 square feet or a 200-foot
travel distance from any point in the compartment to a door in the smoke
barrier.
Smoke subdivision requirements do not apply to any of the stories or areas
described in 18.3.7.2.
18.3.7.1, 18.3.7.2
Detail in REMARKS zone dimensions including length of zones and dead-
end corridors.
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K372 Subdivision of Building Spaces – Smoke Barrier Construction
2012 EXISTING
Smoke barriers shall be constructed to a ½ hour fire resistance rating per
8.5. Smoke barriers shall be permitted to terminate at an atrium wall.
Smoke dampers are not required in duct penetrations in fully ducted HVAC
systems where an approved sprinkler system is installed for smoke
compartments adjacent to the smoke barrier.
19.3.7.3, 8.6.7.1(1)
Describe any mechanical smoke control system in REMARKS.
2012 NEW
Smoke barriers shall be constructed to provide at least a 1-hour fire
resistance rating and constructed in accordance with 8.5. Smoke barriers
shall be permitted to terminate at an atrium wall. Smoke dampers are not
required in duct penetrations of fully ducted HVAC systems.
18.3.7.3, 18.3.7.4, 18.3.7.5, 8.3
Describe any mechanical smoke control system in REMARKS.
K373 Subdivision of Building Spaces – Accumulation Space
Space shall be provided on each side of smoke barriers to adequately
accommodate the total number of occupants in adjoining compartments.
18.3.7.5.1, 18.3.7.5.2, 19.3.7.5.1, 19.3.7.5.2
K374 Subdivision of Building Spaces – Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1¾-inch thick solid bonded wood-core doors or
of construction that resists fire for 20 minutes. Nonrated protective plates of
unlimited height are permitted. Doors are permitted to have fixed fire
window assemblies per 8.5. Doors are self-closing or automatic-closing, do
not require latching, and are not required to swing in the direction of egress
travel. Door opening provides a minimum clear width of 32 in for swinging
or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9
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K374 2012 NEW
Doors in smoke barriers have at least a 20-minute fire protection rating or
are at least 1¾-inch thick solid bonded core wood.
Required clear widths are provided per 18.3.7.6(4) and (5).
Nonrated protective plates of unlimited height are permitted. Horizontal-
sliding doors comply with 7.2.1.14. Swinging doors shall be arranged so
that each door swings in an opposite direction.
Doors shall be self-closing and rabbets, bevels, or astragals are required at
the meeting edges. Positive latching is not required.
18.3.7.6, 18.3.7.7, 18.3.7.8
2012 EXISTING
Openings in smoke barrier doors shall be fire-rated glazing or wired glass
panels in steel frames.
19.3.7.6, 19.3.7.6.2, 8.5
2012 NEW
Windows in smoke barrier doors shall be installed in each cross corridor
swinging or horizontal-sliding door protected by fire-rated glazing or by
wired glass panels in approved frames.
18.3.7.9
K381 Sleeping Room Outside Windows and Doors
Every patient sleeping room has an outside window or outside door. In new
occupancies, sill height does not exceed 36 inches above the
floor. Windows in atrium walls are considered outside windows. Newborn
nurseries and rooms intended for occupancy less than 24 hours have no
outside window or door requirements. Window sills in special nursing care
areas (e.g., ICU, CCU, hemodialysis, neonatal) do not exceed 60 inches
above the floor.
42 CFR 403, 418, 460, 482, 483, and 485
SECTION 4 – SPECIAL PROVISIONS
K400 Special Provisions – Other
List in the REMARKS section any LSC Section 18.4 and 19.4 Special
Provisions requirements that are not addressed by the provided K-tags, but
are deficient. This information, along with the applicable Life Safety Code or
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K421 High-Rise Buildings
2012 EXISTING
High-rise buildings are protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7 within 12 years
of LSC final rule effective date.
19.4.2
2012 NEW
High-rise buildings comply with section 11.8.
18.4.2
SECTION 5 – BUILDING SERVICES

List in the REMARKS section any LSC Section 18.5 and 19.5 Building
Services requirements that are not addressed by the provided K-tags, but
Equipment using gas or related gas piping complies with NFPA 54, National
Fuel Gas Code, electrical wiring and equipment complies with NFPA 70,
National Electric Code. Existing installations can continue in service
provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2
K521 HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be
installed in accordance with the manufacturer’s specifications.
18.5.2.1, 19.5.2.1, 9.2
Any heating device, other than a central heating plant, is designed and
installed so combustible materials cannot be ignited by device, and has a
safety feature to stop fuel and shut down equipment if there is excessive
temperature or ignition failure. If fuel fired, the device also:
 is chimney or vent connected.
 takes air for combustion from outside.
 provides for a combustion system separate from occupied area
atmosphere.
18.5.2.2,
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K523 HVAC – Suspended Unit Heaters
Suspended unit heaters are permitted provided the following are met:
 Not located in means of egress or in patient rooms.
 Located high enough to be out of reach of people in the area.
 Has a safety feature to stop fuel and shut down equipment if there is
excessive temperature or ignition failure.
18.5.2.3(1), 19.5.2.3(1)
K524 HVAC – Direct-Vent Gas Fireplaces
Direct-vent gas fireplaces, as defined in NFPA 54, inside of all smoke
compartments containing patient sleeping areas comply with the
requirements of 18.5.2.3(2), 19.5.2.3(2).
18.5.2.3(2), 19.5.2.3(2), NFPA 54
K525 HVAC – Solid Fuel-Burning Fireplaces
Solid fuel-burning fireplaces are permitted in other than patient sleeping
areas provided:
 Areas are separated by 1-hour fire resistance construction.
 Fireplace complies with 9.2.2.
 Fireplace enclosure resists breakage up to 650°F and has heat-
tempered glass.
 Room has supervised CO detection per 9.8.
18.5.2.3(3) and 19.5.2.3(3)
K531 Elevators
2012 EXISTING
Elevators comply with the provision of 9.4. Elevators are inspected and
tested as specified in ASME A17.1, Safety Code for Elevators and
Escalators. Firefighter’s Service is operated monthly with a written record.
Existing elevators conform to ASME/ANSI A17.3, Safety Code for Existing
Elevators and Escalators. All existing elevators, having a travel distance of
25 feet or more above or below the level that best serves the needs of
emergency personnel for firefighting purposes, conform with Firefighter’s
Service Requirements of ASME/ANSI A17.3. (Includes firefighter’s service
Phase I key recall and smoke detector automatic recall, firefighter’s service
Phase II emergency in-car key operation, machine room smoke detectors,
and elevator lobby smoke detectors.)
19.5.3, 9.4.2, 9.4.3
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K531 2012 NEW
Elevators comply with the provision of 9.4. Elevators are inspected and
tested as specified in ASME A17.1, Safety Code for Elevators and
Escalators. Firefighter’s Service is operated monthly with a written record.
New elevators conform to ASME/ANSI A17.1, Safety Code for Elevators
and Escalators, including Firefighter’s Service Requirements. (Includes
firefighter’s Phase I key recall and smoke detector automatic recall,
firefighter’s service Phase II emergency in-car key operation, machine room
smoke detectors, and elevator lobby smoke detectors.)
18.5.3, 9.4.2, 9.4.3
2012 EXISTING
Escalators, dumbwaiters, and moving walks comply with the provisions of
9.4.
All existing escalators, dumbwaiters, and moving walks conform to the
requirements of ASME/ANSI A17.3, Safety Code for Existing Elevators and
Escalators.
(Includes escalator emergency stop buttons and automatic skirt obstruction
stop. For power dumbwaiters, includes hoistway door locking to keep doors
closed except for floor where car is being loaded or unloaded.)
19.5.3, 9.4.2.2
2012 NEW
Escalators, dumbwaiters, and moving walks comply with the provisions of
9.4.
18.5.3, 9.4.2.2
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2012 EXISTING
(1) Any existing linen and trash chute, including pneumatic rubbish and
linen systems, that opens directly onto any corridor shall be sealed by
fire resistive construction to prevent further use or shall be provided with
a fire door assembly having a fire protection rating of 1-hour. All new
chutes shall comply with 9.5.
(2) Any rubbish chute or linen chute, including pneumatic rubbish and linen
systems, shall be provided with automatic extinguishing protection in
accordance with 9.7.
(3) Any trash chute shall discharge into a trash collection room used for no
other purpose and protected in accordance with 8.4. (Existing laundry
chutes permitted to discharge into same room are protected by
automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.)
(4) Existing fuel-fed incinerators shall be sealed by fire resistive
construction to prevent further use.
19.5.4, 9.5, 8.4, NFPA 82
2012 NEW
Rubbish chutes, incinerators, and laundry chutes shall comply with the
provisions of Section 9.5, unless otherwise specified in 18.5.4.2.
 The fire resistance rating of chute charging room shall not be required
to exceed 1-hour.
 Any rubbish chute or linen chute shall be provided with automatic
extinguishing protection in accordance with Section 9.7.
 Chutes shall discharge into a trash collection room used for no other
purpose and shall be protected in accordance with 8.7.
18.5.4.2, 8.7, 9.5, 9.7, NFPA 82
SECTION 6 – RESERVED
SECTION 7 – OPERATING FEATURES
List in the REMARKS section any LSC Section 18.7 and 19.7 Operating
Features requirements that are not addressed by the provided K-tags, but
NFPA standard citation, should be included in Form CMS-2567.
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There is a written plan for the protection of all patients and for their
evacuation in the event of an emergency.
Employees are periodically instructed and kept informed with their duties
under the plan, and a copy of the plan is readily available with telephone
operator or with security. The plan addresses the basic response required
of staff per 18/19.7.2.1.2 and provides for all of the fire safety plan
components per 18/19.7.2.2.
18.7.1.1 through 18.7.1.3, 18.7.2.1.2, 18.7.2.2, 18.7.2.3, 19.7.1.1 through
19.7.1.3, 19.7.2.1.2, 19.7.2.2, 19.7.2.3
K712 Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of
emergency fire conditions. Fire drills are held at 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.
18.7.1.4 through 18.7.1.7, 19.7.1.4 through 19.7.1.7
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Smoking regulations shall be adopted and shall include not less than the
following provisions:
(1) Smoking shall be prohibited in any room, ward, or compartment where
flammable liquids, combustible gases, or oxygen is used or stored and
in any other hazardous location, and such area shall be posted with
signs that read NO SMOKING or shall be posted with the international
symbol for no smoking.
(2) In health care occupancies where smoking is prohibited and signs are
prominently placed at all major entrances, secondary signs with
language that prohibits smoking shall not be required.
(3) Smoking by patients classified as not responsible shall be prohibited.
(4) The requirement of 18.7.4(3) shall not apply where the patient is under
direct supervision.
(5) Ashtrays of noncombustible material and safe design shall be provided
in all areas where smoking is permitted.
(6) Metal containers with self-closing cover devices into which ashtrays can
be emptied shall be readily available to all areas where smoking is
permitted.
18.7.4, 19.7.4
Draperies, curtains including cubicle curtains and loosely hanging fabric or
films shall be in accordance with 10.3.1. Excluding curtains and draperies:
at showers and baths; on windows in patient sleeping room located in
sprinklered compartments; and in non-patient sleeping rooms in sprinklered
compartments where individual drapery or curtain panels do not exceed 48
square feet or total area does not exceed 20 percent of the wall.
18.7.5.1, 18.3.5.11, 19.7.5.1, 19.3.5.11, 10.3.1
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Newly introduced upholstered furniture meets Class I or char length, and
heat release criteria in accordance with 10.3.2.1 and 10.3.3, unless the
building is fully sprinklered.
Newly introduced mattresses shall meet char length and heat release
criteria in accordance with 10.3.2.2 and 10.3.4, unless the building is fully
sprinklered.
Upholstered furniture and mattresses belonging to nursing home residents
do not have to meet these requirements as all nursing homes are required
to be fully sprinklered.
Newly introduced upholstered furniture and mattresses means purchased
on or after the LSC final rule effective date.
18.7.5.2, 18.7.5.4, 19.7.5.2, 19.7.5.4
K753 Combustible Decorations
Combustible decorations shall be prohibited unless one of the following is
met:
 Flame retardant or treated with approved fire-retardant coating that is
listed and labeled for product.
 Decorations meet NFPA 701.
 Decorations exhibit heat release less than 100 kilowatts in accordance
with NFPA 289.
 Decorations, such as photographs, paintings and other art are attached
to the walls, ceilings and non-fire-rated doors in accordance with
18.7.5.6 or 19.7.5.6.
 The decorations in existing occupancies are in such limited quantities
that a hazard of fire is not present.
18.7.5.6, 19.7.5.6
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K754 Soiled Linen and Trash Containers
Soiled linen or trash collection receptacles shall not exceed 32 gallons in
capacity. The average density of container capacity in a room or space
shall not exceed 0.5 gallons/square feet. A total container capacity of 32
gallons shall not be exceeded within any 64 square feet area. Mobile soiled
linen or trash collection receptacles with capacities greater than 32 gallons
shall be located in a room protected as a hazardous area when not
attended.
Containers used solely for recycling are permitted to be excluded from the
above requirements where each container is ≤ 96 gal. unless attended, and
containers for combustibles are labeled and listed as meeting FM Approval
Standard 6921 or equivalent.
18.7.5.7, 19.7.5.7
K771 Engineer Smoke Control Systems
2012 EXISTING
When installed, engineered smoke control systems are tested in
accordance with established engineering principles. Test documentation is
maintained on the premises.
19.7.7
2012 NEW
When installed, engineered smoke control systems are tested in
accordance with NFPA 92, Standard for Smoke Control Systems. Test
documentation is maintained on the premises.
18.7.7
K781 Portable Space Heaters

Portable space heating devices shall be prohibited in all health care
occupancies. Unless used in nonsleeping staff and employee areas where
the heating elements do not exceed 212 degrees Fahrenheit (100 degrees
Celsius).
18.7.8, 19.7.8
K791 Construction, Repair, and Improvement Operations
Construction, repair, and improvement operations shall comply with 4.6.10.
Any means of egress in any area undergoing construction, repair, or
improvements shall be inspected daily to ensure its ability to be used
instantly in case of emergency and compliance with NFPA 241.
18.7.9, 19.7.9, 4.6.10, 7.1.10.1
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PART II – HEALTH CARE FACILITIES CODE REQUIREMENTS
K900 Health Care Facilities Code - Other
List in the REMARKS section any NFPA 99 requirements (excluding
Chapter 7, 8, 12, and 13) that are not addressed by the provided K-Tags,
but are deficient. This information, along with the applicable Health Care
Facilities Code or NFPA standard citation, should be included on Form
CMS-2567.
K901 Fundamentals – Building System Categories
Building systems are designed to meet Category 1 through 4 requirements
as detailed in NFPA 99. Categories are determined by a formal and
documented risk assessment procedure performed by qualified personnel.
Chapter 4 (NFPA 99)
K902 Gas and Vacuum Piped Systems – Other

List in the REMARKS section any NFPA 99 Chapter 5 Gas and Vacuum
Systems requirements that are not addressed by the provided K-Tags, but
Chapter 5 (NFPA 99)
K903 Gas and Vacuum Piped Systems – Categories

Medical gas, medical air, surgical vacuum, WAGD, and air supply systems
in which failure is likely to cause major injury or death are designated:
☐ Category 1. Systems in which failure is likely to cause minor injury to
patients are designated.
☐ Category 2. Systems in which failure is not likely to cause injury, but can
cause discomfort is designated.
☐ Category 3. Deep sedation and general anesthesia are not administered
when 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)
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K905 Gas and Vacuum Piped Systems – Central Supply System
Identification and Labeling
Containers, cylinders and tanks are designed, fabricated, tested, and
marked in accordance with 5.1.3.1.1 through 5.1.3.1.7. Locations
containing only oxygen or medical air have doors labeled with "Medical
Gases, NO Smoking or Open Flame". Locations containing other gases
have doors labeled "Positive Pressure Gases, NO Smoking or Open Flame,
Room May Have Insufficient Oxygen, Open Door and Allow Room to
Ventilate Before Opening.”
5.1.3.1, 5.2.3.1, 5.3.10 (NFPA 99)
K906 Gas and Vacuum Piped Systems – Central Supply System Operations
Adaptors or conversion fittings are prohibited. Cylinders are handled in
accordance with 11.6.2. Only cylinders, reusable shipping containers, and
their accessories are stored in rooms containing central supply systems or
cylinders. No flammable materials are stored with cylinders. Cryogenic
liquid storage units intended to supply the facility are not used to transfill.
Cylinders are kept away from sources of heat. Valve protection caps are
secured in place, if supplied, unless cylinder is in use. Cylinders are not
stored in tightly closed spaces. Cylinders in use and storage are prevented
from exceeding 130°F, and nitrous oxide and carbon dioxide cylinders are
prevented from reaching temperatures lower than manufacture
recommendations or 20°F. Full or empty cylinders, when not connected, are
stored in locations complying with 5.1.3.3.2 through 5.1.3.3.3, and are not
stored in enclosures containing motor-driven machinery, unless for
instrument air reserve headers.
5.1.3.2, 5.1.3.3.17, 5.1.3.3.1.8, 5.1.3.3.4, 5.2.3.2, 5.2.3.3, 5.3.6.20.4,
5.6.20.5, 5.3.6.20.7, 5.3.6.20.8, 5.3.6.20.9 (NFPA 99)
K907 Gas and Vacuum Piped Systems – Maintenance Program
Medical gas, vacuum, WAGD, or support gas systems have documented
maintenance programs. The program includes an inventory of all source
systems, control valves, alarms, manufactured assemblies, and outlets.
Inspection and maintenance schedules are established through risk
assessment considering manufacturer recommendations. Inspection
procedures and testing methods are established through risk assessment.
Persons maintaining systems are qualified as demonstrated by training and
certification or credentialing to the requirements of AASE 6030 or 6040.
5.1.14.2.1, 5.1.14.2.2, 5.1.15, 5.2.14, 5.3.13.4.2 (NFPA 99)
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K908 Gas and Vacuum Piped Systems – Inspection and Testing Operations
The gas and vacuum systems are inspected and tested as part of a
maintenance program and include the required elements. Records of the
inspections and testing are maintained as required.
5.1.14.2.3, B.5.2, 5.2.13, 5.3.13, 5.3.13.4 (NFPA 99)
K909 Gas and Vacuum Piped Systems – Information and Warning Signs
Piping is labeled by stencil or adhesive markers identifying the gas or
vacuum system, including the name of system or chemical symbol, color
code (Table 5.1.11), and operating pressure if other than standard. Labels
are at intervals not more than 20 feet, are in every room, at both sides of
wall penetrations, and on every story traversed by riser. Piping is not
painted. Shutoff valves are identified with the name or chemical symbol of
the gas or vacuum system, room or area served, and caution to not use the
valve except in emergency.
5.1.14.3, 5.1.11.1, 5.1.11.2, 5.2.11, 5.3.13.3, 5.3.11 (NFPA 99)
K910 Gas and Vacuum Piped Systems – Modifications
Whenever modifications are made that breach the pipeline, any necessary
installer and verification test specified in 5.1.2 is conducted on the
downstream portion of the medical gas piping system. Permanent records
of all tests required by system verification tests are maintained.
5.1.14.4.1, 5.1.14.4.6, 5.2.13, 5.3.13.4.3 (NFPA 99)
K911 Electrical Systems – Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems
requirements that are not addressed by the provided K-Tags, but are
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), 6.3.2.4.2 (NFPA 99)
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K913 Electrical Systems – Wet Procedure Locations
Operating rooms are considered wet procedure locations, unless otherwise
determined by a risk assessment conducted by the facility governing body.
Operating rooms defined as wet locations are protected by either isolated
power or ground-fault circuit interrupters. A written record of the risk
assessment is maintained and available for inspection.
6.3.2.2.8.4, 6.3.2.2.8.7, 6.4.4.2
K914 Electrical Systems – Maintenance and Testing
Hospital-grade receptacles at patient bed locations and where deep
sedation or general anesthesia is administered, are tested after initial
installation, replacement or servicing. Additional testing is performed at
intervals defined by documented performance data. Receptacles not listed
as hospital-grade at these locations are tested at intervals not exceeding 12
months. Line isolation monitors (LIM), if installed, are tested at intervals of
≤ 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates
both visual and audible alarm. For LIM circuits with automated self-testing,
this manual test is performed at intervals ≤ 12 months. LIM circuits are
tested per 6.3.3.3.2 after any repair or renovation to the electric distribution
system. Records are maintained of required tests and associated repairs or
modifications, containing date, room or area tested, and results.
6.3.4 (NFPA 99)
K915 Electrical Systems – Essential Electric System Categories
☐ Critical care rooms (Category 1) in which electrical system failure is likely
to cause major injury or death of patients, including all rooms where electric
life support equipment is required, are served by a Type 1 EES.
☐ General care rooms (Category 2) in which electrical system failure is
likely to cause minor injury to patients (Category 2) are served by a Type 1
or Type 2 EES.
☐ Basic care rooms (Category 3) in which electrical system failure is not
likely to cause injury to patients and rooms other than patient care rooms
are not required to be served by an EES. Type 3 EES life safety branch has
an alternate source of power that will be effective for 1 1/2 hours.
3.3.138, 6.3.2.2.10, 6.6.2.2.2, 6.6.3.1.1 (NFPA 99), TIA 12-3
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K916 Electrical Systems – Essential Electric System Alarm Annunciator
A remote annunciator that is storage battery powered is provided to operate
outside of the generating room in a location readily observed by operating
personnel. The annunciator is hard-wired to indicate alarm conditions of
the emergency power source. A centralized computer system (e.g.,
building information system) is not to be substituted for the alarm
annunciator.
6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99)
K917 Electrical Systems – Essential Electric System Receptacles
Electrical receptacles or cover plates supplied from the life safety and
critical branches have a distinctive color or marking.
6.4.2.2.6, 6.5.2.2.4.2, 6.6.2.2.3.2 (NFPA 99)
K918 Electrical Systems – Essential Electric System Maintenance and

Testing
The generator or other alternate power source and associated equipment is
capable of supplying service within 10 seconds. If the 10-second criterion is
not met during the monthly test, a process shall be provided to annually
confirm this capability for the life safety and critical branches. Maintenance
and testing of the generator and transfer switches are performed in
accordance with NFPA 110.
Generator sets are inspected weekly, exercised under load 30 minutes 12
times a year in 20-40 day intervals, and exercised once every 36 months for
4 continuous hours. Scheduled test under load conditions include a
complete simulated cold start and automatic or manual transfer of all EES
loads, and are conducted by competent personnel. Maintenance and
testing of stored energy power sources (Type 3 EES) are in accordance
with NFPA 111. Main and feeder circuit breakers are inspected annually,
and a program for periodically exercising the components is established
according to manufacturer requirements. Written records of maintenance
and testing are maintained and readily available. EES electrical panels and
circuits are marked 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 continuing training.
10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8
K922 Gas Equipment – Other
List in the REMARKS section any NFPA 99 Chapter 11 Gas Equipment
requirements that are not addressed by the provided K-Tags, but are
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K923 Gas Equipment – Cylinder and Container Storage
≥ 3,000 cubic feet
Storage locations are designed, constructed, and ventilated in accordance
with 5.1.3.3.2 and 5.1.3.3.3.
> 300 but <3,000 cubic feet
Storage locations are outdoors in an enclosure or within an enclosed
interior space of non- or limited- combustible construction, with door (or
gates outdoors) that can be secured. Oxidizing gases are not stored with
flammables, and are separated from combustibles by 20 feet (5 feet if
sprinklered) or enclosed in a cabinet of noncombustible construction having
a minimum 1/2 hr. fire protection rating.
≤ 300 cubic feet
In a single smoke compartment, individual cylinders available for immediate
use in patient care areas with an aggregate volume of ≤ 300 cubic feet are
not required to be stored in an enclosure. Cylinders must be handled with
precautions as specified in 11.6.2.
A precautionary sign readable from 5 feet is on each door or gate of a
cylinder storage room, where the sign includes the wording as a minimum
"CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING".
Storage is planned so cylinders are used in order of which they are
received from the supplier. Empty cylinders are segregated from full
cylinders. When facility employs cylinders with integral pressure gauge, a
threshold pressure considered empty is established. Empty cylinders are
marked to avoid confusion. Cylinders stored in the open are protected from
weather.
11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)
K924 Gas Equipment – Testing and Maintenance Requirements
Anesthesia apparatus are tested at the final path to patient after any
adjustment, modification or repair. Before the apparatus is returned to
service, each connection is checked to verify proper gas and an oxygen
analyzer is used to verify oxygen concentration. Defective equipment is
immediately removed from service. Areas designated for servicing of
oxygen equipment are clean and free of oil, grease, or other flammables.
Manufacturer service manuals are used to maintain equipment and a
scheduled maintenance program is followed.
11.4.1.3, 11.5.1.3, 11.6.2.5, 11.6.2.6 (NFPA 99)
53
Form CMS-2786R (10/2016) Page 45

ID NOT
MET N/A REMARKS
PREFIX MET
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)
54
Form CMS-2786R (10/2016) Page 46

ID NOT
MET N/A REMARKS
PREFIX MET
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.
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
55
Form CMS-2786R (10/2016) Page 47

ID NOT
MET N/A REMARKS
PREFIX MET
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)
56
Form CMS-2786R (10/2016) Page 48

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

K400

Surveyor (Signature) Title Office Date
Fire Authority Official (Signature) Title Office Date
57
Form CMS-2786R (10/2016) Page 49
PART IV - FIRE SAFETY SURVEY REPORT
CRUCIAL DATA EXTRACT
(TO BE USED WITH CMS 2786 FORMS)
Provider Number Facility Name Survey Date
K1 *K4
K6 DATE OF PLAN K3 MULTIPLE CONSTRUCTION

APPROVAL
TOTAL NUMBER OF BUILDINGS ______
󠇃 A. BUILDING
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)
13 2786R 2012 NEW 1. PROMPT

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
58
Form CMS-2786R (10/2016) Page 50
CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB Exempt
FIRE SAFETY EVALUATION SYSTEM
HEALTH CARE FACILITIES
(NFPA 101A, “Guide on Alternative Approaches to Life Safety” 2013 Edition)
Complete the following worksheets for each fire/smoke zone*.
Where conditions are the same in several zones, one set of worksheets can be used for those zones.
* Fire/smoke zone is a space separated from all other spaces by floors, horizontal exits, or smoke barriers
Step 1 — Complete Cover Sheet using Worksheet 4.7.1.
WORKSHEET 4.7.1 – COVER SHEET
ZONE OF ZONES
NAME OF FACILITY ADDRESS OF FACILITY
ZONE(S) EVALUATED
PROVIDER/VENDOR NO. DATE OF SURVEY
SURVEYOR SIGNATURE TITLE OFFICE DATE
SURVEYOR ID
FIRE AUTHORITY SIGNATURE TITLE OFFICE DATE
ADDITIONAL COMMENTS:
59
Form CMS-2786T (10/2016) Page 1
Step 2 — Determine Occupancy Risk Parameter Factors using Worksheet 4.7.2.

For each Risk Parameter in Worksheet 7.2, select and circle the appropriate risk factor value.
Choose only one for each of the five Risk Parameters.
WORKSHEET 4.7.2 – OCCUPANCY RISK PARAMETER FACTORS
Risk Parameters Risk Factor Values
Mobility Status Mobile Limited Mobility Not Mobile Not Movable

1. Patient
Mobility (M)
Risk Factor 1.0 1.6 3.2 4.5
No. of Patients 1–5 6–10 11–30 >30

2. Patient
Density (D)
Risk Factor 1.0 1.2 1.5 2.0
7th and
Floor 1st 2nd or 3rd 4th to 6th Basements
3. Zone Above
Location (L)
Risk Factor 1.1 1.2 1.4 1.6 1.6
4. Ratio of Patients 1–2 3–5 6–10 >10 One or More
Patients to Attendant 1 1 1 1 None
Attendants
(T) Risk Factor 1.0 1.1 1.2 1.5 4.0*
5. Patient Age Under 65 Years and Over 1 65 Years and Over or 1 Year and
Average Year Younger
Age (A) Risk Factor 1.0 1.2
*A risk factor of 4.0 is charged to any zone that houses patients without any staff in immediate attendance.
Step 3 — Compute Occupancy Risk Factor (F) using Worksheet 4.7.3.

(1) Transfer the circled risk factor values from Worksheet 4.7.2 to the corresponding blocks in Worksheet 4.7.3.
(2) Compute F by multiplying the risk factor values as indicated in Worksheet 4.7.3.
WORKSHEET 4.7.3 - OCCUPANCY RISK FACTOR CALCULATION
M D L T A F
OCCUPANCY RISK x x x x =
Step 4 — Compute Adjusted Building Status (R) - Use Worksheets 4.7.4 or 4.7.5.
(1) If building is classified as “NEW” use Worksheet 4.7.4. If building is classified as “Existing” use Worksheet
4.7.5.
(2) Transfer the value of F from Worksheet 4.7.3 to Worksheets 4.7.4 or 4.7.5, as appropriate. Calculate R.
(3) Transfer R to the block labeled R in Worksheet 4.7.9.
(4) In Worksheets 4.7.4 and 4.7.5, results are always rounded up (i.e., 3.2 is rounded to 4.0).
WORKSHEET 4.7.4 ADJUSTED WORKSHEET 4.7.5 ADJUSTED

OCCUPANCY RISK FACTOR (NEW) OCCUPANCY RISK FACTOR (EXISTING)
F R F R
0.6 x =
Form CMS-2786T (10/2016) 60Page 2

Step 5 — Determine Safety Parameter Values using Worksheet 4.7.6.

(1) Select and circle the safety value for each safety parameter that best describes the conditions in the zone.
(2) Choose only one value for each of the 13 parameters.
(3) If two or more appear to apply, choose the one with the lowest point value.
WORKSHEET 4.7.6 – SAFETY PARAMETER VALUES
Safety Parameters Parameters Values
1. Construction Combustible Non-Combustible
Types III, IV, and V Types I and II
Floor or Zone 000 111 200 211, 2HH 000 111 222, 322, 442
First -2 0 -2 0 0 2 2
Second -7 -2 -4 -2 -2 2 4
Third -9 -7 -9 -7 -7 2 4
4th and Above -13 -7 -13 -7 -9 -7 4
2. Interior Finish Class C Class B Class A

(Corridors and Exits) -5(0)f 0(3)f 3
3. Interior Finish Class C Class B Class A

(Rooms) -3(1)f 1(3)f 3
4. Corridor None or Incomplete <1/2 hour >1/2 to <1 hour ≥1 hour
Partitions/Walls -10(0)a 0 1(0)a 2(0)a
5. Doors to Corridor No Door <20 min FPR ≥ 20 min FPR ≥ 20 min FPR and
Auto Closure
-10 0 1(0)d 2(0)d
6. Zone Dimensions Dead End No Dead Ends >30 ft. and Zone Length Is
>100 ft. >50 ft. to 100 ft. 30 ft. to 50 ft. >150 ft. 100 ft. to 150 ft. <100 ft.
-6(0)b -4(0)b -2(0)b -2(0)c (0)h 0(0)h 1
7. Vertical Openings Open 4 or More Open 2 or 3 Enclosed with Indicated Fire Resistance
Floors Floors <1 hr. ≥1 hr. to <2 hr. ≥2 hr.
-14 -10 0 2(0)e 3(0)e
8. Hazardous Areas Double Deficiency Single Deficiency No Deficiencies
In Zone Outside Zone In Zone In Adjacent Zone
-11 -5 -6 -2 0
9. Smoke Control No Control Smoke Barrier Mechanically Assisted Systems
Serves Zone by Zone
-5(0)c
0 3
10. Emergency <2 Routes Multiple Routes Direct Exit(s)
Movement W/O Horizontal Horizontal
Deficient
Routes -8 Exit(s) Exit(s)
-2 0 1 5
11.Manual Fire Alarm No Manual Fire Alarm Manual Fire Alarm
W/O F.D. Conn. W/F.D. Conn.
-4 1 2
12. Smoke Detection Corridor and Total Spaces
None Corridor Only Rooms Only
and Alarm Habit. Spaces in Zone
0(3)g 2(3)g 3(3)g 4 5
13. Automatic Corridor and Entire
None Habit. Space Building
Sprinklers
0 8 10
a Use (0) where parameter 5 is -10. f Use ( ) if the area of Class B or C interior finish in the corridor and exit or room is
b Use (0) where parameter 10 is -8. protected by automatic sprinklers and Parameter 13 is 0; use ( ) if the room with
c Use (0) on floor with fewer than 31 existing Class C interior finish is protected by automatic sprinklers, Parameter 4 is
greater than or equal to 1, and Parameter 13 is 0.
patients (existing buildings only). g Use this value in addition to Parameter 13 if the entire zone is protected with quick-
d Use (0) where parameter 4 is -10.
response automatic sprinklers.
e Use (0) where Parameter 1 is based on first floor zone h Use (0) where zone area ≤ 22,500 ft.2 and distance from any point to
or on an unprotected type of construction (columns
reach a door in smoke barrier is ≤ 200 ft.

marked “000” or “200”).
For SI Units: 1 ft.² = 0.3048 m²
Form CMS-2786T (10/2016) 61Page 3

Step 6 — Compute Individual Safety Evaluations using Worksheet 4.7.7.

(1) Transfer each of the 13 circled Safety Parameter Values from Worksheet 4.7.6 to every unshaded block in
the line with the corresponding Safety Parameter in Worksheet 4.7.7. For Safety Parameter 13 (Sprinklers)
the value entered in the People Movement Safety column is recorded in Worksheet 4.7.7 as 1/2 the
corresponding value circled in Worksheet 4.7.6.
(2) Add the four columns, keeping in mind that any negative numbers deduct.
(3) Transfer the resulting total values for S1, S2, S3, S4 to blocks labeled S1, S2, S3, S4 in Worksheet 4.7.9 on
page 4 of this sheet.
WORKSHEET 4.7.7 - INDIVIDUAL SAFETY EVALUATIONS
Safety Parameters Containment Extinguishment People General
Safety (S1) Safety (S2) Movement Safety (S4)
Safety (S3)
1. Construction
2. Interior Finish (Corr. and Exit)
3. Interior Finish (Rooms)
4. Corridor Partitions and Walls
5. Doors to Corridor
6. Zone Dimensions
7. Vertical Openings
8. Hazardous Areas
9. Smoke Control
10. Emergency Movement Routes
11. Manual Fire Alarm
12. Smoke Detection and Alarm
13. Automatic Sprinklers ÷2=
Total Value S1= S2= S3= S4=
Form CMS-2786T (10/2016)
62Page 4
Step 7 — Determine Mandatory Safety Requirement values using Worksheet 4.7.8A, 4.7.8B, or 4.7.8C.
(1) Using the facility type (i.e., Hospital or Nursing Home), classification (i.e., New, Existing or Rehabilitated)
and the floor where the zone is located, circle the appropriate value in each of the three columns found in
Worksheet 4.7.8A, 4.7.8B, or 4.7.8C.
(2) Transfer the three circled values to the blocks marked Sa, Sb, and Sc in Worksheet 4.7.9.
(3) The Mandatory Safety Requirement value for basements are based on the distance of the basement level
from the closest level of discharge (See 4.6.1.2 and 4.6.1.3).
WORKSHEET 4.7.8A - MANDATORY SAFETY REQUIREMENTS –
NEW HOSPITALS, EXISTING HOSPITALS OR NEW NURSING HOMES
Containment Extinguishment People Movement

Zone Location (Sa) (Sb) (SC)
New Existing New Existing New Existing
1st story
11 5 15(12)a 4 8(5)a 1
2nd or 3rd storyb
15 9 17(14)a 6 10(7)a 3
4th story or higher, but not high rise
18 9 19(16)a 6 11(8)a 3
High rise
18 17 19(16)a 16 11(8)a 7
a. Use ( ) in zones that do not contain patient sleeping rooms.

nd
b. For a 2 story zone location in a sprinklered EXISTING hospital, as an alternative to the mandatory safety requirement values set
specified in the table, the following mandatory values set shall be permitted to be used: Sa=7, Sb=10, and Sc=7
WORKSHEET 4.7.8B - MANDATORY SAFETY REQUIREMENTS –

EXISTING NURSING HOMES
Zone Location
(Sa) (Sb) (Sc)
1st story
0 10 0
2nd story
2 10 2
3rd story
6 14 2
4th story or higher
8 16 2
WORKSHEET 4.7.8C - MANDATORY SAFETY REQUIREMENTS –
MAJOR REHABILITATION IN NONSPRINKLERED EXISTING HOSPITALS

Zone Location
(Sa) (Sb) (Sc)
1st story
13 17(14)* 8(5)*
2nd or 3rd story
17 19(16)* 10(7)*
4th story or higher
18 19(16)* 11(8)*
*Use ( ) in zones that do not contain patient sleeping rooms.
Form CMS-2786T (10/2016) 63Page 5

Step 8 — Identify Zone Fire Safety Equivalency using Worksheet 4.7.9.

(1) Transfer the three circled values from Worksheet 4.7.8A, 4.7.8B, or 4.7.8C to the blocks marked Sa, Sb,
and Sc in Worksheet 4.7.9.
(2) For each row check “Yes” if the value in the answer block is zero or greater. Check “No” if the value in the
answer block is a negative number.
WORKSHET 4.7.9 - ZONE FIRE SAFETY EQUIVALENCY EVALUATION
YES NO
S1 Sa C
Containment Mandatory
minus ≥0 __
Safety (S1) Containment (Sa)
=
S2 Sb E
Extinguishment Mandatory
minus ≥0 __
Safety (S2) Extinguishment (Sb) =
S3 Sc P
People Movement Mandatory People
minus ≥0 __
Safety (S3) Movement (Sc) =
S4 R G
General
minus Occupancy Risk (R) ≥0 __
Safety (S4) =
Step 9 — Evaluate other considerations not previously addressed using Worksheet 4.7.10.
Complete one copy of this separate worksheet for each facility.
For each consideration, select and mark the appropriate column.
WORKSHEET 4.7.10 FACILITY FIRE SAFETY REQUIREMENTS WORKSHEET
Met Not Not
Met Applic.
A. Building utilities conform to the requirements of Section 9.1.

In new facilities only, life-support systems, alarms, emergency communication
B. systems, and illumination of generator set locations are powered as prescribed by
18.5.1.2 and 18.5.1.3.
Heating and air conditioning systems conform with the air conditioning, heating, and
C. ventilating systems requirements within Section 9.2, except for enclosure of vertical
openings, which have been considered in Safety Parameter 7 of Worksheet 4.7.6.
D. Fuel-burning space heaters and portable electrical space heaters are not used.
E. There are no flue-fed incinerators.

An evacuation plan is provided and fire drills conducted in accordance with
F.
18.7.1/18.7.2 and 19.7.1/19.7.2.
Smoking regulations have been adopted and implemented in accordance with 18.7.4
G.
and 19.7.4.
Draperies, upholstered furniture, mattresses, furnishings, and decoration
H.
combustibility is limited in accordance with 18.7.5 and 19.7.5.
Fire extinguishers are provided in accordance with the requirements of 18.3.5.12 and
I.
19.3.5.12.
J. Exit signs are provided in accordance with the requirements of 18.2.10.1 and 19.2.10.
K. Emergency lighting is provided in accordance with 18.2.9.1 or 19.2.9.1.
L. Standpipes are provided in all new high rise buildings as required by 18.4.2.
Form CMS-2786T (10/2016) 64Page 6

Step 10 — Determine the equivalency Conclusion to determine if the level of life safety is at least equivalent to that
prescribed by the Life Safety Code using Worksheet 4.7.11.
WORKSHEET 4.7.11- CONCLUSIONS
All of the checks in Worksheet 4.7.9 are in the “Yes” column and all applicable considerations in Worksheet
1.
4.7.10 are marked as “Met”. The level of safety is at least equivalent to that prescribed by NFPA 101, Life
Safety Code, for health care occupancies.
All of the checks in Worksheet 4.7.9 are in the “Yes” column and all considerations in Worksheet 4.7.10
2.
marked as “Not Met” have been evaluated and mitigated to the satisfaction of the AHJ. The level of safety is
at least equivalent to that prescribed by NFPA 101, Life Safety Code, for health care occupancies
One or more of the checks on Worksheet 4.7.9 are in the “No” column or any considerations in Worksheet
3.
4.7.10 marked as “Not Met” have NOT been evaluated and mitigated to the satisfaction of the AHJ. The level
of safety is not shown by this system to be equivalent to that prescribed by NFPA 101, Life Safety Code, for
health care occupancies.
Form CMS-2786T (10/2016) 65Page 7

CENTERS FOR MEDICARE & MEDICAID SERVICES Form approved OMB Exempt
FIRE SAFETY SURVEY REPORT – 2012 LIFE SAFETY CODE 1. (A) PROVIDER NO. 1. (A) MEDICAID I.D. NO.
Intermediate Care Facilities for Individuals with Intellectual Disabilities
SMALL FACILITIES K1 K2
PART I – Instructions for Completing the Form (CMS-2786V)

PART II – Existing Resident Board & Care Occupancies Requirements (NFPA 101, Chapter 33)
PART III – New Residential Board & Care Occupancies Requirements (NFPA 101, Chapter 32)
PART IV – Building Services (New and Existing Facilities)
PART V – Operating Features (New and Existing Facilities)
PART VI – Crucial Data Extract
Optional – Fire Safety Evaluation System for Board and Care Occupancies (CMS-2786Y, NFPA 101A, Chapter 7)
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 FACULTY (STREET, CITY, STATE, A. ☐ Fully Sprinklered
ZIP CODE)
A. BUILDING (All required areas are sprinklered)
B. WING B. ☐ Partially Sprinklered
C. FLOOR (Not all required areas are sprinklered)
C. ☐ None (No sprinkler system)

K3 K0180
3. SURVEY FOR 4. DATE OF SURVEY DATE OF PLAN APPROVAL SURVEY UNDER:
☐ MEDICARE ☐ MEDICAID 5. ☐ 2012 EXISITING 6. ☐ 2012 NEW

K4 K6 K7
5. SURVEY FOR CERTIFICATION OF: SMALL FACILITY - LEVEL OF EVACUATON

E-SCORE USE FOR EXISTING FACILITIES ONLY DIFFICULTY (Check one)
E-Score Level of Evacuation Difficulty USE FOR EXISTING FACILITIES ONLY
≤ 1.5 Prompt
> 1.5 ≤ 5.0 Slow 1. ☐ Prompt 2. ☐ Slow 3. ☐ Impractical
> 5.0 Impractical
K5 K8
6. BED COMPOSITION e. NUMBER OF ICF/IID BEDS CERTIFIED FOR MEDICAID

a. TOTAL NO. OF BEDS IN THE FACILITY
6. A. ☐ THE FACILITY MEETS, BASED UPON (check all appropriate boxes):
1. ☐ COMPLIANCE WITH ALL PROVISIONS 2. ☐ ACCEPTANCE OF A PLAN OF CORRECTION 4. ☐ FSES 5. ☐ PERFORMANCE BASED DESIGN
B. ☐ THE FACILITY DOES NOT MEET THE STANDARD
K9
SURVEYOR (Signature) TITLE OFFICE DATE
SURVEYOR ID
K10
FIRE AUTHORITY OFFICIAL (Signature) TITLE OFFICE DATE
Form CMS-2786V (10/2016) Page 1

66

PART I - INSTRUCTIONS FOR COMPLETING THE FORM (CMS-2786V)

(SMALL FACILITIES — 16 BEDS OR LESS)
EXISTING OCCUPANCIES
1. Complete the “Worksheets for Determining Evacuation Capabilities” (CMS-2786M) for each resident in the facility.
Note: Completing these worksheets is the ONLY method permitted for determining Evacuation Capabilities.
2. Transfer the calculated E-Score obtained in Worksheet 6.8.10 to the E-SCORE block (Page 1 of this form).
3. Determine the Level of Evacuation Capability, obtained in Worksheet 6.8.11 (i.e., Prompt, Slow or Impractical).
4. Complete a survey using Part II –Existing Residential Board & Care Occupancies of this form for compliance with the NFPA 101,
Chapter 33.
If Level of Evacuation Capability is:
1. PROMPT - Complete Part III PROMPT EVACUATION section ONLY.
2. SLOW - Complete Part III PROMPT and SLOW EVACUATION sections.
3. IMPRACTICAL - Complete all three sections, Part III PROMPT, SLOW, and IMPRACTICAL.
5. Complete the Part IV – Building Services section.
6. Complete the Part V – Operating Features section.
NEW OCCUPANCIES
1. Complete a survey using Part III – New Residential Board & Care Occupancies of this form for compliance with the NFPA 101,
Chapter 32.
OPTIONAL FIRE SAFETY EVALUATION SYSTEM

1. Use CMS - 2786Y and reference NFPA 101A – Fire Safety Evaluation System for Board and Care Occupancies (Chapter 7).
Form CMS-2786V (10/2016) 67 Page 2


ID PART II – EXISTING RESIDENT BOARD & CARE OCCUPANCIES MET NOT N/A REMARKS
MET
PREFIX (PROMPT EVACUATION)
GENERAL
List in the REMARKS section any LSC Section 33.1 or 33.2 General
Requirements of Chapter 33.
Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6.
33.1.1.3, 4.6.7, 43.1.2.1
Any building undergoing change of use or change of occupancy classification
complies with the requirements of Section 43.7.
33.1.1.3, 4.6.7, 43.1.2.2 (43.7)
Additions
building, the common wall is a fire barrier having at least a 2-hour fire
approved self-closing fire doors with at least a 1-1/2-hour fire resistance
33.1.1.3, 4.6.7, 43.1.2.3(43.8)
Form CMS-2786V (10/2016) 68 Page 3


MET
K131 Multiple Occupancies – Sections of Residential Board and Care
Facilities
Multiple occupancies shall comply with 6.1.14.
No board and care occupancy shall have its sole means of escape pass
through any nonresidential or non-health care occupancy in the same
building.
No board and care occupancy shall be located above a nonresidential or
non-health care occupancy, unless one of the following are met:
1. The board and care occupancy and exits are separated by construction
having a minimum 2-hour fire resistance rating.
2. The nonresidential or non-health care occupancy is protected throughout
by an approved sprinkler system in accordance with 9.7 and is separated
by construction having a minimum 1-hour fire resistance rating.
33.1.3
In Prompt Evacuation Capability facilities, there are no construction
requirements.
MEANS OF ESCAPE REQUIREMENTS
K200 Means of Escape Requirements – Other
List in the REMARKS section any LSC Section 33.2.2 Means of Escape
K211 Means of Escape – General
Designated means of escape shall be continuously maintained clear of
obstructions and impediments to full instant use in the case of fire or
emergency.
33.2.2
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MET
K222 Egress Doors
Doors and paths of travel to a means of escape shall not be less than 28
inches. Bathroom doors shall not be less than 24 inches. Doors are
swinging or sliding. Every closet door latch shall be readily opened from
the inside in case of an emergency. Every bathroom door shall be
designed to allow opening from the outside during an emergency when
locked. No door in any means of escape shall be locked against egress
when the building is occupied.
Delayed egress locks complying with 7.2.1.6.1 shall be permitted on exterior
doors only. Access-controlled egress locks complying with 7.2.1.6.2 shall be
permitted. Forces to open doors shall comply with 7.2.1.4.5.
Door-latching devices shall comply with 7.2.1.5.10. Corridor doors are
provided with positive latching hardware, and roller latches are prohibited.
Door assemblies for which the door leaf is required to swing in the direction
of egress travel shall be inspected and tested not less than annually in
accordance with 7.2.1.15.
33.2.2.5.1 through 33.2.2.5.7, 33.7.7, 42 CFR 483.470(j)(1)(ii)
Form CMS-2786V (10/2016) 70 Page 5


MET
Interior stairs used as a primary means of escape shall be enclosed with
fire barriers in accordance with Section 8.3 having a minimum 1/2-hour
fire resistance rating. Stairs shall comply with 7.2.2.5.3. The entire
primary means of escape shall be arranged so that it is not necessary for
the occupants to pass through a portion of a lower story unless that
route is separated from all spaces on that story by construction having
not less than a 1/2-hour fire resistance rating. In buildings of construction
other than Type II (000), Type III (200), or Type V (000), the supporting
construction shall be protected to afford the required fire resistance
rating of the supported wall.
1. Stairs that connect a story at street level to only one other story shall
be permitted to be open to the story that is not at street level.
2. In Prompt Evacuation Capability facilities, stair enclosures shall not
be required in buildings of three or fewer stories protected throughout
by an approved automatic sprinkler system in accordance with 33.2.3.5
that uses quick response or residential sprinklers. This exception shall
be permitted only if a primary means of escape from each sleeping
area still exists that does not pass through a portion of a lower floor,
unless that route is separated from all spaces on that floor by
construction having a 1/2-hour fire resistance rating.
3. In Prompt Evacuation Capability facilities, stair enclosures shall not be
required in buildings of two or fewer stories with not more than eight
residents and are protected by an approved automatic sprinkler system
in accordance with 33.2.3.5 that uses quick-response or residential
sprinklers. The requirement found at section 33.2.2.3.3, 33.2.3.4.6 or
33.2.3.4.3.7 are not permitted to be used in this instance.
4. In Prompt Evacuation Capability facilities, of three or fewer stories
protected by an approved automatic sprinkler system in accordance with
33.2.3.5 stairs shall be permitted to be open at the topmost story only.
The entire primary means of escape of which the stairs are a part shall
be separated from all portions of lower stories.
Stairs shall comply with 7.2.2 unless otherwise specified in Chapter 33.
Winders complying with 7.2.2.2.4 shall be permitted. Exterior stairs shall be
protected against blockage caused by fire within the building.
33.2.2.4, 33.2.2.6
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MET
Each normally occupied story shall have not less than two remotely located
means of escape that do not involve using windows. In Prompt Evacuation
Capability facilities, one means of escape can be a window complying with
33.2.2.3.1(3). A second means of escape from each story is not required
where the building is protected throughout by an approved automatic
sprinkler system complying with 33.2.3.5 and the facility has two means of
escape. At less one of the required means of escape shall comply with
primary means of escape provisions under of 33.2.2.2.
33.2.2.1
Every sleeping room and living area shall have access to a primary
means of escape located to provide a safe path of travel to the outside.
Where sleeping rooms or living areas are above or below the level of exit
discharge, the primary means of escape shall be an interior stair in
accordance with 33.2.2.4, an exterior stair, a horizontal exit, or a fire
escape stair.
In addition to the primary route, each sleeping room shall have a second
means of escape that consists of one of the following:
1. It shall be a door, stairway, passage, or hall providing a way of
unobstructed travel to the outside of the dwelling at street or
ground level that is independent of and remotely located from the
primary means of escape.
2. It shall be a passage through an adjacent nonlockable space,
independent of and remotely located from the primary means of
escape, to approved means of escape.
Form CMS-2786V (10/2016) 72 Page 7


MET
K253 3. It shall be an outside window or door operable from the inside
without the use of tools, keys, or special effort that provides a clear
opening of not less than 5.7 square feet The width shall be not less
than 20 inches. The height shall be not less than 24 inches. The
bottom of the opening shall be not more than 44 inches above the
floor. Such means of escape shall be acceptable where one of the
following criteria are met:
a. The window shall be within 20 feet of finished ground level.
b. The window shall be directly accessible to fire department
rescue apparatus as approved by the authority having
jurisdiction.
c. The window or door shall open onto an exterior balcony.
4. Windows having a sill height below the adjacent finished ground
level are that provided with a window well meet the following
criteria:
a. The window well allows the window to be fully openable.
b. The window is not less than 9 square feet with a length and width
of not less than 36 inches.
c. Window well deeper than 43 inches has an approved, permanently
affixed ladder or steps complying with the following:
1. The ladder or steps do not extend more than 6 inches into the
well.
2. The ladder or steps are not obstructed by the window.
5. If the sleeping room has a door leading directly to the outside of the
building with access to finished ground level or to a stairway that meets
the requirements of exterior stairs in 33.2.2.2.2, that means of escape
shall be considered as meeting all the escape requirements for the
sleeping room.
a. A second means of escape from each sleeping room shall not be
required where the facility is protected throughout by approved
automatic sprinkler system in accordance with 33.2.3.5.
b. Existing approved means of escape shall be permitted to
continue to be used.
33.2.2.2.1, 33.2.2.2, 33.2.2.3.1 through 33.2.2.3.4
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MET
PROTECTION
List in the REMARKS section any LSC Section 33.2.3 Protection

Vertical openings shall be protected so as not to expose a primary means of
escape. Vertical openings shall be considered protected if separated by
smoke partitions in accordance with 8.2.4 that resist the passage of smoke
from one story to any primary means of escape on another story. Smoke
partitions shall have a fire resistance rating on not less than 1/2 hour. Any
doors or openings to the vertical opening shall be capable of resisting fire for
not less than 20 minutes.
Stairs shall be permitted to be open where complying with sections
33.2.2.4.6 or 33.2.2.7.
33.2.3.1.1 through 33.2.3.1.4
Form CMS-2786V (10/2016) 74 Page 9


MET
Any hazardous area that is on the same floor as, and is in or abut, a
primary means of escape or a sleeping room shall be protected by one of
the following means:
1. Protection shall be an enclosure with a fire resistance rating of not
less than 1 hour, with a self-closing or automatic closing fire door in
accordance with 7.2.1.8 that has a fire protection rating of not less
than 3/4 hour.
2. Protection shall be automatic sprinkler protection, in accordance with
33.2.3.5, and a smoke partition, in accordance with 8.4 located
between the hazardous area and the sleeping area or primary escape
route. Any doors in such separation shall be self-closing or automatic
closing in accordance with 7.2.1.8.
Other hazardous areas shall be protected in accordance with
33.2.3.2.5 by one of the following:
1. An enclosure having a fire resistance rating of not less than 1/2 hour,
with a self-closing or automatic-closing door in accordance with 7.2.1.8
that is equivalent to not less than a 1-3/4 inch (4.4 cm) thick, solid-
bonded wood core construction.
2. Automatic sprinkler protection in accordance with 33.2.3.5, regardless
of enclosure.
Areas with approved, properly installed and maintained furnaces and
heating equipment, and cooking and laundry facilities are not classified as
hazardous areas solely on basis of such equipment.
Standard response sprinklers shall be permitted for use in hazardous areas in
33.2.2.2.4, 33.2.3.2, 33.2.3.2.5
Interior wall and ceiling finish in accordance with section 10.2. In
Prompt Evacuation Capability facilities, Class A, Class B, or Class C is
permitted. There are no requirements for interior floor finish.
33.2.3.3, 33.2.3.3.3
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MET
A manual fire alarm system shall be provided in accordance with
Section 9.6, unless smoke alarms are interconnected and comply with
33.2.3.4.3 and there is not less than one manual fire alarm box per
floor arranged to continuously sound the required smoke alarms.
33.2.3.4.1, 33.2.3.4.1.1, 33.2.3.4.1.2
audible and visual signals.
33.2.3.4.2, 9.6.3
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.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
K346 Fire Alarm System – Out of Service
Where a required fire alarm system is out of service for more than four 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.
33.2.3.4.1, 9.6.1.3, 9.6.1.5, 9.6.1.6
Form CMS-2786V (10/2016) 76 Page 11


MET
K347 Smoke Alarms
Approved smoke alarms shall be provided in accordance with 9.6.2.10,
unless either of the following exist:
1. Buildings protected throughout by an approved automatic sprinkler
system, in accordance with 33.2.3.5, that uses quick response or
residential sprinklers, and protected with approved smoke alarms
installed in each sleeping room in accordance with 9.6.2.10, that are
powered by the building electrical system, or
2. Buildings are protected throughout by an approved automatic sprinkler
system, in accordance with 33.3.2.5, that uses quick-response or
residential sprinklers, with existing battery-powered smoke alarms in
each sleeping room, and where, in the opinion of the authority having
jurisdiction, the facility has demonstrated that testing, maintenance, and
a battery replacement program ensure the reliability of power to smoke
alarms.
Smoke alarms shall be installed on all levels, including basement but
excluding crawl spaces and unfinished attics. Additional smoke alarms shall
be installed for living rooms, dens, day rooms, and similar spaces. These
alarms shall be powered from the building electrical system and when
activated, shall initiate an alarm that is audible in all sleeping areas.
33.2.3.4.3
Form CMS-2786V (10/2016) 77 Page 12


MET
Where an automatic sprinkler system is installed, for either total or partial
building coverage, the system shall be in accordance with Section 9.7 and
shall initiate the fire alarm system in accordance with Section 9.6, as
modified below. The adequacy of the water supply shall be documented.
In Prompt Evacuation facilities, an automatic sprinkler system in accordance
with NFPA 13D, Standard for the Installation of Sprinkler Systems in One
and two Family Dwellings and Manufactured Homes, shall be permitted.
Automatic sprinklers shall not be required in closets not exceeding 24 square
feet and in bathrooms not exceeding 55 square feet, provided that such
spaces are finished with lath and plaster or materials providing a 15-minute
thermal barrier.
In Prompt Evacuation Capability facilities where an automatic sprinkler
system is in accordance with NFPA 13, Standard for the Installation of
Sprinkler Systems, automatic sprinklers shall not be required in closets not
exceeding 24 square feet and in bathrooms not exceeding 55 square feet,
provided that such spaces are finished with lath and plaster or material
providing a 15-minute thermal barrier.
In Prompt Evacuation Capability facilities in buildings four or fewer stories
above grade plane, systems in accordance with NFPA 13R, Standard for the
Installation of Sprinkler Systems in Residential Occupancies up to and
including Four Stories in Height, shall be permitted.
Initiation of the fire alarm system shall not be required for existing
installations in accordance with 33.2.3.5.6.
Where an automatic sprinkler is installed, attics used for living purposes,
storage, or fuel-fired equipment are sprinkler protected. Attics not used for
living purposes, storage, or fuel-fired equipment meet one of the following:
1. Protected by heat detection system to activate the fire alarm system
according to 9.6.
2. Protected by automatic sprinkler system according to 9.7.
3. Constructed of noncombustible or limited-combustible construction; or
4. Constructed of fire-retardant-treated wood according to NFPA 703.
33.2.3.5.3, 33.2.3.5.3.1, 33.2.3.5.3.3, 33.2.3.5.3.4, 33.2.3.5.3.6, 33.2.3.5.7
Form CMS-2786V (10/2016) 78 Page 13


MET
Where a required automatic sprinkler system is installed, supervisory
attachments are installed and monitored for integrity in accordance with
NFPA 72, National Fire Alarm and Signaling Code, and provide a signal
that sounds and is displayed at a continuously attended location or
approved remote facility, when sprinkler operation is impaired.
An automatic sprinkler system in accordance with NFPA 13D would not
require water flow alarms where a facility has smoke alarms or smoke
detectors in accordance with NFPA 72.
9.7.2.1, 7.6 (NFPA 13D), NFPA 72
NFPA 13 and 13R Systems
All sprinkler systems installed in accordance with NFPA 13, Standard for
the Installation of Sprinkler Systems, and NFPA 13R, Standard for the
Installation of Sprinkler Systems in Residential Occupancies Up To and
Including Four Stories in Height, are inspected, tested and maintained in
accordance with NFPA 25, Standard for Inspection, Testing and
Maintenance of Water Based Fire Protection System.
NFPA 13D Systems
Sprinkler systems installed in accordance with NFPA 13D “Standard for
the Installation of Sprinkler Systems in One – and Two – Family Dwellings
and Manufactured Homes” are inspected, tested and maintained in
accordance with the following requirements of NFPA 25:
1. Control valves inspected monthly (NFPA 25, section 13.3.2).
2. Gauges inspected monthly (NFPA 25, section 13.2.71).
3. Alarm devices inspected quarterly (NFPA 25, section 5.2.6).
4. Alarm devices tested semiannually (NFPA 25, section 5.3.3).
5. Valve supervisory switches tested semiannually (NFPA 25, section
13.3.3.5).
6. Visible sprinklers inspected annually ((NFPA 25, section 5.2.1).
7. Visible pipe inspected annually (NFPA 25, section 5.2.2).
8. Visible pipe hangers inspected annually (NFPA 25, section 5.2.3).
9. Buildings inspected annually prior to freezing weather for adequate
heat for water filled piping (NFPA 25, section 5.2.5).
10. A representative sample of fast response sprinklers are tested at 20
years (NFPA 25, section 5.3.1.1.1.2).
Form CMS-2786V (10/2016) 79 Page 14


MET
K353 11. A representative sample of dry pendant sprinklers are tested at 10
years (NFPA 25, section 5.3.1.1.15).
12. Antifreeze solutions are tested annually (NFPA 25, section 5.3.4).
13. Control valves are operated through their full range and returned to
normal annually (NFPA 25, section 13.3.3.1).
14. Operating stems of OS&Y valves are lubricated annually (NFPA 25,
section 13.3.4).
15. Dry pipe systems extending into unheated portions of the building are
inspected, tested and maintained (NFPA 25, section 13.4.4).
A. Date sprinkler system last checked and necessary maintenance
provided. __________________________
B. Show who provided the service. _________________________
C. Note the source of the water supply for the automatic sprinkler system.
__________________________________
(Provide in REMARKS information on coverage for any non-required or
partial automatic sprinkler system.)
33.2.3.5.3, 33.2.3.5.8, 9.7.5, 9.7.7, 9.7.8, and NFPA 25
Where a required automatic sprinkler system is out of service for more
than 10 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.
33.2.3.5.3, 9.7.6.1, 15.5.2 (NFPA 25)
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MET
Unless otherwise indicated below, corridor walls shall meet all of the
following:
 Walls separating sleeping rooms have a minimum ½-hour fire
resistance rating, which is considered to be achieved if the partitioning
is finished on both sides with lath and plaster or materials providing a
15-minute thermal barrier.
 Sleeping room doors are substantial doors, such as those of 1-3/4 inch
thick, solid-bonded wood-core construction or other construction of
equal or greater stability and fire integrity.
 Any vision panels are fixed fire window assemblies in accordance with
8.3.4 or are wired glass not exceeding 9 square feet each in area and
installed in approved frames.
This requirement shall not apply to corridor walls that are smoke partitions in
accordance with 8.4 and that are protected by automatic sprinklers in
accordance with 33.2.3.5 on both sides of the wall and door. In such
instances, there shall be no limitation on the type or size of glass panels.
In Prompt Evacuation facilities, all sleeping rooms shall be separated from
the escape route by smoke partitions in accordance with 8.2.4.
Sleeping arrangements that are not located in sleeping rooms shall be
permitted for nonresident staff members, provided that the audibility of the
alarm in the sleeping area is sufficient to awaken staff that might be
sleeping.
In previously approved facilities, where the group achieves an E-score of
three or less using the board and care methodology of NFPA 101A. Guide
on Alternative Approaches to Life Safety, sleeping rooms shall be separated
from escape routes by walls and doors that are smoke resistant.
33.2.3.6
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MET
Doors shall meet all of the following requirements:
1. Doors shall be provided with latches or other mechanisms suitable for
keeping the door closed.
2. No doors shall be arranged to prevent the occupant from closing the
door.
3. Doors shall be self-closing or automatic-closing in accordance with
7.2.1.8 in buildings other than those protected throughout by an
approved automatic sprinkler system in accordance with 33.2.3.5.
33.2.3.6.4
No louvers or operable transoms or other air passages shall penetrate the
wall, except properly installed heating and utility installations other than
transfer grilles. Transfer grilles shall be prohibited.
33.2.3.6.3
SPECIAL PROVISIONS (RESERVED)
IF THE LEVEL OF EVACUATION DIFFICULTY IS PROMPT,

STOP HERE & CONTINUE TO PART IV AND PART V.

Form CMS-2786V (10/2016) 82 Page 17


ID PART II – EXISTING RESIDENT BOARD & CARE OCCUPANCIES MET

NOT
N/A REMARKS
PREFIX (SLOW EVACUATION) MET
GENERAL
In Slow Evacuation Capability facilities, the facility shall be housed in a
building where the interior is fully sheathed with lath and plaster or
other material providing a 15-minute thermal barrier, including all
portions of bearing walls, bearing partitions, floor construction, and
roofs.
All columns, beams, girders, and trusses shall be similarly encased or
otherwise shall provide not less than a 1/2-hour fire resistance rating,
unless modified by the modified by the following:
Exposed steel or wood columns, girders, and beams (but not
joists) located in the basement shall be permitted.
Buildings of Type I, Type II (222), Type II (111), Type III (211), Type
IV, Type V (111) construction shall not be required to meet the
requirements of 33.2.1.3.2 (See 8.2.1).
Areas protected by approved automatic sprinkler systems in
accordance with 33.2.3.5 shall not be required to meet the
requirements of 33.2.1.3.2.
Unfinished, unused, and essentially inaccessible loft, attic, or
crawl space. shall not be required to meet the requirements
of 33.2.1.3.2.
Where the facility achieves an E-score of 3 or less using the
board and care occupancies evacuation capability determination
methodology of NFPA 101A, Guide on Alternative Approaches to
Life Safety. The requirements of 33.2.1.3.2 shall not apply.
33.2.1.3.2.1 through 33.2.1.3.2.7
Form CMS-2786V (10/2016) 83 Page 18



NOT
N/A REMARKS

In Slow Evacuation Capability facilities, stair enclosures shall not be
required in buildings of three or fewer stories protected throughout by an
approved automatic sprinkler system in accordance with 33.2.3.5 that uses
quick response or residential sprinklers. This exception shall be permitted
only if a primary means of escape from each sleeping area still exists that
does not pass through a portion of a lower floor, unless that route is
separated from all spaces on that floor by construction having a 1/2-hour fire
resistance rating.
In Slow Evacuation Capability facilities, of three or fewer stories protected
by an approved automatic sprinkler system in accordance with 33.2.3.5
stairs shall be permitted to be open at the topmost story only. The entire
primary means of escape of which the stairs are a part shall be separated
from all portions of lower stories.
33.2.2.4.6, 33.2.2.4.9
In Slow Evacuation Capability facilities, the primary means of escape for
each sleeping room shall not be exposed to living areas and kitchens,
unless the building is protected by an approved automatic sprinkler system
in accordance with 33.2.3.5 utilizing quick-response or residential sprinklers
throughout.
33.2.2.2.3
PROTECTION
In Slow Evacuation Capability facilities, interior wall and ceiling finish
materials in accordance with 10.2. Class A or Class B is permitted. There
are no requirements for interior floor finish.
33.2.3.3.2, 33.2.3.3.3

In Slow Evacuation Capability facilities where an automatic sprinkler system
is installed, for either total or partial building coverage, the system shall be
in accordance with Section 9.7and shall initiate the fire alarm system in
accordance with 9.6, as modified below. The adequacy of the water supply
shall be documented.
Form CMS-2786V (10/2016) 84 Page 19



NOT
N/A REMARKS
K356 In Slow Evacuation Capability facilities, an automatic sprinkler system in

accordance with NFPA 13D, Standard for the Installation of Sprinkler
Systems in One and two Family Dwellings and Manufactured Homes, shall
be permitted. Automatic sprinklers shall not be required in closets not
provided that such spaces are finished with lath and plaster or materials
In Slow Evacuation Capability facilities, where an automatic sprinkler
In Slow Evacuation Capability facilities, in buildings four or fewer stories
above grade plane, systems in accordance with NFPA 13R, Standard for
the Installation of Sprinkler Systems in Residential Occupancies up to and
storage, or fuel-fired equipment are sprinkler protected. Attics not used for
living purposes, storage, or fuel-fired equipment meet one of the following:
according to 9.6.
33.2.3.5.3, 33.2.3.5.3.2 through33.2.3.5.3.4, 33.2.3.5.3.6
In Slow Evacuation Capability facilities where an automatic sprinkler
system is installed, for either total or partial building coverage, the system
shall be in accordance with Section 9.7 and shall initiate the fire alarm
system in accordance with 9.6, as modified below. The adequacy of the
water supply shall be documented.
Form CMS-2786V (10/2016) 85 Page 20



NOT
N/A REMARKS
K358 In Slow Evacuation Capability facilities, an automatic sprinkler system in

accordance with NFPA 13D, Standard for the Installation of Sprinkler
Systems in One and two Family Dwellings and Manufactured Homes, shall
be permitted. Automatic sprinklers shall not be required in closets not
provided that such spaces are finished with lath and plaster or materials
In Slow Evacuation Capability facilities, where an automatic sprinkler
In Slow Evacuation Capability facilities, in buildings four or fewer stories
above grade plane, systems in accordance with NFPA 13R, Standard for
the Installation of Sprinkler Systems in Residential Occupancies up to and
storage, or fuel-fired equipment are sprinkler protected. Attics not used
for living purposes, storage, or fuel-fired equipment meet one of the
following:
according to 9.6.
33.2.3.5.3, 33.2.3.5.3.2 through33.2.3.5.3.4, 33.2.3.5.3.6
IF THE LEVEL OF EVACUATION DIFFICULTY IS SLOW,


(ENSURE PROMPT AND SLOW SECTIONS ARE COMPLETE)

Form CMS-2786V (10/2016) 86 Page 21



NOT
N/A REMARKS
PREFIX (IMPRACTICAL EVACUATION) MET
GENERAL
In Impractical Evacuation Capability facilities, nonsprinklered buildings shall
be of any construction type in accordance with 8.2.1 other than Type II
(000), Type III (200), or Type V (000) construction. Buildings protected
throughout by an approved, supervised automatic sprinkler system in
accordance with 33.2.3.5 shall be permitted to be of any type of
construction.
33.2.1.3.3
In Impractical Evacuation Capability facilities, the primary means of escape
for each sleeping room shall not be exposed to living areas and kitchens,
unless the building is protected by an approved automatic sprinkler system
in accordance with 33.2.3.5 utilizing quick-response or residential sprinklers
throughout.
33.2.2.2.3
PROTECTION
All Impractical Evacuation Capability facilities shall be protected throughout
by an approved, supervised automatic sprinkler system in accordance with
33.2.3.5.3.
The system shall be in accordance with Section 9.7 and shall initiate the fire
alarm system in accordance with 9.6, as modified below. The adequacy of
the water supply shall be documented.
In Impractical Evacuation Capability Facilities, an automatic sprinkler
system in accordance with NFPA 13D, Standard for the Installation of
Sprinkler Systems in One-and-Two-Family Dwellings and Manufactured
Homes, with a 30-minute water supply, shall be permitted. All habitable
areas and closets shall be sprinklered.
Form CMS-2786V (10/2016) 87 Page 22



NOT
N/A REMARKS
K359 Automatic Sprinklers shall not be required in bathrooms not exceeding 55

square feet, provided that such spaces are finished with lath and plaster or
materials provided a 15-minute thermal barrier.
In Impractical Evacuation Capability Facilities up to and including four
stories above grade plane, systems in accordance with NFPA 13R,
Standard for the Installation of Sprinkler Systems in Residential
Occupancies up to and Including Four Stories in Height, shall be permitted.
All habitable areas and closets shall be sprinklered. Automatic sprinklers
shall not be required in bathrooms not exceeding 55 square feet provided
that such spaces are finished with lath and plaster or materials providing a
Attics used for living purposes, storage, or fuel-fired equipment are sprinkler
protected. Attics not used for living purposes, storage, or fuel-fired
equipment meet one of the following:
according to 9.6.
33.2.3.5.3, 33.2.3.5.3.2, 33.2.3.5.3.5 through33.2.3.5.3.7, 42 CFR
483.470(j)(1)(ii)
IF THE LEVEL OF EVACUATION DIFFICULTY IS IMPRACTICAL,

(ENSURE PROMPT, SLOW AND IMPRACTICAL SECTIONS ARE COMPLETE)

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GENERAL
 Requirements of Chapter 32.
 Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6.
32.1.1.3, 4.6.7, 43.1.2.1
32.1.1.3, 4.6.7, 43.1.2.2 (43.7)
Additions
approved self-closing fire doors with at least a 1½-hour fire resistance rating.
Additions comply with the requirements of Section 43.8.
32.1.1.3, 4.6.7, 43.1.2.3(43.8)
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K131 Multiple Occupancies – Sections of Residential Board and Care
Facilities
Multiple occupancies shall comply with 6.1.14.
No board and care occupancy shall have its sole means of escape pass
through any nonresidential or non-health care occupancy in the same
building.
No board and care occupancy shall be located above a nonresidential or
non-health care occupancy, unless one of the following are met:
1. The board and care occupancy and exits are separated by construction
having a minimum 2-hour fire resistance rating.
2. The nonresidential or non-health care occupancy is protected throughout
by an approved sprinkler system in accordance with 9.7 and is separated
by construction having a minimum 1-hour fire resistance rating.
32.1.3
In New Occupancies, there are no construction requirements.

List in the REMARKS section any LSC Section 32.2.2 Means of Escape
K211 Means of Escape – General
Designated means of escape shall be continuously maintained clear of
obstructions or impediments to full instant use in the case of fire or
emergency.
32.2.2
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K222 Egress Doors
Doors and paths of travel to a means of escape shall not be less than 32
inches wide. Bathroom doors shall not be less than 24 inches wide. In
conversions (see 32.1.1.6), 28 inch doors are permitted. Doors shall be
swinging or sliding. Every closet door latch shall be readily opened from
the inside. Every bathroom door shall be designed to allow opening from
the outside during an emergency when locked. No door in any means of
escape shall be locked against egress when the building is occupied.
Delayed egress locks complying with 7.2.1.6.1 shall be permitted on
exterior doors. Access-control egress locks complying with 7.2.1.6.2 shall
be permitted. Force to open doors shall comply with 7.2.1.4.5. Door
latching devices shall comply with 7.2.1.5.10. Corridor doors are provided
with positive latching hardware, and roller latches are prohibited. Floor
levels at doors shall comply with 7.2.1.3.
Door assemblies for which the door leaf is required to swing in the direction
of egress travel shall be inspected and tested not less than annually in
32.2.2.5.1 through 32.2.2.5.8, 32.7.7, 42 CFR 483.470(j)(1)(ii)
Interior stairs used as a primary means of escape shall be enclosed with fire
barriers in accordance with Section 8.3 having a minimum 1/2 hour fire
resistance rating. Stairs shall comply with 7.2.2.5.3.
The entire primary means of escape shall be arranged so that it is not
necessary for the occupants to pass from all spaces on that story by
construction having not less than a 1/2 hour fire resistance rating. In
buildings of construction other than Type II (000), Type III (200), or Type V
(000), the supporting construction shall be protected to afford the required
fire resistance rating of the supported wall unless the following requirements
are met:
1. Stairs that connect a story at street level to only one other story shall
be permitted to be open to the story that is not at street level.
2. In buildings three or fewer stories in height, and protected by an
approved automatic sprinkler system in accordance with 32.2.3.5 stair
enclosures shall not be required provided that there remains a primary
means of escape from each sleeping area that does not require
occupants to pass through a portion of a lower floor, unless that route is
separated from all spaces on that floor by construction having a
minimum ½-hour fire resistive rating.
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K225 3. Stairs serving a maximum of two stories in buildings protected with an
approved automatic sprinkler system in accordance with 32.2.3.5 shall
be permitted to be unenclosed.
Stairs shall comply with 7.2.2 unless other-wise specified in Chapter 32.
Winders complying with 7.2.2.2.4 shall be permitted only in conversions.
Exterior stairs shall be protected against blockage caused by fire within the
building.
32.2.2.4, 32.2.2.6
Every sleeping room and living area shall have access to a primary means of
escape located to provide a safe path of travel to the outside.
Where sleeping rooms or living areas are above or below the level of exit
discharge, the primary means of escape shall be an interior stair in
accordance with 32.2.2.4, an exterior stair, a horizontal exit, or a fire escape
stair.
In addition to the primary route, sleeping rooms, other than those having a
door leading directly to the outside of the building in accordance with
32.2.2.3.2, and living areas in facilities without a sprinkler system installed in
accordance with 32.2.3.5 shall a second means of escape consisting of one
of the following:
1. It shall be a door, stairway, passage, or hall providing a way of
unobstructed travel to the outside of the dwelling at street or the finished
ground level that is independent of and remotely located from the
primary means of escape.
2. It shall be a passage through an adjacent nonlockable space,
independent of and remotely located from the primary means of
escape, to approved means of escape.
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K253 3. *It shall be an outside window or door operable from the inside
without the use of tools, keys, or special effort that provides a clear
opening of not less than 5.7 square feet The width shall be not less
than 20 inches. The height shall be not less than 24 inches. The
bottom of the opening shall be not more than 44 inches above the
floor. Such means of escape shall be acceptable where one of the
following criteria are met:
a. The window shall be within 20 feet of the finished ground level.
b. The window shall be directly accessible to fire department
rescue apparatus as approved by the authority having
jurisdiction.
The window or door shall open onto an exterior balcony
4. Windows having a sill height below the adjacent finished ground level
are that provided with a window well meet the following criteria:
a. The window well allows the window to be fully openable.
b. The window is not less than 9 square feet with a length and width of
not less than 36 inches.
c. Window well deeper than 43 inches has an approved, permanently
affixed ladder or steps complying with the following:
1. The ladder or steps do not extend more than 6 inches into the
well.
2. The ladder or steps are not obstructed by the window.
5. If the sleeping room has a door leading directly to the outside of the
building with access to the finish ground level or to and exterior stairway
meeting the requirements of 32.2.2.6.3, that means of escape shall be
considered as meeting all the escape requirements for a second means.
32.2.2.3.1, 32.2.2.3.2
PROTECTION
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Vertical openings shall be separated by smoke partitions in accordance with
section 8.4 having a minimum 1/2 hour fire resistance rating. Stairs shall be
permitted to open where complying with 32.2.2.4.6 or 32.2.2.4.7. (See items
(2) and (3) at K223).
32.2.3.1.2, 32.2.3.1.4
K321 Hazardous Areas – Enclosures
Any hazardous area that is on the same floor as, and is in or abut, a
primary means of escape or a sleeping room shall be protected by one of
the following means:
1. Protection shall be an enclosure with a fire resistance rating of not less
than 1 hour in accordance with 8.2.3. The enclosure shall be protected
by an automatic fire detection system connected to the fire alarm
system provided in 32.2.3.4.1.
2. Protection shall be automatic sprinkler protection, in accordance with
32.2.3.5, and a smoke partition, in accordance with 8.4, located
between the hazardous area and the sleeping area or primary escape
route. Any doors in such separation shall be self-closing or automatic
closing in accordance with 7.2.1.8.
Other hazardous areas shall be protected by one of the following:
1. An enclosure having a fire resistance rating of not less than ½-hour,
with a self-closing or automatic closing door in accordance with 7.2.1.8
that is equivalent of not less than 1-3/4 inches (4.4 cm) thick, solid-
bonded wood core construction and is protected by an automatic fire
detection system connected to the fire alarm system provided in
32.2.3.4.1.
2. Automatic sprinkler protection in accordance with 32.2.3.5, regardless
of enclosure.
32.2.3.2
Interior wall and ceiling finish materials in accordance with 10.2. Class
A, Class B, or Class C is permitted.
Interior floor finishes must meet 10.2.7.1 or 10.2.7.2
32.2.3.3.2, 32.2.3.3
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A manual fire alarm system shall be provided in accordance with
Section 9.6.
32.2.3.4.1
audible and visual signs.
32.2.3.4.2, 9.6.3
program complying with the requirements of NFPA 70, National Electric
Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of
9.7.5, 9.7.7, 9.7.8, and NFPA 25
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.
32.2.3.4.1, 9.6.1.3, 9.6.1.5, 9.6.1.6
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K347 Smoke Alarms
Approved smoke alarms shall be provided in accordance with 9.6.2.10.
Smoke alarms shall be installed on all levels, including basements but
excluding crawl spaces and unfinished attics. Additional smoke alarms
shall be installed for all living areas as defined in 3.3.21.5. Each sleeping
room shall be provided with an approved smoke alarm in accordance with
9.6.2.10.
32.2.3.4.3
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All new occupancies shall be protected throughout by an approved,
supervised automatic sprinkler system in accordance with 32.2.3.5.3 using
quick response or residential sprinklers.
The system shall be in accordance with NFPA 13, Standard for the
Installation of Sprinkler Systems, and shall initiate the fire alarm system in
accordance with 9.6. The adequacy of the water supply shall be documented.
In new occupancies up to and including four stories above grade plane,
systems in accordance with NFPA 13R, Standard for the Installation of
Sprinkler Systems in Residential Occupancies up to and Including Four
Stories in Height, shall be permitted. All habitable areas, closets, roofed
porches, roofed decks, and roof balconies shall be sprinklered.
In new occupancies, an automatic sprinkler system in accordance with NFPA
13D, Standard for the Installation of Sprinkler Systems in One-and-Two-
Family Dwellings and Manufactured Homes, with a 30-minute water supply,
shall be permitted. All habitable areas, closets roofed porches, roofed decks,
and roof balconies shall be sprinklered.
Automatic sprinklers systems in accordance with NFPA 13 and 13R are
provided with electrical supervision in accordance with 9.7.2.
Automatic sprinkler systems in accordance with NFPA 13D shall be provided
with valve supervision by one of these methods:
1. Single listed control valve that shuts off both domestic and sprinkler
system, and separate shutoff for domestic system only.
2. Electrical supervision in accordance with 9.7.2.
3. Valve closure that caused the sounding of an audible signal in the facility
Attics used for living purposes, storage, or fuel-fired equipment are sprinkler
protected in accordance with 9.7.1.1.
Attics not used for living purposes, storage, or fuel-fired equipment meet one
of the following:
according to 9.6.
2. Protected by automatic sprinkler system according to 9.7.1.1.
3. Constructed of noncombustible or limited-combustible construction;
32.2.3.5.1, 32.2.3.5.3, 32.2.3.5.4, 32.2.3.5.5, 32.2.3.5.3.7
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Where a required automatic sprinkler system is installed, supervisory
attachments are installed and monitored for integrity in accordance with
NFPA 72, National Fire Alarm and Signaling Code, and provide a signal
that sounds and is displayed at a continuously attended location or
approved remote facility, when sprinkler operation is impaired.
9.7.2.1, 7.6 (NFPA 13D), NFPA 72

NFPA 13 and 13R Systems
All sprinkler systems installed in accordance with NFPA 13, Standard for
the Installation of Sprinkler Systems, and NFPA 13R, Standard for the
Installation of Sprinkler Systems in Residential Occupancies Up To and
Including Four Stories in Height, are inspected, tested and maintained in
accordance with NFPA 25, Standard for Inspection, Testing and
Maintenance of Water Based Fire Protection System.
NFPA 13D Systems
Sprinkler systems installed in accordance with NFPA 13D “Standard for
the Installation of Sprinkler Systems in One – and Two – Family Dwellings
and Manufactured Homes” are inspected, tested and maintained in
accordance with the following requirements of NFPA 25:
1. Control valves inspected monthly (NFPA 25, section 13.3.2).
2. Gauges inspected monthly (NFPA 25, section 13.2.71).
3. Alarm devices inspected quarterly (NFPA 25, section 5.2.6).
4. Alarm devices tested semiannually (NFPA 25, section 5.3.3).
5. Valve supervisory switches tested semiannually (NFPA 25, section
13.3.3.5).
6. Visible sprinklers inspected annually ((NFPA 25, section 5.2.1).
7. Visible pipe inspected annually (NFPA 25, section 5.2.2).
8. Visible pipe hangers inspected annually (NFPA 25, section 5.2.3).
9. Buildings inspected annually prior to freezing weather for adequate
heat for water filled piping (NFPA 25, section 5.2.5).
10. A representative sample of fast response sprinklers are tested at 20
years (NFPA 25, section 5.3.1.1.1.2).
11. A representative sample of dry pendant sprinklers are tested at
10 years (NFPA 25, section 5.3.1.1.15).
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K353 12. Antifreeze solutions are tested annually (NFPA 25, section 5.3.4).
13. Control valves are operated through their full range and returned to
normal annually (NFPA 25, section 13.3.3.1).
14. Operating stems of OS&Y valves are lubricated annually (NFPA 25,
section 13.3.4).
15. Dry pipe systems extending into unheated portions of the building
are inspected, tested and maintained (NFPA 25, section 13.4.4).
Date sprinkler system last checked and necessary maintenance provided.
__________________________
Show who provided the service. _________________________
Note the source of the water supply for the automatic sprinkler system.
__________________________________
32.2.3.5.3, 9.7.5, 9.7.7, 9.7.8, and NFPA 25
Where a required automatic sprinkler system is out of service for more
than 10 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.
32.2.3.5.3, 9.7.6.1, 15.5.2 (NFPA 25)
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Unless otherwise indicated below, corridor walls shall meet all of the
following:
 Walls separating sleeping rooms have a minimum ½-hour fire
resistance rating, which is considered to be achieved if the partitioning
is finished on both sides with lath and plaster or materials providing a
 Sleeping room doors are substantial doors, such as those of 1-3/4 inch
thick, solid-bonded wood-core construction or other construction of
equal or greater stability and fire integrity.
 Any vision panels are fixed fire window assemblies in accordance with
8.3.4 or are wired glass not exceeding 9 square feet each in area and
installed in approved frames.
This requirement shall not apply to corridor walls that are smoke
partitions in accordance with 8.4 and that are protected by automatic
sprinklers in accordance with 32.2.3.5 on both sides of the wall and
door. In such instances, there shall be no limitation on the type or size of
glass panels.
32.2.3.6
Doors shall meet all of the following requirements:
1. Doors shall be provided with latches or other mechanisms suitable for
keeping the door closed.
2. No doors shall be arranged to prevent the occupant from closing the
door.
3. Doors shall be self-closing or automatic-closing in accordance with
7.2.1.8 in buildings other than those protected throughout by an
32.2.3.6.4
No louvers or operable transoms or other air passages shall penetrate the
wall, except properly installed heating and utility installations other than
transfer grilles. Transfer grilles shall be prohibited.
32.2.3.6.3
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IF NEW RESIDENTAL BOARD AND CARE OCCUPANCY,


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NOT
N/A REMARKS
PREFIX MET
(New and Existing Facilities)
List in the REMARKS section any LSC Section 32.2.5 and 33.2.5 Building
Services 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.
Equipment using gas or related gas piping complies with NFPA 54, National
Fuel Gas Code, electrical wiring and equipment complies with NPFA 70,
National Electric Code.
32.2.5.1, 33.2.5.1, 9.1.1, 9.1.2
K521 HVAC
Heating, ventilation, and air-conditioning equipment comply with 9.2.1
and 9.2.2, except as otherwise permitted by Chapter 33.
32.2.5.2.1, 33.2.5.2.1
No stove or combustion heater are located to block escape in case of
fire caused by the malfunction of a heater or stove.
Unvented fuel-fired heaters shall not be used in any residential board
and care facility.
32.2.5.2.2, 33.2.5.2.2
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NOT
N/A REMARKS
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List in the REMARKS section any LSC Section 32.7 and 33.7 Operating
Features requirements that are not addressed by the provided K-tags, but
The administration of every resident board and care facility shall have in
effect and available to all supervisory personnel written copies of a plan
for protecting all persons in the event of fire, for keeping persons in
place, for evacuating persons to areas of refuge, and for evacuating
person from the building when necessary. The plan shall include special
staff response, including fire protection procedures needed to ensure the
safety of any resident, and shall be amended or revised whenever any
resident with unusual needs is admitted to the home. All employees shall
be periodically instructed and kept informed with respect to their duties
and responsibilities under the plan. Such instruction shall be reviewed by
the staff not less than every two months. A copy of the plan shall be
readily available at all times within the facility.
All residents participating in the emergency plan shall be trained in the
proper actions to be taken in the event of fire. Training shall include
proper actions to be taken if the primary escape route is blocked. If the
resident is given rehabilitation or habilitation training, training in fire
prevention and the actions to be taken in the event of a fire shall be part
of the training program. Residents shall be trained to assist each other in
case of fire to the extent that their physical and mental abilities permit
them to do so without additional personal risk.
32.7.1, 32.7.2, 33.7.1, 33.7.2
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K712 Fire Drills
1. The facility must hold evacuation drills at least quarterly for each
shift of personnel and under varied conditions to:
a. Ensure that all personnel on all shifts are trained to perform
assigned tasks;
b. Ensure that all personnel on all shifts are familiar with the use
of the facility’s emergency and disaster plans and procedures.
2. The facility must:
a. Actually evacuate clients during at least one drill each year on
each shift;
b. Make special provisions for the evacuation of clients with
physical disabilities;
c. File a report and evaluation on each drill;
d. Investigate all problems with evacuation drills, including
accidents and take corrective action; and
e. During fire drills, clients may be evacuated to a safe area in
facilities certified under the Health Care Occupancies Chapter of
the Life Safety Code.
3. Facilities must meet the requirements of paragraphs (i) (1) and (2) of
this section for any live-in and relief staff that they utilize.
42 CFR 483.470(i)
Smoking regulations shall be adopted by the administration of board
and care occupancies. Where smoking is permitted, noncombustible
safety type ashtrays or receptacles shall be provided in convenient
locations.
32.7.4.1, 32.7.4.2, 33.7.4.1, 33.7.4.2
New draperies, curtains, and other similar loosely hanging furnishings and
decorations in board and care facilities shall be in accordance with
provisions of 10.3.1.
In other than common areas, new draperies, curtains and other similar
loosely hanging furnishings and decorations are not required to comply
with 10.3.1 where building is protected throughout by an approved
automatic sprinkler system installed in accordance with 33.2.3.5 for small
facilities.
32.7.5.1.1, 32.7.5.2, 33.7.5.1.1, 33.7.5.2
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New upholstered furniture within board and care facilities shall be tested
in accordance with the provisions of 10.3.2.1(1) and 10.3.3.
Upholstered furniture belonging to the resident(s) in sleeping rooms shall
not be required to be tested, provided that a smoke alarm is installed in
such rooms. Battery-powered single-station smoke alarms shall be
permitted.
Newly introduced mattresses shall be tested in accordance with the
provisions of 10.3.2.2 and 10.3.4.
Mattresses belonging to the resident(s) in sleeping rooms shall not be
required to be tested, provided that a smoke alarm is installed in such
rooms. Battery-powered single-station smoke alarms shall be permitted.
32.7.5.2.1, 32.7.5.3.2, 33.7.5.2.2, 33.7.5.3.1, 33.7.5.2.1, 33.7.5.2.2,
33.7.5.3.1, 33.7.5.3.2
K761 Staff
Staff shall be on duty in the facility at all times when residents requiring
evacuation assistance are present.
32.7.6, 33.7.6

Form CMS-2786V (10/2016) 105 Page 40

PART VI - FIRE SAFETY SURVEY REPORT


K1 *K4

K6 DATE OF PLAN K3 MULTIPLE CONSTRUCTION A. BUILDING
APPROVAL
TOTAL NUMBER OF BUILDINGS ______ B. WING
C. FLOOR
EXISTING
HEALTH CARE FORM
13 2786R 2012 NEW 1. PROMPT

K8
2. SLOW
3. IMPRACTICAL
AHCO FORM LARGE
4. PROMPT
15 2786U 2012 NEW 5. SLOW
K8
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

K321: K351: K5: e.g. 2.5
A1. A2. A3. A4. A5.

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

Form CMS-2786V (10/2016)

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106
FIRE SAFETY SURVEY REPORT - 2012 LIFE SAFETY CODE 1. (A) PROVIDER NO. 1. (B) MEDICAID I.D. NO.
Intermediate Care Facilities for Individuals with Intellectual Disabilities
LARGE FACILITIES K1 K2
PART I – Instructions for Completing the Form (CMS 2786W)

PART II – Existing Resident Board & Care Occupancies Requirements (NFPA 101, Chapter 33)
PART III – New Residential Board & Care Occupancies Requirements (NFPA 101, Chapter 32)
PART IV – Building Services (New and Existing Facilities)
PART V – Operating Features (New and Existing Facilities)
PART VI – Crucial Data Extract
OPTIONAL – Fire Safety Evaluation System for Board and Care Occupancies (2013 NFPA 101A, Chapter 7)
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 2. (B) ADDRESS OF THE FACILITY (CITY, STREET, A. Fully Sprinklered
STATE, ZIP CODE) (All required areas are sprinklered)
A. BUILDING
B. Partially Sprinklered
B. WING (Not all required areas are sprinklered)
C. FLOOR C. None (No sprinkler system)

K3 K0180
3. SURVEY FOR: 4. DATE OF SURVEY DATE OF PLAN APPROVAL SURVEY UNDER:

MEDICARE MEDICAID 9. 2012 New 2012 Existing
K4 K7
E-Score 5. SURVEY OF CERTIFICATION OF LARGE FACILITY LEVEL OF EVACUATION

EXISTING FACILITIES ONLY DIFFICULTY (check one)
E-Score Level of Evacuation Difficulty
≤ 1.5 Prompt
4. Prompt 5. Slow 6. Impractical
> 1.5 ≤ 5.0 Slow
K8
> 5.0 Impractical
K5
6. BED COMPOSITION E. NUMBER OF BEDS CERTIFIIED FOR MEDICAID
A. TOTAL NO. OF BEDS IN THE FACILITY
7. A. THE FACLITIY MEETS, BASED UPON (CHECK ALL APPROPRIATE BOXES)
1. COMPLIANCE WITH ALL PROVISIONS 2. ACCEPTANCE OF A PLAN OF CORRECTION 4. FSES 5. PERFORMANCE BASED DESIGN
B. THE FACILITY DOES NOT MEET THE STANDARDS
K9
SURVEYOR (SIGNATURE) TITLE OFFICE DATE
SURVEYOR ID
K10
FIRE AUTHORITY OFFICIAL (SIGNATURE) TITLE OFFICE DATE
Form CMS-2786W (10/2016)

107 Page 1
PART I – INSTRUCTIONS FOR COMPLETING THE FORM (CMS-2786W)
(LARGE FACILITIES — 17 BEDS OR MORE)
EXISTING OCCUPANCIES
1. Complete a “Worksheet for Rating Residents” (CMS-2786M) for each resident in the facility.
Note: Completing this worksheet is the ONLY method permitted to determine Level of Evacuation Difficulty.
2. Transfer the calculated E-Score obtained in Worksheet 6.8.10 to the E-SCORE block (Page 1 of this form).
3. Determine the Level of Evacuation Capability, obtained in Worksheet 6.8.11 (i.e., Prompt, Slow or Impractical).
4. Complete a survey using Part II – Existing Residential Board & Care Occupancies of this form for compliance with the NFPA 101,
Chapter 33.
If Level of Evacuation Capability is:
1. PROMPT OR SLOW - Complete Part II PROMPT OR SLOW EVACUATION section ONLY.
2. IMPRACTICAL - Complete both sections, Part II PROMPT OR SLOW and IMPRACTICAL.
6. Complete Part V – Operating Features section.
NEW OCCUPANCIES
1. New Residential Board & Care Occupancies of this form for compliance with the NFPA 101, Chapter 32.
2. Complete the Part IV – Building Services section
OPTIONAL FIRE SAFETY EVALUATION SYSTEM

1. Reference 2013 edition NFPA 101A – Fire Safety Evaluation System for Board and Care Occupancies (Chapter 7)
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MET N/A REMARKS
PREFIX (PROMPT OR SLOW EVACUATION) MET
GENERAL
• Requirements of Chapter 33.
• Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6.
33.1.1.3, 4.6.7, 43.1.2.1
33.1.1.3, 4.6.7, 43.1.2.2 (43.7)
Additions
building, the common wall is a fire barrier having at least a two hour fire
33.1.1.3, 4.6.7, 43.1.2.3(43.8)
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MET N/A REMARKS
GENERAL
Stories are counted from primary level of exit discharge and end with the
highest story normally used by residents.
One and Two Story
Any construction type of one-hour or greater fire rating, or
Type IV (2HH), or
Interiors walls fully sheathed providing a minimum 15 minute FRR, or
With automatic sprinkler system throughout, in accordance with Section 9.7
(33.3.3.5).
Type I, Type II (222), and Type II (111) roofing systems with combustible
supports, decking, or roofing comply with the requirements of Table 33.3.1.3 d
and e.
One story prompt evacuation capability facilities having 30 or fewer
residents with egress directly to the exterior at the finished ground level are
permitted to be of any construction type.
Three to Six Stories
Type I, II or Ill construction of one-hour or greater fire resistance rating, or
Type II (000), Type III (200), and Type V (111) construction with interior
walls minimum 15 minute FRR and with automatic sprinkler system in
accordance with 33.3.3.5, or
Type IV construction with automatic sprinkler system throughout in
Three or four story facilities of Type V (000), sheathed and with automatic
sprinkler system throughout, in accordance with 33.3.3.5.
More than Six Stories
Type I or II (222) construction, or
Type II (111), Type III (211), and Type IV (2HH) with automatic sprinkler
system throughout in accordance with 33.3.3.5.
33.3.1.3 and Table 33.3.1.3
Occupant Load
The occupant load, in number of persons for whom means of egress and
other provisions are required, shall be determined on the basis of the
occupant load factors or Table 7.3.1.2 that are characteristic of the use of the
space or shall be determined as the maximum probable population of the
space under consideration, whichever is greater.
33.3.1.4
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MEANS OF ESCAPE
List in the REMARKS section any LSC Section 33.2 Means of Escape
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.
Means of egress from resident rooms and resident dwelling units to the
outside of the building 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.
Means of escape within a resident room or resident dwelling unit complies
with 24.2 for one- and two-family dwellings.
33.3.2.1
K222 Egress Doors
Doors in means of egress shall be as follows:
1. Doors complying with 7.2.1 shall be permitted.
2. Doors within individual rooms and suites of rooms shall be permitted to be
swinging or sliding.
3. No door in any means of egress, other than those complying with (4) or
(5), shall be locked against egress when the building is occupied.
4. Delayed-egress locks in accordance with 7.2.1.6.1 shall be permitted.
5. Access-controlled egress doors in accordance with 7.2.1.6.2 shall be
permitted.
6. Revolving doors complying with 7.2.1.10 shall be permitted.
Corridor doors must be provided with positive latching hardware and roller
latches are not permitted. Lockups are not permitted by regulation.
33.3.2.2.2, 33.3.2.11.2, 42 CFR 483.470
Stairs and smokeproof enclosures used as exits are in accordance with 7.2.2
and 7.2.3.
33.3.2.2.3, 33.3.2.2.4
Horizontal exits complying with 7.2.4 are permitted.
33.3.2.2.5
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Ramps, exit passageways, fire escape ladders, alternating tread devices, and
areas of refuge are in accordance with the provisions 7.25 through 7.2.12.
33.3.2.2.6 through 33.3.2.2.10
Capacity of means of egress shall be in accordance with 7.3.
Street floor exits shall be sufficient for the occupant load of the street floor
plus the required capacity of stairs and ramps discharging onto the street
floor.
33.3.2.3.1, 33.3.2.3.2
K232 Corridor Width
Corridor width serving an occupant load of 50 or more shall be sufficient for
the occupant load served but not less than 44 inches.
The width of corridors serving an occupant load of less than 50 shall not be
less than 36 inches.
33.3.2.3.3, 33.3.2.3.4
K241 Number of Exits – Story
Means of egress shall comply with the following:
1. The number of means of egress shall be in accordance with 7.4.1.1 and
7.4.1.3 through 7.4.1.6.
2. Not less than two separate exits shall be provided on every story.
3. Not less than two separate exits shall be accessible from every part of
every story.
Exit access, as required in number 3 above, shall be permitted to include a
single exit access path for the distances permitted as common paths of travel
by 33.3.2.5.2 and 33.3.2.5.3.
33.3.2.4.1, 33.3.2.4.2
K251 Dead-End Corridors and Common Paths of Travel
Dead-end corridors shall not exceed 50 feet
Common paths of travel shall not exceed 110 feet in buildings not protected
by an automatic sprinkler in accordance with 33.3.3.5. In buildings protected
by an automatic sprinkler, common paths of travel shall not exceed 160 feet.
33.3.2.5.2, 33.3.2.5.3, 33.3.2.5.4
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Travel distance from a door within a room, suite, or living unit to a corridor
door shall not exceed 75 feet in buildings without an approved automatic
sprinkler system and shall not exceed 125 feet in buildings protected
throughout by an approved automatic sprinkler system in accordance with
33.3.3.5.
Travel distance from the corridor door of any room to the nearest exit shall not
exceed 100 feet.
Travel distance to exits shall not exceed 200 feet for exterior ways of exit
access arranged in accordance with 7.5.3.
Travel distance to exits shall not exceed 200 feet if the exit access and any
portion of the building that is tributary to the exit access are protected
throughout by an approved automatic sprinkler system. In addition, the portion
of the building in which 200 feet travel distance is permitted, shall be
separated from the remainder of the building by construction having a
minimum 1-hour FRR for a building three or few stories in height, and a
minimum 2-hour FRR for buildings four or more stories in height.
33.3.2.6.1, 33.3.2.6.2, 33.3.2.6.3, 33.3.2.6.3.1, 33.3.2.6.3.2, 33.3.2.6.3.3
Exit discharge shall comply with Section 7.7.
33.3.2.7
Means of egress shall be illuminated in accordance with Section 7.8
33.3.2.8
Emergency lighting in accordance with 7.9 shall be provided in facilities with
prompt or slow evacuation capability having more than 25 rooms, unless each
room has a direct exit to the outside of the building at finished ground level.
33.3.2.9
K293 Exit Signage
Means of egress shall be marked in accordance with Section 7.10.
33.3.2.10
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PROTECTION
This information, along with the applicable Life Safety Code or NFPA standard
citation, should be included on Form CMS-2567.
Vertical openings shall be enclosed or protected in accordance with 8.6
unless:
1. Unprotected vertical openings not part of required egress shall be
permitted by the authority having jurisdiction where such openings do not
endanger required means of egress. This shall apply only in buildings
protected throughout by an approved automatic sprinkler system in
accordance with 33.3.3.5, and exits and required ways of travel thereto
are adequately safeguarded against fire and smoke within the building, or
in which every individual room has direct access to an exterior exit without
passing through a public corridor.
2. In buildings not more than two stories in height, unprotected vertical
openings shall be permitted by the authority having jurisdiction if the
building is protected throughout by an approved automatic sprinkler
system in accordance with 33.3.3.5.
No floor below the level of exit discharge used only for storage, heating
equipment, or purposes other than residential occupancy shall have
unprotected openings to floors used for residential occupancy.
33.3.3.1.1.1, 33.3.3.1.1.2, 33.3.3.1.1.3, 33.3.3.1.3
Rooms containing high-pressure boilers, refrigerating machinery,
transformers, or other service equipment subject to possible explosion shall
not be located under or adjacent to exits. All such rooms shall be effectively
separated from other parts of the building as specified in section 8.7.
Hazardous areas shall be separated with construction of a minimum of 1-hour
fire resistance with openings protected with self-closing fire doors or have an
automatic extinguishment system and smoke partition in accordance with 8.4.
Hazardous areas shall include but not be limited to the following: boiler or
heating rooms, laundries, repair shop, spaces storing combustibles in
quantities deemed hazardous.
33.3.3.2.1, 33.3.3.2.2
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Interior wall and ceiling finish shall be Class A or Class B in accordance with
Section 10.2.
33.3.3.3.2
Interior floor finish other than approved, existing floor coverings, shall be
Class I or Class II in corridors or exits.
33.3.3.3.3
A fire alarm system shall be installed, maintained, and tested in accordance
with section 9.6, unless the following conditions are met:
1. The evacuation capability is prompt or slow.
2. Each bedroom has an exterior exit access in accordance with 7.5.3.
3. The building is not greater than three stories.
33.3.3.4.1
The required fire alarm system shall be initiated by each of the following
means:
1. Manual means in accordance with 9.6.2 unless there are other effective
means (such as a complete automatic sprinkler or detection system) for
notification of fire as required.
2. Manual fire alarm box located at a convenient central control point under
continuous supervision of responsible employees.
3. Automatic sprinkler system, other than that not required by another
section of this code.
4. Required detection system, other than sleeping room smoke alarms, shall
not be required to initiate the building fire alarm system.
33.3.3.4.2
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Occupant notification shall be provided automatically, without delay, by
internal audible alarm in accordance with 9.6.3.
Where the existing fire alarm system does not provide for automatic
emergency forces notification in accordance with 9.6.4, provisions shall be
made for the immediate notification of the public fire department by either
telephone or other means. Where there is no public fire department, this
notification shall be made to the private fire brigade.
Where a new fire alarm system is installed, or the existing system is replaced,
emergency forces notification shall be provided in accordance with 9.6.4.
33.3.3.4.4, 33.3.3.4.6
K345 Fire Alarm System - Testing and Maintenance
program complying with the requirements of NFPA70, National Electric Code,
and NFPA 74, National Fire Alarm and Signaling Code. Records of the
33.3.3.4.1, 9.6.1.3

33.3.3.4.1, 9.6.1.8
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K347 Smoke Alarms and Smoke Detection Systems

Each sleeping room shall be provided with an approved smoke alarm in
accordance with 9.6.2.10 that is powered from the building electrical system.
Existing occupancies with battery-powered smoke alarms, rather than building
electrical service-powered smoke alarms, shall be accepted where the facility
has demonstrated that testing, maintenance, and battery replacement
programs ensure the reliability of power to the smoke alarms.
Sleeping room smoke alarms shall be required in facilities having an existing
corridor smoke detection system in accordance with Section 9.6 that is
connected to the building fire alarm system.
All living areas as defined in 3.3.21.5 and corridors shall be provided with
smoke detectors in accordance NFPA 72, National Fire Alarm and Signaling
Code, that are arranged to initiate an alarm that is audible in all sleeping
areas except as modified by one of the following:
1. Detectors shall not be required in living areas of buildings having prompt
or slow evacuation capability protected throughout by an approved
automatic sprinkler system installed in accordance with 33.3.3.5.
2. Unenclosed corridors, passageways, balconies, colonnades, or other
arrangements with one or more sides along the long dimension fully or
extensively open to the exterior at all times.
33.3.3.4.7, 33.3.3.4.8
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Where an automatic sprinkler system is installed for total or partial building
coverage, the system shall be in accordance with Section 9.7, except as
modified by the following:
1. In buildings not more than four stories above grade plane, a sprinkler
system complying with NFPA 13R, Standard for the Installation of
Sprinkler Systems in Residential Occupancies up to and Including Four
Stories in Height, shall be permitted.
2. In facilities having prompt or slow evacuation capabilities, automatic
sprinklers shall not be required in small clothes closets where the area
does not exceed 24 square feet (2.2 meters squared) and in bathrooms
not exceeding 55 square feet provided that such spaces are finished with
noncombustible or limited-combustible material.
3. Initiation of the fire alarm system shall not be required for existing
Where a sprinkler system is installed, attics used for living purposes, storage,
or fuel-fired equipment shall be covered, by July 5, 2019. Attics not used for
these purposes shall meet one of the following:
according to 9.6, by July 5, 2019.
2. Protected by automatic sprinkler system according to 9.7, by July 5, 2019.
33.3.3.5.1, 33.3.3.5.1.1, 33.3.3.5.1.2, 33.3.3.5.3, 33.3.3.5.4
K352 Sprinkler System - Supervisory Signals
Automatic sprinkler system shall be supervised in accordance with 9.7;
waterflow alarms are not required to be transmitted offsite.
33.3.3.5.5
K353 Sprinkler System - Maintenance and Testing
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 was last checked. _______________________
b) Who provided system test. __________________________________
c) Water system supply source. ________________________________
33.3.3.5.1, 9.7.5, 9.7.7, 9.7.8, NFPA 25
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K354 Sprinkler System - Out of Service

Where a required automatic sprinkler system is out of service for more than
10 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.
33.2.3.5.3, 9.7.6.1, 15.5.2 (NFPA 25)
Portable fire extinguishers shall be provided near hazardous areas in
33.3.3.5.7
Access shall be provided from every resident use area to not less than one
means of egress that is separated from all other rooms or spaces by walls
complying with 33.3.3.6.3 through 33.3.3.6.6.3 as modified by the following:
1. Rooms or spaces, other than sleeping rooms, protected throughout by an
2. Prompt evacuation capability facilities in buildings not over two stories in
height, where not less than one required means of egress from each
sleeping room provides a path of travel to the outside without traversing
any corridor or other spaces exposed to unprotected vertical openings,
living areas, and kitchens.
3. Rooms or spaces, other than sleeping rooms, provided with a smoke
detection and alarm system connected to activate the building evacuation
alarm. Furnishings, finishes, and furniture, in combination with all other
combustibles within the spaces, shall be of minimum quantity and
arranged so that a fully developed fire is unlikely to occur.
33.3.3.6.1, 33.3.3.6.1.1, 33.3.3.6.1.2, 33.3.3.6.1.3
Sleeping rooms shall be separated from corridors, living areas, and kitchens
by walls complying with 33.3.3.6.3 through 33.3.3.6.6.3.
Walls required shall have a fire resistance rating of not less than 1/2 hour
unless the following conditions apply:
1. In buildings protected throughout by an approved automatic sprinkler
system in accordance with 33.3.3.5, walls shall be smoke partitions in
accordance with 8.4. The provisions of 8.4.3.5 shall not apply.
2. In buildings not more than two stories in height that are classified as
prompt evacuation capability and that house not more than 30 residents,
walls shall be smoke partitions in accordance with 8.4. The provisions of
8.2.4.3.5 shall not apply.
33.3.3.6.2, 33.3.6.3.1, 33.3.6.3.2, 33.3.3.6.3.3
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Doors shall have a fire protection rating of not less than 20 minutes, unless
the following condition exist:
1. Solid-bonded wood core doors of not less than 1-3/4 inches (4.4cm)
thickness shall be permitted to continue to be used.
system in accordance with 33.3.3.5, doors that are nonrated shall be
permitted to continue to be used.
3. Where automatic sprinkler protection is provided in the corridor in
accordance with 31.3.5.8, doors shall not be required to have a fire
protection rating but shall be in accordance with 8.4.3. The provisions of
8.4.3.5 shall not apply. Doors shall be equipped with latches for keeping
the doors tightly closed.
Walls and doors required by 33.3.3.6.1 and 33.3.3.6.2 shall be constructed as
smoke partitions in accordance with 8.4. The provisions of 8.4.3.5 shall not
apply.
Doors shall be self-closing or automatic-closing in accordance with 7.2.1.8.
Doors in walls separating sleeping rooms from corridors shall be automatic-
closing in accordance with 7.2.1.8.2 unless the following conditions exist:
1. Doors to sleeping rooms that have occupant- control locks such that
access is normally restricted to the occupants or staff personnel shall be
permitted to be self-closing.
system installed in accordance with 33.3.3.5, doors, other than doors to
hazardous areas, vertical openings, and exit enclosures, shall not be
required to be self-closing or automatic-closing.
33.3.3.6.4.1, 33.3.3.6.4.2, 33.3.3.6.4.3, 33.3.3.6.4.4, 33.3.3.6.5, 33.3.3.6.6.1,
33.3.6.6.2, 33.3.3.6.6.3
K364 Corridor - Openings
No louvers, transfer grills, operable transoms, or other air passages shall
penetrate such walls or doors, except properly installed heating and utility
installations.
33.3.3.6.5(3)
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Every sleeping room floor shall be divided into not less than two smoke
compartments of approximately the same size, unless one of the following
conditions exists:
1. Buildings having prompt or slow evacuation capability protected
throughout by an approved automatic sprinkler system installed in
2. Buildings having prompt or slow evacuation capability where each
sleeping room is provided with exterior ways of exit access arranged in
accordance with 7.5.3.
3. Buildings having prompt or slow evacuation capability where the
aggregate corridor length on each floor is not more than 150 feet.
33.3.3.7.1, 33.3.3.7.4 through 33.3.3.7.6
K372 Subdivision of Building Spaces- Smoke Barrier Construction
Required smoke barriers in accordance with 8.5.
Smoke partitions in accordance with Section 8.4 shall be permitted on stories
used for sleeping by not more than 30 residents. Smoke dampers shall not be
required. Additional smoke barriers shall be provided such that the travel
distance from a sleeping room corridor to a smoke barrier does not exceed
150 feet.
33.3.3.7.1, 33.3.3.7.2, 33.3.3.7.3, 33.3.3.7.8
K374 Subdivision of Building Spaces- Smoke Barrier Doors
Doors are in accordance with 8.5. Positive latching hardware shall not be
required on smoke barrier doors.
33.3.7.1, 33.3.3.7.7
K421 High-rise Buildings
All high-rise buildings shall be protected throughout by an approved,
supervised automatic sprinkler system in accordance with 33.3.3.5. Such
systems shall initiate the fire alarm system in accordance with 9.6.
33.3.3.5.3
IF THE LEVEL OF EVACUATION DIFFICULTY IS PROMPT OR SLOW,

STOP HERE & CONTINUE TO PART IV and PART V.
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MEANS OF ESCAPE
Emergency Lighting
Emergency lighting in accordance with 7.9 shall be provided in all impractical
K299
evacuation capability facilities.
33.3.2.9
PROTECTION
Hazardous areas shall be separated from other parts of the building by smoke
partitions in accordance with 8.4.
33.3.3.2.3
All facilities having impractical evacuation capability shall be protected
throughout by and approved, supervised automatic sprinkler system in
accordance with 9.7.1.1(1).
33.3.3.5.2
IF THE LEVEL OF EVACUATION DIFFICULTY IS IMPRACTICAL,
(ENSURE PROMPT, SLOW AND IMPRACTICAL SECTIONS ARE COMPLETE)
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PREFIX MET
GENERAL
• Requirements of Chapter 33.
• Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6.
33.1.1.3, 4.6.7, 43.1.2.1
33.1.1.3, 4.6.7, 43.1.2.2 (43.7)
Additions
32.1.1.3, 4.6.7, 43.1.2.3(43.8)
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Minimal Construction Requirements: Stories are counted from primary level of
exit discharge and end with the highest story normally used by residents.
One and Two Story
Type I, Type II, Type III, and Type V construction types of 1 hour or
greater FRR or Type IV (2HH) is permitted.
Type III (200) and Type V (000) is limited to 1 story only.
Three to Six Stories
Type I or Type II (222) construction are permitted
Type II (111) constructed limited to 3 stories
Four to Twelve Stories
Type I or II (222) construction are permitted
More Than Twelve Stores
Limited to Type I construction
32.3.1.3 and Table 32.3.1.3
Occupant Load
The occupant load, in number of persons for who means of egress and other
provisions are required, shall be determined on the basis of the occupant load
factors or Table 7.3.1.2 that are characteristic of the use of the space or shall
be determined as the maximum probable population of the space under
consideration, whichever is greater.
32.3.1.4
MEANS OF ESCAPE
List in the REMARKS section any LSC Section 32.2 Means of Escape
Means of egress from resident rooms and resident dwelling units to the
outside of the building 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.
Means of escape within a resident room or resident dwelling unit complies
with 24.2 for one- and two-family dwellings.
33.3.2.1
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K222 Egress Doors
Doors in means of egress shall be as follows:
1. Doors complying with 7.2.1 shall be permitted.
2. Doors within individual rooms and suites of rooms shall be permitted to
be swinging or sliding.
3. No door, other than those meeting the requirements of items 4. and 5.
below, shall be equipped with a lock or latch that requires the use of a
tool or key form the egress side.
4. Delayed-egress locks in accordance with 7.2.1.6.1 shall be permitted.
5. Access-controlled egress doors in accordance with 7.2.1.6.2 shall be
permitted.
Corridor doors must be provided with positive latching hardware and roller
latches are not permitted.
Lockups are not permitted by regulation.
32.3.2.2.2, 32.3.2.11.2, 42 CFR 483.470
Stairs and smokeproof enclosures used as exits are in accordance with 7.2.2
and 7.2.3.
32.3.2.2.3, 32.3.2.2.4
Horizontal exits complying with 7.2.4 are permitted.
32.3.2.2.6
Ramps, exit passageways, fire escape ladders, alternating tread devices, and
areas of refuge are in accordance with the provisions 7.25 through 7.2.12.
33.3.2.2.6 through 33.3.2.2.11
Capacity of means of egress shall be in accordance with 7.3.
Street floor exits shall be sufficient for the occupant load of the street floor
plus the required capacity of stairs and ramps discharging onto the street
floor.
32.3.2.3.1, 32.3.2.3.2
K232 Corridor Width
The width of corridors are sufficient for the occupant load served but is not
less than 60 inches.
32.3.2.3.3
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K241 Number of Exits – Story
Means of egress shall comply with the following:
1. The number of means of egress shall be in accordance with 7.4.
2. Not less than 2 separate exits shall be provided on every story.
3. Not less than 2 separate exits shall be accessible from every part of
every story.
Exit access, as required in number 3 above, shall be permitted to include a
single exit access path for the distances permitted as common paths of travel
by 32.3.2.5.2.
32.3.2.4.1, 32.3.2.4.2
K251 Dead-End Corridors and Common Paths of Travel
Dead-end corridors shall not exceed 30 feet.
Common paths of travel shall not exceed 75 feet.
32.3.2.5.2, 32.3.2.5.4
Travel distance from any point in a room to the nearest exit, measured in
accordance with Section 7.6, shall not exceed 250 feet.
32.3.2.6
Exit discharge shall comply with Section 7.7.
32.3.2.7
Means of egress shall be illuminated in accordance with Section 7.8.
32.3.2.8
Emergency lighting in accordance with 7.9 shall be provided, unless each
sleeping room has a direct exit to the outside at the finished ground level.
32.3.2.9
K293 Exit Signage
Means of egress shall be marked in accordance with Section 7.10.
32.32.10
PROTECTION
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Vertical openings shall be enclosed or protected in accordance with 8.6
unless unprotected vertical openings are in accordance with 8.6.9.1.
No floor below the level of exit discharge used only for storage, heating
equipment, or purposes other than residential occupancy shall have
unprotected openings to floors used for residential occupancy.
32.3.3.1.1, 32.3.3.1.2, 32.3.3.1.3
K321 Hazardous Areas – Enclosures
Hazardous areas shall be protected in accordance with 8.7. The following
areas shall be protected as indicated:
1. Boiler and fuel-fired heater rooms: 1 hour FRR separation
2. Central / Bulk laundries larger than 100 square feet: 1 hour FRR
separation
3. Paint shops employing hazardous substances and materials in quantities
less than those classified as a severe hazardous: 1 hour FRR separation
4. Physical plant maintenance shops: 1 hour FRR separation
5. Soiled linen rooms: 1 hour FRR separation
6. Storage rooms larger than 50 square feet but not exceeding 100 square
feet storing combustible materials: smoke patrician
7. Storage rooms larger 100 square feet storing combustible materials: 1
hour FRR separation
8. Trash collection rooms: 1 hour FRR separation
32.3.3.2.1, 32.3.3.2.2
Cooking facilities, other than those within individual residential units, shall be
protected in accordance with 9.2.3.
32.3.3.8
Interior wall and ceiling finish materials complying with 10.2 shall be permitted
as follows:
1. Exit enclosures - Class A
2. Lobbies and corridors - Class A or Class B
3. Rooms and enclosed spaces – Class A or Class B
32.3.3.3.2
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PREFIX MET
Interior floor finish shall comply with 10.2.
Interior floor finish in exit enclosures and exit access corridors and spaces not
separated from them by walls complying with 32.2.3.6 shall not be less than
Class II.
Interior floor finish shall comply with 10.2.7.1 or 10.2.7.2, as applicable.
32.3.3.3.3.1, 32.3.3.3.3.2, 32.3.3.3.3.3
A fire alarm system shall be installed, maintained, and tested in accordance
with section 9.6.
32.3.3.4.1
The required fire alarm system shall be initiated by each of the following
means:
1. Manual means in accordance with 9.6.2.
2. Manual fire alarm box located at a convenient central control point under
continuance supervision of responsible employees.
3. Required automatic sprinkler system.
4. Required detection system.
32.3.3.4.2
Occupant notification shall be provided automatically, without delay, by
internal audible alarm in accordance with 9.6.3.
High-rise buildings shall be provided with an approved emergency
voice/alarm system in accordance with 11.8.
Emergency forces notification shall meet the following requirements:
1. Fire department notification in accordance with 9.6.4.
2. Smoke detection devices shall initiate a positive alarm sequence in
accordance with 9.6.3.4 for not more than 120 seconds.
An annunciator panel, connected to the fire alarm system, shall be provided
at a location readily accessible from the primary point of entry for emergency
response personnel.
32.3.3.4.3, 32.3.3.4.4, 32.3.3.4.5, 32.3.3.4.6
128
Form CMS-2786W (10/2016) Page 22
PREFIX MET
K345 Fire Alarm System - Testing and Maintenance
program complying with the requirements of NFPA70, National Electric Code,
and NFPA 74, National Fire Alarm and Signaling Code. Records of the
32.3.3.4.1, 9.6.1.3
32.2.3.4.1, 9.6.1.3, 9.6.1.5, 9.6.1.6
K347 Smoke Alarms and Smoke Detection Systems
Approved smoke alarms shall be installed in accordance with 9.6.2.10 inside
every sleeping room, outside every sleeping area in the immediate vicinity of
the bedrooms and on all levels within a resident unit.
Corridor and spaces open to the corridors shall be provided with smoke
detectors complying with NFPA 72, and are arranged to initiate and alarm that
is audible in all sleeping areas.
Smoke detection systems shall not be required in unenclosed corridors,
passageways, balconies, colonnades, or other arrangements with one or
more sides along the long dimension fully or extensively open to the exterior
at all times.
32.3.3.4.7, 32.3.3.4.8.1, 32.3.3.4.8.3
All buildings shall be protected throughout by an approved automatic sprinkler
system in accordance with Section 9.7.1.1(1) and provided with Quick-
response or residential sprinklers throughout.
32.3.3.5.1
K352 Sprinkler System - Supervisory Signals
Automatic sprinkler system shall be provided with electrical supervision in
accordance with 9.7.2.
32.3.3.5.5
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PREFIX MET
K353 Sprinkler System - Maintenance and Testing
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 was last checked. __________________________
b) Who provided system test. _____________________________________
c) Water system supply source. ___________________________________
33.3.3.5.1, 9.7.5, 9.7.7, 9.7.8, NFPA 25
K354 Sprinkler System - Out of Service

Where a required automatic sprinkler system is out of service for more than
10 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.
33.2.3.5.3, 9.7.6.1, 15.5.2 (NFPA 25)
Portable fire extinguishers shall be in accordance with 9.7.4.1.
32.3.3.5.7
Access shall be provided from every resident use area to not less than one
means of egress that is separated from all sleeping rooms by walls complying
with 32.3.3.6.3 through 32.3.3.6.6.
Sleeping rooms shall be separated from corridors, living areas, and kitchens
by walls complying with 32.3.3.6.3 through 32.3.3.6.6.
Walls required by 32.3.3.6.1 or 32.3.3.6.2 shall have a fire resistance rating of
not less than 1/2 hour.
32.3.3.6.1, 32.3.3.6.2, 32.3.3.6.3
Doors protecting corridors shall not be required to have a fire protection
rating, but shall be constructed to resist the passage of smoke.
Door-closing devices shall not be required on doors in corridor wall openings,
other than those serving exit enclosures, smoke barriers, enclosures of
vertical openings and hazardous areas.
32.3.3.6.4, 32.3.3.6.5, 32.3.3.6.6
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PREFIX MET
K364 Corridor - Openings
No louvers, transfer grills, operable transoms, or other air passages other
than properly installed heating and utility installations, shall penetrate the
walls or doors specified 32.3.3.6.
2.3.3.6.6
Every story shall be divided into not less than two smoke compartments, not
exceeding 22,500 sq. feet with a travel distance not exceeding 200 feet from
any point to a smoke barrier door. Smoke barriers are not required:
1. On stories that do not contain a board and care occupancy located above
the board and care occupancy.
2. In areas that do not containing a board and care occupancy which is
separated by a fire barrier in accordance with 8.3.
3. On stories that do not contain a board and care occupancy and that are
more than one story below the board and care occupancy.
4. In open parking structures protected by an approved sprinkler system in
32.3.3.7.1 through 32.3.7.7
K372 Subdivision of Building Spaces- Smoke Barrier Construction
Smoke barriers are constructed in accordance with 8.5 and have a 1-hour
FRR. In atriums smoke barriers shall be permitted to terminate at an atrium
wall constructed in accordance with 8.6.7(1) (c), in which case not less than
two separate smoke compartments shall be provided on each floor. Dampers
are not required in duct penetrations in fully ducted heating, ventilating and
air- conditioning systems.
32.3.3.7.8, 32.3.3.7.9, 32.3.3.7.10
K373 Subdivision of Building Spaces- Accumulation Space
Not less than 15 net square feet per resident shall be provided within the
aggregate area of corridors, lounge, or dining areas and other low hazard
areas on each side of the smoke barrier. On stories not housing residents, not
less than 6 net square feet per occupant shall be provided on each side of the
smoke barrier for the total number of occupants in adjoining compartments.
32.3.3.7.11, 32.3.3.7.12
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PREFIX MET
K374 Subdivision of Building Spaces- Smoke Barrier Doors
Doors are substantial such as 1-3/4 inches thick, solid-bonded wood-core or
of construction that resists fire for a minimum of 20-minutes.
Nonrated protective plates of unlimited height are permitted.
Cross-corridor openings are protected by a pair of swinging doors or a
horizontal-sliding for complying with 7.2.1.14.
Swinging doors are arranged so that each door swings in a direction opposite
from the other.
Doors comply with 8.5.4 and are self-closing or automatic closing in
Rabbets, bevels, or astragals are at the meeting edges, and stops at the head
and sides of door frames in smoke barriers. Positive latching hardware shall
not be required.
Center mullions are prohibited.
32.3.3.7.13, 32.3.3.7.14, 32.3.3.7.15, 32.3.3.7.16, 32.3.3.7.17, 32.3.3.7.19,
32.3.3.7.20
Vision panels consisting of fire-rated glazing or wired glass panels in
approved frames shall be provided in each cross-corridor swinging door and
in each cross-corridor horizontal-sliding door in a smoke barrier.
32.3.3.7.18
K421 High-rise Buildings

High-rise buildings are protected throughout by an approved, supervised
automatic sprinkler system in accordance with Section 9.7. Class I standpipe
systems shall be installed throughout all high-rise buildings.
32.3.3.9.2, 32.3.4.1, 11.8
IF NEW RESIDENT BOARD & CARE OCCUPANCIES,
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Form CMS-2786W (10/2016) Page 26
ID PART IV – BUILDING SERVICES MET NOT N/A REMARKS
PREFIX (New and Existing Facilities) MET
List in the REMARKS section any LSC Section 33.2.5 or 32.2.5 Building
Services that are not addressed by the provided K-tags, but are deficient.
Utilities shall comply with the provisions of 9.1.
33.3.6.1, 32.3.6.1
K521 HVAC
Heating, ventilating, and air conditioning equipment shall comply with the
provisions of 9.2 and shall be installed in accordance with manufacturer
specifications.
33.3.6.2.1, 32.3.6.2.1
K522 HVAC - Any Heating Device
No stove or combustion heater shall be located to block escape in case of fire
caused by the malfunction of the stove or heater. Unvented fuel-fired heaters
shall not be used in any board and care occupancy.
33.3.6.2.1 through 33.3.6.2.3, 32.3.6.2.1, through 32.3.6.2.3
K531 Elevators
2012 EXISTING
Elevators shall comply with the provisions of 9.4.
33.3.6.3
Elevators
2012 NEW
Elevators shall comply with the provisions of 9.4.
In high-rise buildings, one elevator shall be provided with a protected power
supply and shall be available for use by the fire department in case of
emergency.
32.3.6.3.1, 32.3.6.3.2*
Dumbwaiters, and vertical conveyors shall comply with the provisions of 9.4.
33.3.6.3
Rubbish chutes, incinerators, and laundry chutes shall comply with the
provisions of 9.5.
33.3.6.4, 32.3.6.4
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Form CMS-2786W (10/2016) Page 27
ID PART V – OPERATING FEATURES MET NOT N/A REMARKS

List in the REMARKS section any LSC Section 33.7 or 32.7 Operating
Features requirements that are not addressed by the provided K-tags, but are
The administration of every resident board and care facility shall have in
effect and available to all supervisory personnel written copies of a plan for
protecting all persons in the event of fire, for keeping persons in place, for
evacuating persons to areas of refuge, and for evacuating person from the
building when necessary. The plan shall include special staff response,
including fire protection procedures needed to ensure the safety of any
resident, and shall be amended or revised whenever any resident with
unusual needs is admitted to the home. All employees shall be periodically
instructed and kept informed with respect to their duties and responsibilities
under the plan. Such instruction shall be reviewed by the staff not less than
every 2 months.
A copy of the plan shall be readily available at all times within the facility.
All residents participating in the emergency plan shall be trained in the proper
actions to be taken in the event of fire. Training shall include proper actions to
be taken if the primary escape route is blocked. If the resident is given
rehabilitation or habilitation training, training in fire prevention and the actions
to be taken in the event of a fire shall be part of the training program.
Residents shall be trained to assist each other in case of fire to the extent that
their physical and mental abilities permit them to do so without additional
personal risk.
32.7.1, 32.7.2, 33.7.1, 33.7.2
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Form CMS-2786W (10/2016) Page 28
K712 Fire Drills
1. The facility must hold evacuation drills at least quarterly for each shift of
personnel and under varied conditions to
a. Ensure that all personnel on all shifts are trained to perform
assigned tasks;
b. Ensure that all personnel on all shifts are familiar with the use of
the facility’s emergency and disaster plans and procedures.
2. The facility must
a. Actually evacuate clients during at least one drill each year on
each shift;
b. Make special provisions for the evacuation of clients with physical
disabilities;
c. File a report and evaluation on each drill;
d. Investigate all problems with evacuation drills, including accidents
and take corrective action; and
e. During fire drills, clients may be evacuated to a safe area in
facilities certified under the Health Care Occupancies Chapter of
the Life Safety Code.
3. Facilities must meet the requirements of paragraphs (i) (1) and (2) of this
section for any live-in and relief staff that they utilize.
42 CFR 483.470(i)
Smoking regulations shall be adopted by the administration of board and care
occupancies. Where smoking is permitted, noncombustible safety type
ashtrays or receptacles shall be provided in convenient locations.
32.7.4.1, 32.7.4.2, 33.7.4.1, 33.7.4.2
New draperies, curtains, and other similar loosely hanging furnishings and
decorations in board and care facilities shall be in accordance with provisions
of 10.3.1.
In other than common areas, new draperies, curtains and other similar loosely
hanging furnishings and decorations are not required to comply with 10.3.1
where building is protected throughout by an approved automatic sprinkler
system installed in accordance with 33.2.3.5 for small facilities.
32.7.5.1.1, 32.7.5.2, 33.7.5.1.1, 33.7.5.2
135
Form CMS-2786W (10/2016) Page 29
New upholstered furniture within board and care facilities shall be tested in
accordance with the provisions of 10.3.2.1(1) and 10.3.3.
Upholstered furniture belonging to the resident (s) in sleeping rooms shall not
be required to be tested, provided that a smoke alarm is installed in such
rooms. Battery-powered single-station smoke alarms shall be permitted.
Newly introduced mattresses shall be tested in accordance with the
provisions of 10.3.2.2 and 10.3.4.
Mattresses belonging to the resident(s) in sleeping rooms shall not be
required to be tested, provided that a smoke alarm is installed in such rooms.
Battery-powered single-station smoke alarms shall be permitted.
32.7.5.2.1, 33.7.5.2.2, 33.7.5.3.1, 32.7.5.3.2, 33.7.5.2.1, 33.7.5.2.2,
33.7.5.3.1, 33.7.5.3.2
K761 Staff
Staff shall be on duty in the facility at all times when residents requiring
evacuation assistance are present.
32.7.6, 33.7.6
136
Form CMS-2786W (10/2016) Page 30
PART VI - FIRE SAFETY SURVEY REPORT
K1 *K4
K6 DATE OF PLAN K3 MULTIPLE CONSTRUCTION A. BUILDING

APPROVAL
TOTAL NUMBER OF BUILDINGS ______ B. WING
C. FLOOR
EXISTING
HEALTH CARE FORM
13 2786R 2012 NEW 1. PROMPT

K8
2. SLOW
3. IMPRACTICAL
AHCO FORM LARGE
4. PROMPT
15 2786U 2012 NEW 5. SLOW
K8
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

K321: K351: K5: e.g. 2.5

A1. A2. A3. A4. A5.
A. B. C.
B. FULLY SPRINKLERED PARTIALLY SPRINKLERED NONE
(All required areas are (Not all required areas are (No sprinkler system)
*MANDATORY
Form CMS-2786W (10/2016) Page 31

137
DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop C2-21-16
Baltimore, Maryland 21244-1850
Center for Clinical Standards and Quality/Survey & Certification Group
Ref: S&C: 16-29-LSC

DATE: June 20, 2016
TO: State Survey Agency Directors
FROM: Director
Survey and Certification Group
SUBJECT: Adoption of the 2012 edition of the National Fire Protection Association (NFPA)
101 - Life Safety Code (LSC) and 2012 edition of the NFPA 99 - Health Care
Facilities Code (HCFC)
Memorandum Summary
• The Centers for Medicare & Medicaid Services (CMS) has adopted by regulation the
2012 LSC and the 2012 HCFC. The regulation effective date is July 5, 2016.
• CMS will begin surveying for compliance with the 2012 LSC and HCFC on November
1, 2016.
• CMS will offer an online transitional training course for existing LSC surveyors to
provide an update on the new requirements. The course will be available on September
2, 2016 via the CMS Surveyor Training Website.
• CMS will update the ASPEN program (i.e., the information system which tracks
surveys) and CMS Fire Safety Forms (2786) prior to the November 1, 2016 survey start
date.
Background
The purpose of this policy memorandum is to notify the State Agencies (SA) and Regional
Offices (RO) that CMS has adopted by regulation the NFPA 2012 LSC and 2012 HCFC. This
memorandum supersedes S&C 03-21. In addition, this policy memorandum is intended to notify
the SAs and ROs on the status of associated training, survey forms, and ASPEN program.
Regulation
On May 4, 2016, CMS adopted the 2012 LSC and the 2012 HCFC by final rule. The final rule
was published in the Federal Register (Vol. 81, No. 86), is entitled “Medicare and Medicaid
Programs; Fire Safety Requirements for Certain Health Care Facilities”, and is effective July 5,
2016. The final rule also adopted 2012 LSC Tentative Interim Amendments (TIA) 12–1, 12–2,
12–3, and 12–4, and 2012 HCFC TIA 12–2, 12–3, 12–4, 12–5 and 12–6.
138
Page 2 – State Survey Agency Directors
The final rule eliminates all references to the previously adopted 2000 edition of the LSC, and
requires providers and suppliers to comply with the 2012 LSC with certain modifications, and
the 2012 HCFC excluding chapters 7, 8, 12, and 13 by the effective date of July 5, 2016.
Buildings constructed before July 5, 2016 can meet Existing Occupancy requirements. In
addition, buildings that receive design approval or building permits for construction before July
5, 2016 can meet Existing Occupancy requirements. All other building construction must meet
New Occupancy requirements.
The final rule includes requirements for Religious Non-Medical Health Care Institutions
(RNHCI), Ambulatory Surgical Centers (ASC), Hospice, Program of All-Inclusive Care for the
Elderly (PACE), Hospitals, Long Term Care, Intermediate Care Facilities for Individuals with
Intellectual Disabilities (ICFs/IID), and Critical Access Hospitals (CAH).
The final rules continues to allow CMS to waive, for periods deemed appropriate, specific
provisions of the Life Safety Code, which would result in an unreasonable hardship upon a
facility, providing the waiver will not adversely affect the health and safety of the patients.
The final rule also continues to allow the ability of a State to request that its State fire safety
requirements, imposed by State law, be used in lieu of the 2012 edition of the LSC and HCFC
with CMS.
Survey Process
CMS will begin surveying facilities for compliance with the 2012 edition of the LSC and
HCFC on November 1, 2016. In addition, this will allow CMS the opportunity to train existing
surveyors, revise fire safety survey forms, and update the ASPEN program.
Surveyors will continue to use the current process, tags and forms until November 1, 2016. In
instances where the survey process identified deficiencies that would be compliant under the
2012 LSC, a facility may verify compliance with the 2012 LSC as an acceptable plan of
correction and the deficiency would not be cited.
The LSC shortened survey process, outlined in the CMS Survey and Certification letter
(https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-22.pdf) will no
longer be able to be used after October 31, 2016. CMS will analyze the data required to
determine which facilities will be able to be surveyed using the shortened survey process. Any
State that believes losing the shortened survey process for a period of time will cause it staffing
and/or scheduling difficulty should contact their Regional Office immediately with their
concerns. CMS will notify State Survey Agencies if the determination is made to use the LSC
shortened survey process again.
Training: CMS will provide an online transition course for existing LSC surveyors. The
transition course is intended to inform existing surveyors of the new regulatory requirements and
instruct existing surveyors on how to apply the new Codes when surveying health care facilities.
139
Page 3 – State Survey Agency Directors
The transition course will be self-paced and will take approximately 20 hours to complete. It
will begin with a pre-test and conclude with a post-test that will require a passing score of 85
percent. All existing SA surveyors that conduct LSC surveys are required to complete the
transition course and obtain a passing score before conducting LSC surveys using the 2012 LSC
and HCFC.
The transition course will address: the requirements of the adopted regulation and associated
policy and procedures; changes that have occurred in the Health Care Occupancies, Ambulatory
Health Care Occupancies, Residential Board and Care Occupancies, and Building Rehabilitation
chapters of the LSC; changes that have occurred in the NFPA 99; and the K-tags associated with
new CMS-2786 forms.
This course will be available to all existing LSC surveyors on September 2, 2016 via the
CMS Surveyor Training Website.
The reoccurring 2012 Basic Life Safety Code, NFPA 99, FSES/Health Care, and
FSES/Residential Board and Care courses for new LSC surveyors will also be updated, and
information regarding these courses will be provided when course development is complete. All
previous prerequisites and requirements for new LSC surveyors to attend these reoccurring
courses will continue.
ASPEN: The ASPEN program will be updated with new regulation sets that correlate with the
2012 LSC and HCFC requirements and associated K-tags. The ASPEN system will be updated
prior to the November 1, 2016 survey start date.
If you have questions concerning this memorandum, please send them to

[email protected]. To view the Final Rule, 05042016 Fire Safety
Requirements Final Rule please see https://www.federalregister.gov/articles/2016/05/04/2016-
10043/medicare-and-medicaid-programs-fire-safety-requirements-for-certain-health-care-
facilities
Training: Immediately. The information provided in this memorandum should be

communicated with all survey and certification staff, their managers, and the State/Regional
Office training coordinators within 30 days of this memorandum.
Effective Date: CMS will begin to survey all health care facilities referenced in this final rule
for compliance with the 2012 editions of the LSC and HCFC on November 1, 2016.
/s/
David R. Wright
Acting Director
cc: Survey and Certification Regional Office Management
140
DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop C2-21-16
Baltimore, Maryland 21244-1850
Center for Clinical Standards and Quality /Survey & Certification Group
Ref: S&C: 14-46-LSC

DATE: September 26, 2014
TO: State Survey Agency Directors
FROM: Director
Survey and Certification Group
SUBJECT: Categorical Waiver for Power Strips Use in Patient Care Areas
Memorandum Summary
• Categorical Waiver: CMS has determined that the 2000 edition of the National Fire
Protection Association (NFPA) 101® Life Safety Code (LSC) contains provisions on the
use of power strips in health care facilities that may result in unreasonable hardship for
providers or suppliers. Further, an adequate alternative level of protection may be
achieved by compliance with the 2012 edition of the LSC, which has extended
allowances on the use of power strips in patient care areas.
o CMS is permitting a categorical waiver to allow for the use of power strips in existing
and new health care facility patient care areas, if the provider/supplier is in
compliance with all applicable 2012 LSC power strip requirements and with all other
2000 LSC electrical system and equipment provisions.
o Resident rooms in long-term care or other residential care facilities that do not use
line-operated electrical appliances for diagnostic, therapeutic, or monitoring purposes
are not subject to the more restrictive NFPA 99 requirements regarding the use of
power strips in patient care areas/rooms. Resident rooms using line-operated patient-
care-related electrical equipment in the patient care vicinity must comply with the
NFPA 99 power strip requirement and may elect to utilize this categorical waiver.
• Individual waiver applications are not required: Providers and suppliers are expected to
have written documentation that they have elected to use the waiver. A provider or
supplier must notify the LSC survey team at the entrance conference that it has elected
the use the waiver permitted under this guidance and that it meets the applicable waiver
requirements. The survey team will review the information and confirm the facility meets
the conditions for the waiver.
Various regulations governing certain certified providers and suppliers require compliance with
the 2000 edition of the NFPA LSC. The LSC establishes minimum requirements for the design,
operation, and maintenance of buildings and structures to protect individuals from fire and
related hazards. The 1999 edition NFPA 99, Health Care Facilities Code is cross-referenced in
141
the 2000 LSC and, as a result, it contains requirements applicable to providers and suppliers who
must meet the 2000 edition of the LSC under our regulations.
As allowed by the various regulations referencing the LSC, CMS may waive specific provisions
of the 2000 edition of the LSC which, if rigidly applied, would result in unreasonable hardship
upon a provider or supplier, but only if the waiver does not adversely affect the health and safety
of patients. CMS has determined that the 1999 edition of the NFPA 99 contains provisions on
the use of power strips in health care facilities that may result in unreasonable hardship for
providers or suppliers, and for which an adequate alternative level of protection may be achieved
by compliance with the 2012 edition of the LSC. Accordingly, CMS is making available a
categorical waiver for providers and suppliers subject to the LSC requirements regarding the use
of power strips in patient care areas.
Categorical Waiver
The increasing need for electrical equipment in health care facilities has resulted in a need for
more electrical receptacles in areas where patients receive examination and treatment. As a
result, the 1999 NFPA 99 requirements regarding the use of power strips in “patient care areas”
has become outmoded and unduly burdensome to providers and suppliers.
The 1999 edition of NFPA 99 requires that there be sufficient receptacles located in all “patient
care areas” in order to avoid the need for power strips. An exception is provided, but only in
anesthetizing locations where power strips can be used if they are an integral component of
portable patient-care-related equipment assemblies that are tested by the manufacturer, and if the
integrity of the assembly is regularly verified and documented through an ongoing maintenance
program.
By contrast, the 2012 edition of NFPA 99 has extended allowances for use of power strips in
“patient care rooms,” which replaces the term “patient care area”. The requirement for there to
be sufficient receptacles located in all patient care areas as to avoid the need for power strips has
been removed, but the minimum number of receptacles in patient care rooms has been increased.
The exception provided for power strips used an integral component of portable patient-care-
related equipment assemblies that are tested by the manufacturer has been expanded beyond
anesthetizing locations to all patient care rooms. In addition, the exception no longer requires a
power strip to be an integral component of a manufacturer tested equipment assembly.
Accordingly, we are permitting a categorical waiver to allow for the use of power strips in
existing and new health care facility patient care areas/rooms, if the provider/supplier complies
with all applicable 2012 NFPA 99 power strip requirements and with all other 1999 NFPA 99
and 2000 LSC electrical system and equipment provisions.
Waiver Not Required for Certain Resident Rooms
Resident rooms in long-term care or other residential care facilities that do not use line-operated
electrical appliances for diagnostic, therapeutic, or monitoring purposes are not subject to the
more restrictive NFPA 99 requirements regarding the use of power strips in patient care
142
areas/rooms. In this setting, power strips may be used in the resident rooms in accordance with
the standard precautions and Underwriter Laboratory (UL) listings as discussed below.
Resident rooms using line-operated patient-care-related electrical equipment in the patient care
vicinity must comply with the NFPA 99 power strip requirement and may elect to utilize this
categorical waiver.
Pertinent 2012 NFPA 99 Definitions:
• “Patient bed location” is defined in section 3.3.136 as the location of a patient sleeping bed,
or the bed or procedure table of a critical care area.
• “Patient-care-related electrical equipment” is defined in section 3.3.137 as electrical

equipment that is intended to be used for diagnostic, therapeutic, or monitoring purposes in
the patient care vicinity;
• “Patient care room” is defined in section 3.3.138 as any room of a health care facility
wherein patients are intended to be examined or treated. Note that this term replaces the term
“patient care area” used in the 1999 NFPA 99, but the definition has not changed.
• “Patient care vicinity” is defined in section 3.3.139 as a space, within a location intended for
the examination and treatment of patients (i.e., patient care room) extending 6 ft. beyond the
normal location of the bed, chair, table, treadmill, or other device that supports the patient
during examination and treatment and extends vertically 7 ft. 6 in. above the floor.
Requirements:
• Patient bed locations in new health care facilities, or in existing facilities that undergo
renovation or a change in occupancy, shall be provided with the minimum number of
receptacles as required by section 6.3.2.2.6.2.
• Power strips may be used in a patient care vicinity to power rack-, table-, pedestal-, or cart-
mounted patient care-related electrical equipment assemblies, provided all of the following
conditions are met, as required by section 10.2.3.6:
1) The receptacles are permanently attached to the equipment assembly.
2) The sum of the ampacity of all appliances connected to the receptacles shall not exceed
75 percent of the ampacity of the flexible cord supplying the receptacles.
3) The ampacity of the flexible cord is suitable in accordance with the current edition of
NFPA 70, National Electric Code.
4) The electrical and mechanical integrity of the assembly is regularly verified and
documented through an ongoing maintenance program.
143
5) Means are employed to ensure that additional devices or nonmedical equipment cannot
be connected to the multiple outlet extension cord after leakage currents have been
verified as safe.
• Power strips may not be used in a patient care vicinity to power non-patient care-related
electrical equipment (e.g., personal electronics).
• Power strips may be used outside of the patient care vicinity for both patient care-related
electrical equipment & non-patient-care-related electrical equipment.
• Power strips providing power to rack-, table-, pedestal-, or cart-mounted patient care-related
electrical equipment assemblies are not required to be an integral component of manufacturer
tested equipment. Power strips may be permanently attached to mounted equipment
assemblies by personnel who are qualified to ensure compliance with section 10.2.3.6.
• Resident rooms in long-term care or other residential care facilities that do not use line-
operated patient-care-related electrical equipment are not subject to the more restrictive
NFPA 99 requirements regarding the use of power strips in patient care areas/rooms.
• Resident rooms using line-operated patient-care-related electrical equipment in the patient

care vicinity must comply with the NFPA 99 power strip requirement and may elect to utilize
this categorical waiver.
• If power strips are used in any manner, precautions as required by the LSC and reference
documents are required, including but not limited to: installing internal ground fault and
over-current protection devices; preventing cords from becoming tripping hazards;
connecting devices so that tension is not transmitted to joints or terminals; no “daisy
chaining” power strips; using power strips that are adequate for the number and types of
devices, and no overloading power strips with high load devices. In addition, the use of
ground fault circuit interruption (GFCIs) may be required in locations near water sources to
prevent electrocution.
• Power strips providing power to patient care-related electrical equipment must be Special-
purpose Relocatable Power Taps (SPRPT) listed as UL 1363A or UL 60601-1.
• Power strips providing power to non- patient-care-related electrical equipment must be

Relocatable Power Taps (RPT) listed as UL 1363.
Waiver Process
Providers and suppliers that want to take advantage of the categorical waiver identified above
must formally elect to use the waiver and must document their election decision. If a
provider/supplier conforms to the requirements identified for the categorical waiver elected, it
will not need to apply specifically to CMS for the waiver, nor will it need to wait until being
144
cited for a deficiency in order to use this waiver. At the entrance conference for any survey
assessing LSC compliance, a provider/supplier that has elected to use a categorical waiver must
notify the survey team of this fact, and that it meets the applicable waiver provisions. It is not
acceptable for a healthcare facility to first notify surveyors of waiver election after a LSC
citation has been issued.
The survey team will review the provider’s/supplier’s documentation electing to use the
categorical waiver and confirm it is meeting all applicable categorical waiver provisions. This
will ensure an adequate level of protection is afforded. The waiver elected by the
provider/supplier must be described under Tag K000. Categorical waivers do not need to be
cited as deficiencies nor do they require Regional Office approval. Therefore the applicable field
on the Form CMS-2786 should be marked as “Facility Meets, Based Upon, 3. Waivers.” If the
survey team determines that the waiver provisions are not being met, the provider/supplier will
be cited as a deficiency under §482.41(b)(2), §485.623(d)(3), §483.70(a)(2), §416.44(b)(2), or
§418.110(d)(2), as appropriate.
Questions: If you have questions regarding this memorandum please contact

[email protected].
Effective Date: Immediately. This policy should be communicated with all survey and
certification staff, their managers and the State/Regional Office training coordinators within 30
days of this memorandum.
/s/
Thomas E. Hamilton
cc: Survey and Certification Regional Office Management
145
Fire Safety information provided by CMS for distribution to surveyors and
providers- May 23, 2018
Fire in facilities – Sent on 4/7/17

There have been two fires in the Midwest recently where the fire occurred
overnight in a locked area and staff did not have access to the room. As a result
staff were unable to take appropriate action before things got out of control. There
are many code references that cover this situation, for example: NFPA Standard:
2012 NFPA 101, 19.1.1.3.1 All health care facilities shall be designed, constructed,
maintained, and operated to minimize the possibility of a fire emergency requiring
the evacuation of occupants.
If you have a locked room and none of your staff have keys, how can staff who
know there is a fire situation gain access to the area to help fight the fire? Consider
your kitchens, staff offices, boiler rooms, laundry rooms, etc. All areas must be
maintained and operated to minimize the possibility of a fire.
Have you had a fire? Don’t forget to notify your Fire Marshal and State Health
Agency.
Fire Watch Policies Sent 5/2017

Did you know that the outage time was increased for sprinkler outages from four
hours to ten hours with the adoption of the 2012 Life Safety Code? (The time for
fire alarm outages remained the same – four hours.) Does your plan call for a fire
watch when there is a water outage? Does your plan say you don’t have to do the
fire watch if the systems are only down for routine testing and maintenance? If so,
you should remove that statement as the fire watch is required for any type of
outage. Does your sprinkler impairment plan meet the 2011 edition of NFPA 25?
You can view the requirements for free online at NFPA.org. (Go to the 2011
edition of NFPA 25, chapter 15 Impairments.) Are the staff dedicated to the task?
Are the rounds continuous? Do you notify your insurance company when the
sprinkler system is out of service? Do you notify the local fire department, Fire
Marshal and Health Department? Do you have accurate telephone numbers in the
146
policy or in your emergency numbers/calling tree? Don’t forget to in-service staff
when you change your policies. Make sure you have a documentation sheet
prepared for the person doing fire watch to make it easier – every room, canopies,
garages, basement, stairwells, attic spaces – anywhere there are sprinklers.
Don’t forget to implement the plan when you have an outage. If your sprinkler
system has been determined to be obstructed, that also requires a fire watch until
the system is flushed or replaced. Failure to implement the plan can be an
Immediate Jeopardy.
Are you ready for the NEW annual requirements due 7/5/2017? Sent 6/2017
There are a few new requirements under the 2012 edition of the Life Safety Code
that are coming due on July 5th, 2017.
2010 edition of NFPA 80 - Standard for Fire Doors and Other Opening
Protectives
Requirements for all fire-rated door assemblies to be inspected and maintained by

a qualified person:
3.3.95 Qualified Person. A person who, by possession of a recognized degree,

certificate, professional standing, or skill, and who, by knowledge, training, and
experience, has demonstrated the ability to deal with the subject matter, the work,
or the project.
5.2.3 Functional Testing. 5.2.3.1 Functional testing of fire door and window
assemblies shall be performed by individuals with knowledge and understanding of
the operating components of the type of door being subject to testing.
Is the door and frame free from holes and breaks in all surfaces?
Are all the glazing, vision light frames and glazing beads intact and securely
fastened?
147
Are the doors, hinges, frame, hardware and threshold secure, aligned and in
working order with no visible signs of damage?
Are there any missing or broken parts?
Is the clearance from the door edge to the frame no more than 1/8 inch?
Is the door undercut no more than ¾ inch?
Does the active door leaf completely closes when operated from the full open
position?
Does the inactive leaf close before the active leaf when a coordinator is used?
Does the latching hardware operate and secure the door in the closed position?
Is the door assembly free from are auxiliary hardware items which could interfere
with its operation?
Has the door been modified since it was originally installed?
If gasketing and edge seals are installed, have they been verified for integrity and
operation?
2012 edition of NFPA 99 - Health Care Facilities Code
Requirements for receptacle, main and circuit breaker testing and maintenance:
6.3.3.2 Receptacle Testing in Patient Care Rooms

6.3.3.2.1 The physical integrity of each receptacle shall be confirmed by visual
inspection.
6.3.3.2.2 The continuity of the grounding circuit in each electrical receptacle shall
be verified.
6.3.3.2.3 Correct polarity of the hot and neutral connections in each electrical
receptacle shall be confirmed.
6.3.3.2.4 The retention force of the grounding blade of each electrical receptacle
(except locking-type receptacles) shall be not less than 115 g (4 oz).
6.3.4.1 Maintenance and Testing of Electrical System

6.3.4.1.1 Where hospital-grade receptacles are required at patient bed locations and
in locations where deep sedation or general anesthesia is administered, testing shall
be performed after initial installation, replacement, or servicing of the device.
6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed
at intervals defined by documented performance data.
6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in
locations where deep sedation or general anesthesia is administered, shall be tested
at intervals not exceeding
12 months.
148
6.3.4.1.4 The LIM circuit shall be tested at intervals of not more than 1 month by
actuating the LIM test switch (see 6.3.2.6.3.6). For a LIM circuit with automated
self-test and self-calibration capabilities, this test shall be performed at intervals of
not more than 12 months. Actuation of the test switch shall activate both visual and
audible alarm indicators.
6.3.4.1.5 After any repair or renovation to an electrical distribution system, the
LIM circuit shall be tested in accordance with 6.3.3.3.2.
6.4.4.1.2 Maintenance and Testing of Circuitry

6.4.4.1.2.1* Circuit Breakers. Main and feeder circuit breakers shall be inspected
annually, and a program for periodically exercising the components shall be
established according to manufacturer’s recommendations.
2012 edition of NFPA 99 - Health Care Facilities Code
This requires training of personnel who work with medical gases.
11.5.2.1 Qualification and Training of Personnel

11.5.2.1.1* Personnel concerned with the application and maintenance of medical
gases and others who handle medical gases and the cylinders that contain the
medical gases shall be trained on the risks associated with their handling and use.
11.5.2.1.2 Health care facilities shall provide programs of continuing education for
their personnel.
11.5.2.1.3 Continuing education programs shall include periodic review of safety
guidelines and usage requirements for medical gases and their cylinders.
11.5.2.1.4 Equipment shall be serviced only by personnel trained in the
maintenance and operation of the equipment.
11.5.2.1.5 If a bulk cryogenic system is present, the supplier shall provide annual
training on its operation.
Fire Alarm System Inspection, Testing and Maintenance (ITM) 7-2017
All devices connected to your fire alarm system need to have evidence that each
individual device was tested. That means you also need an accurate inventory of
every device, complete with a description as to where it is located. The test report
149
needs to list each and every individual device (individually itemized), a description
of where it is located, and whether it passed or failed its test.
Get those fire alarm interface relays included in the fire alarm testing process and
document each one individually, with a “Pass” or a “Fail” notation. Here is a list of
the most common interface relays used in healthcare fire alarm systems:
x Magnetic hold-open devices

x Air handler shutdown
x Kitchen hood suppression system
x Elevator recall
x Magnetic locks
x Fire pump
x Smoke dampers
x Clean agent suppression systems
x Sprinkler dry pipe/pre-action systems
x Overhead rolling fire doors
If the company that completes the fire alarm ITM is different than the range hood
and sprinkler company vendors, then provide a copy of that report to the fire alarm
company and they can write in the comments section that these devices were tested
by ‘vendor’ on ‘date’, and pass/fail.
Don’t forget to keep a disposition of the devices that failed or had a comment
regarding how the system is not to code with your semi-annual inspection and
testing. That way we know corrections were made and you don’t have to search for
paperwork during a survey.
A note about dampers: Electric fire and smoke dampers must be tested annually
with the fire alarm system. Fusible link dampers are required to be exercised and
lubricated once every four years in LTC/once every six years in hospitals. Electric
fire/smoke dampers are required to be tested annually with the fire alarm.
References: NFPA 72 National Fire Alarm and Signaling Code
Useful Websites sent 8/2017
150
Would you like to read the new 2012 Life Safety Code K-tags? Go to:
https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-List.html
Enter 2786; then choose your form based on your occupancy type. LTC and
hospitals use the Healthcare form, 2786R.
Would you like to view the NFPA codes referenced in the K-tags? Go to
NFPA.org and sign up (it’s free). Then go to the list of codes and standards.
Choose free access:
http://www.nfpa.org/codes-and-standards/all-codes-and-standards/free-access
Choose your book and appropriate year (Here is a list to get you started):
NFPA 101, 2012 (LSC)
NFPA 25, 2011 (Sprinkler Systems)
NFPA 72, 2010 (Fire Alarms)
NFPA 99, 2012 (Health Care Facilities)
NFPA 110, 2010 (Generators)
NFPA 70, 2011 (Electrical)
Would you like to see the Life Safety Code survey and certification memos? Go to:
https://www.cms.gov/Medicare/Provider-Enrollment-and-
Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-
Regions.html
Enter LSC to filter out the other type of memos.
Fire and Smoke Door ITM – S&C Memo 17-38

The latest S&C memo is 17-38. This is in reference to fire door inspection, testing
and maintenance. According to the memo, the new compliance date is 1/1/2018. (It
was 7/5/2017). If you have a citation and are unable to complete the work timely,
you may use the new compliance date in your Plan of Correction.
151
Plan review Sent 9/2017
Are you planning on making changes to equipment in your facility? Examples
might be a new fire alarm system, sprinkler system, boiler, elevator, generator,
range hood, HVAC, locking devices, electrical work, lighting or walk-in
refrigerator/freezer? Or perhaps you are thinking of doing some renovations such
as adding/removing doors, walls, smoke barriers, wall coverings, ceilings, changes
to locking devices (such as the timing of delayed egress), outdoor storage room,
outdoor smoking area, canopy, or exits? Do you know the construction type of
your facility? (This is important! If it is of non-combustible construction, you can’t
use wood studs during your renovation.) Have you run the proposed changes
through your State Agency plan review team? If not, you might be making a
change that does not comply with the Life Safety Code and/or Health Care
regulations. Please send your information in just to make sure. Depending on your
State Agency, you might need a code foot print, blue print, stamped/sealed
documents from an architect or engineer, or specification sheets on your new
finishes, fire stopping products, etc.
Sprinkler Systems – Sent 10/2017

When it is required that all areas of a facility be completely sprinkler protected,
make sure that you have coverage under that garage door. We frequently see these
areas with a sprinkler above the door, but when the garage door is in the open
position, that sprinkler pattern is blocked. You might need to add a side wall
sprinkler to ensure full coverage under the garage door.
Do you have painted, loaded (other substances – kitchen grease, cigarette tar, bird
nest) or corroded (green or rusty) sprinklers? These are required to be replaced,
not cleaned – there is no such thing as a UL listed paint remover.
5.2.1.1 Sprinklers shall be inspected from the floor level annually.
5.2.1.1.1 Sprinklers shall not show signs of leakage; shall be free of

corrosion, foreign materials, paint, and physical damage; and shall be
installed in the correct orientation (e.g., upright, pendent, or sidewall).
152
5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be
replaced:
(1) Leakage
(2) Corrosion
(3) Physical damage
(4) Loss of fluid in the glass bulb heat responsive element
(5) Loading
(6) Painting unless painted by the sprinkler manufacturer
5.2.1.1.3 Any sprinkler that has been installed in the incorrect orientation
shall be replaced.
5.2.1.1.4 Any sprinkler shall be replaced that has signs of leakage; is

painted, other than by the sprinkler manufacturer, corroded, damaged, or
loaded; or is in the improper orientation.
5.2.1.1.5 Glass bulb sprinklers shall be replaced if the bulbs have emptied.
Is your sprinkler system obstructed? You must then complete a flush of the system.
If this is not possible and the system must be replaced – don’t forget to
implement a fire watch until the flush and/or replacement is completed.
4.1.9.1 Where an impairment to a water-based fire protection system occurs,
the procedures outlined in Chapter 15 of this standard shall be followed,
including the attachment of a tag to the impaired system.
4.1.9.2 Where a water-based fire protection system is returned to service

following an impairment, the system shall be verified to be working properly
by means of an appropriate inspection or test.
Don’t forget to keep a disposition of the devices that failed or had a comment
regarding how the system is not to code with your inspection and testing. That way
everyone knows corrections were made and you don’t have to search for
paperwork during a survey.
4.3.1 Records shall be made for all inspections, tests, and maintenance of the
system and its components and shall be made available to the authority
having jurisdiction upon request.
153
4.3.2 Records shall indicate the procedure performed (e.g., inspection, test,
or maintenance), the organization that performed the work, the results, and
the date.
References: 2011 edition of NFPA 25 Inspection, Testing and Maintenance of

Water-Based Fire Protection Systems
Fire plans Sent 12-2017

With all the scrutiny on emergency preparedness, take a fresh look at your fire
plan. Do you have one complete plan or do you have multiple versions in your
disaster manual? Do you have multiple ‘sections’ that are not incorporated into one
complete plan? Make sure that everything is in one plan, so there are no conflicts
and that the reader does not think they are done reading ‘the’ plan when in fact
there are multiple editions/sections. Also make sure every manual in your facility
has been updated.
Are the numbers in your plan or calling tree out of date? Or did you use a sister
facility’s plan that has different phone numbers for your area – Fire Marshal,
Health Department and Fire Department?
Do you have an assignment for an evacuation point outside? If you used a sister
facility’s plan, is the evacuation point accurate for your facility? Have you shared
this plan with the local fire department? They might want to set up command in
that very spot.
Do you have an assignment for who will be the designee to call 911? This is a new
requirement to the 2012 Life Safety Code. This might be a redundant concept, but
there is a good reason – what if the fire alarm did not transmit? Or, if it did
transmit and the fire department is on the way, staff can now give them good
information: (for example) yes, we have a real fire, it is this big, in this room, we
used two fire extinguishers and it is not extinguished, we are evacuating to this
154
wing and we will meet you at the front door. Don’t forget to have a backup for the
night shift if your assignment is the receptionist and that is not a 24/7 position.
Does everyone know to pull a pull station for a fire no matter what? Old plans for
‘major’ and ‘minor’ fires are not current/acceptable.
Do you have a plan for the preparation and evacuation of a floor or wing?
Do you have a smoke compartment evacuation plan? Once staff determine the
need to evacuate, start with residents in immediate surrounding area of fire, then
the triangle of rooms around the room of fire origin (next to and across the hall
from the room of origin), then the remaining rooms in the smoke compartment
working away from the room of origin, trying not to cross the line of fire with the
residents. Some residents may be evacuated outside while others may be evacuated
beyond a set of smoke doors.
Exit or 2 Fire 1 2 Exit or

Smoke Smoke
Barrier Barrier
2
Do your evacuation and fire plans say to evacuate based on if the residents are
ambulatory, use wheelchairs or are bedridden? After evacuation of the
compartment of origin, and you find the need to evacuate further away, then it
would be prudent to evacuate based on ambulation status (ambulatory, wheelchair,
bedridden) since you can move faster. But it would not be fair to residents
occupying the triangle of rooms around the room of fire origin to be last out
because they are bedridden. If you have separate fire and evacuation plans, make
sure they are consistent.
Keep this as simple as possible – if you have a smoke compartment plan from
every smoke zone in your building, will staff be able to remember all of those
155
instructions? If they know the above information, they should be able to find the
safe zone every time, no matter where they are in the building (and be able to
articulate this to a surveyor).
Do you have cross-corridor doors? Examples might be at the entrance to a memory

care unit or doors to a service hall. Cross-corridor doors are access control doors
that are not smoke barrier doors. You need to evaluate your building and identify
where all of your smoke/fire barriers are and if you have cross-corridor doors.
Make sure staff know these are not part of the smoke compartment plan as they
sometimes look like smoke barrier doors.
If you care for residents with specialized needs (such as ventilator or bariatric
units), have a general plan in place and make sure staff know what to do. If the bed
won’t fit through the door, you need to have a plan in place for rescue. Always
make sure you are adequately staffed for emergencies when you are providing care
to special populations.
Does your plan or training materials cover all aspects of what your facility offers
staff to fight a fire? Does it cover a bit about the construction, the fire alarm and
sprinkler systems, the generator, the smoke barriers, identification of smoke doors,
identification of cross–corridor doors that are not smoke barrier doors, all types of
fire extinguishers in your facility – including the K or halon, the range hood, etc. It
is important for all staff to know what equipment is in the kitchen. There was a
recent IJ as a result of a fire where the night shift nursing staff were unable to
extinguish the fire because they used the wrong type of extinguisher and didn’t
know about the range hood or how to activate it.
Do you have the required print copies at the security station or nurse’s station?
Don’t just rely on the computer – it will be the first thing to go down in the event
of an emergency.
Don’t forget to in-service staff when you change your policies.
156
19.7.2.1* Protection of Patients.
19.7.2.1.1 For health care occupancies, the proper protection of patients shall
require the prompt and effective response of health care personnel.
19.7.2.1.2 The basic response required of staff shall include the following:
(1) Removal of all occupants directly involved with the fire emergency
(2) Transmission of an appropriate fire alarm signal to warn other building
occupants and summon staff
(3) Confinement of the effects of the fire by closing doors to isolate the fire area
(4) Relocation of patients as detailed in the health care occupancy’s fire safety plan
19.7.2.2 Fire Safety Plan. A written health care occupancy fire safety plan shall
provide for all of the following:
(1) Use of alarms

(2) Transmission of alarms to fire department
(3) Emergency phone call to fire department
(4) Response to alarms
(5) Isolation of fire
(6) Evacuation of immediate area
(7) Evacuation of smoke compartment
(8) Preparation of floors and building for evacuation
(9) Extinguishment of fire
157

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Life Safety Codes

LONG-TERM CARE SURVEY MANUAL

K100 General Requirements – Other

PART III — Recommendation for Waiver

PART IV – Crucial Data Extract

B. WING _______________ B. Partially Sprinklered

C. None (No sprinkler system)

3. SURVEY FOR 4. DATE OF SURVEY DATE OF PLAN APPROVAL SURVEY UNDER

5. SURVEY FOR CERTIFICATION OF

1. HOSPITAL 2. SKILLED/NURSING FACILITY 4. ICF/IID UNDER HEALTH CARE 5. HOSPICE

SURVEYOR (Signature) TITLE OFFICE DATE

FIRE AUTHORITY OFFICIAL (Signature) TITLE OFFICE DATE

Form CMS-2786R (10/2016) 9 Page 1

Sprinklered stories must be sprinklered throughout by an approved,

SECTION 2 – MEANS OF EGRESS REQUIREMENTS

K222 Egress Doors

K231 Means of Egress Capacity

Area Automatic Sprinkler Separation N/A

a. Boiler and Fuel-Fired Heater Rooms

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

c. Repair, Maintenance, and Paint Shops

d. Soiled Linen Rooms

Area Automatic Sprinkler Separation N/A

a. Boiler and Fuel-Fired Heater Rooms

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

c. Repair, Maintenance, and Paint Shops

d. Soiled Linen Rooms

K332 Interior Floor Finish

K352 Sprinkler System – Supervisory Signals

SECTION 5 – BUILDING SERVICES

K781 Portable Space Heaters

K902 Gas and Vacuum Piped Systems – Other

K903 Gas and Vacuum Piped Systems – Categories

K918 Electrical Systems – Essential Electric System Maintenance and

PROVISION NUMBER(S) JUSTIFICATION

Surveyor (Signature) Title Office Date

Fire Authority Official (Signature) Title Office Date

CRUCIAL DATA EXTRACT

(TO BE USED WITH CMS 2786 FORMS)

Provider Number Facility Name Survey Date

K6 DATE OF PLAN K3 MULTIPLE CONSTRUCTION

13 2786R 2012 NEW 1. PROMPT

COMPLETE IF ICF/IID IS SURVEYED UNDER CHAPTER 33,

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

FIRE SAFETY EVALUATION SYSTEM

HEALTH CARE FACILITIES

(NFPA 101A, “Guide on Alternative Approaches to Life Safety” 2013 Edition)

Complete the following worksheets for each fire/smoke zone*.

Step 1 — Complete Cover Sheet using Worksheet 4.7.1.

WORKSHEET 4.7.1 – COVER SHEET

NAME OF FACILITY ADDRESS OF FACILITY

PROVIDER/VENDOR NO. DATE OF SURVEY

SURVEYOR SIGNATURE TITLE OFFICE DATE

FIRE AUTHORITY SIGNATURE TITLE OFFICE DATE

Step 2 — Determine Occupancy Risk Parameter Factors using Worksheet 4.7.2.

Mobility Status Mobile Limited Mobility Not Mobile Not Movable

No. of Patients 1–5 6–10 11–30 >30

Step 3 — Compute Occupancy Risk Factor (F) using Worksheet 4.7.3.

WORKSHEET 4.7.3 - OCCUPANCY RISK FACTOR CALCULATION