CMS Issue Affecting theCMS Issue Affecting the … Issue Affecting theCMS Issue Affecting the ... Ventilation Control and Fire Protection ofVentilation Control and Fire Protection

CMS Issue Affecting theCMS Issue Affecting theCMS Issue Affecting the CMS Issue Affecting the Physical EnvironmentPhysical Environment

South Carolina SocietySouth Carolina Society

of Hospital Engineers

Presented November 3, 2011Presented November 3, 2011By Ken GregoryBy Ken Gregory

p g

By Ken GregoryBy Ken GregoryVice President, AccreditationVice President, Accreditation

TSIG Consulting, IncTSIG Consulting, Inc

CongressSupreme Court Federal Circuit

CourtsCenters for Medicaid and

Who Regulates Hospitals?

Departmental Appeals

Healthcare Integrity Program Contractors PRRB

Medicare ServicesOIG

Regional Offices

DME Regional Contractors

Intermediaries Carriers PROs

Regional Home Health Intermediaries

State Level• Survey and Certification • Courts• Attorneys General• Medicaid

YOUR HOSPITAL

FAA

DEA

FDA

OPOs

Medicaid• Health Boards• Medical Boards• Local Governments• Licensure

DOT

SEC

FBI

OSHA

Treasury

DOJ

DOT

IRS

FCCFTC

EPA

HHS/ NIOSH

NRC

HSS/ HRSA TJC / DNV DOL

Chart Legend

DEA: Drug Enforcement AdministrationFAA: Federal Aviation AdministrationOPO: Organ Procurement Organizations

TJC/DNV: Joint Commission/ DNV HealthcareNRC: Nuclear Regulatory CommissionO O O ga ocu e e t O ga at o s

SEC: Securities and Exchange CommissionIRS: Internal Revenue ServiceEPA: Environmental Protection AgencyFTC: Federal Trade CommissionFCC: Federal Commerce CommissionHHS: Health and Human ServicesHRSA: Health Resources and Services AdminNIOSH: National Institution for Occupational Safety & Health

DOL: Department of LaborFBI: Federal bureau of InvestigationDOJ: Department of JusticeOSHA: Occupational Safety and Health AdminDOT: Department of TransportationFDA: Food and Drug AdministrationOIG: Office of Inspector GeneralPRO: Peer Review OrganizationPRRB: Provider Reimbursement Review Board

CMSCMSCMSCMSKey MilestonesKey Milestonesyy

In 1965 Medicare and Medicaid were enacted as Title XVIII and In 1965 Medicare and Medicaid were enacted as Title XVIII and Title XIX of the Social Security Act, extending health coverage to Title XIX of the Social Security Act, extending health coverage to y , g gy , g galmost all Americans aged 65 or older (e.g., those receiving almost all Americans aged 65 or older (e.g., those receiving retirement benefits from Social Security or the Railroad Retirement retirement benefits from Social Security or the Railroad Retirement Board), and providing health care services to lowBoard), and providing health care services to low--income children income children deprived of parental support their caretaker relatives the elderlydeprived of parental support their caretaker relatives the elderlydeprived of parental support, their caretaker relatives, the elderly, deprived of parental support, their caretaker relatives, the elderly, the blind, and individuals with disabilities. Seniors were the the blind, and individuals with disabilities. Seniors were the population group most likely to be living in poverty; about half had population group most likely to be living in poverty; about half had insurance coverage. insurance coverage.

**** The Social Security Act was established in 1935 as “The Old **** The Social Security Act was established in 1935 as “The Old Age Benefits ProgramAge Benefits Program


1966 Medicare was implemented and more than 19 million 1966 Medicare was implemented and more than 19 million individuals enrolled on July 1.individuals enrolled on July 1.yy1972 Medicare eligibility was extended to individuals under age 65 1972 Medicare eligibility was extended to individuals under age 65 with longwith long--term disabilities and to individuals with endterm disabilities and to individuals with end--stage renal stage renal disease (ESRD).disease (ESRD).1977 The Health Care Financing Administration (HCFA) was 1977 The Health Care Financing Administration (HCFA) was established to administer the Medicare and Medicaid programs. established to administer the Medicare and Medicaid programs. 1985 The Emergency Medical Treatment and Labor Act (EMTALA) 1985 The Emergency Medical Treatment and Labor Act (EMTALA) required hospitals participating in Medicare that operated activerequired hospitals participating in Medicare that operated activerequired hospitals participating in Medicare that operated active required hospitals participating in Medicare that operated active emergency rooms to provide appropriate medical screenings and emergency rooms to provide appropriate medical screenings and stabilizing treatments. stabilizing treatments.


1988 The Medicare Catastrophic Coverage Act was enacted, which 1988 The Medicare Catastrophic Coverage Act was enacted, which included the most significant changes since enactment of the Medicare included the most significant changes since enactment of the Medicare

i d h i l d kill d i f ili b fi di d h i l d kill d i f ili b fi dprogram, improved hospital and skilled nursing facility benefits, covered program, improved hospital and skilled nursing facility benefits, covered mammography, and included an outpatient prescription drug benefit and mammography, and included an outpatient prescription drug benefit and a cap on patient liability. a cap on patient liability. 1996 The Health Insurance Portability and Accountability Act of 19961996 The Health Insurance Portability and Accountability Act of 19961996 The Health Insurance Portability and Accountability Act of 1996 1996 The Health Insurance Portability and Accountability Act of 1996 (HIPAA) had several provisions. (HIPAA) had several provisions. 1998 The internet site www.medicare.gov was launched to provide 1998 The internet site www.medicare.gov was launched to provide updated information about Medicare. updated information about Medicare. 2003 The Medicare Prescription Drug, Improvement, and Modernization 2003 The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) made the most significant changes to Medicare since the Act (MMA) made the most significant changes to Medicare since the program began. program began.

CMS?CMS?CMS?CMS?Centers for Medicare and Medicaid ServicesCenters for Medicare and Medicaid Services–– CMS is a “Federal” program, however it is “CMS is a “Federal” program, however it is “StateState

Administered”, therefore each state set’s its own Administered”, therefore each state set’s its own guidelines based around the Conditions of Participationguidelines based around the Conditions of Participationguidelines based around the Conditions of Participation guidelines based around the Conditions of Participation (CoP)(CoP)

§§ 482.41 Condition of participation: Physical environment.482.41 Condition of participation: Physical environment.

–– Determines funding reimbursements to healthcare Determines funding reimbursements to healthcare entities who treat medicare/medicaid patientsentities who treat medicare/medicaid patientsentities who treat medicare/medicaid patientsentities who treat medicare/medicaid patients

CMS?CMS?CMS?CMS?

What is the purpose of CMS as related to the Healthcare What is the purpose of CMS as related to the Healthcare Industries “physical environment”Industries “physical environment”–– NFPA 101NFPA 101–– NFPA 99NFPA 99

All supporting codes for 101 NFPA & NFPA 99All supporting codes for 101 NFPA & NFPA 99–– All supporting codes for 101 NFPA & NFPA 99All supporting codes for 101 NFPA & NFPA 99

2000 LSC References to 1999 2000 LSC References to 1999 9999NFPA 99NFPA 99

8.4.4 exception8.4.4 exception 18.5.1.318.5.1.38.4.58.4.59.2.49.2.418 2 9 218 2 9 2

19.3.2.219.3.2.219.3.2.319.3.2.319 3 2 419 3 2 418.2.9.218.2.9.2

18.2.10.218.2.10.2Table 18.3.2.1Table 18.3.2.1

19.3.2.419.3.2.420.2.9.220.2.9.220.3.2.120.3.2.1

18.3.2.218.3.2.218.3.2.318.3.2.318 3 2 418 3 2 4

20.3.2.220.3.2.221.2.9.221.2.9.221 3 2 121 3 2 118.3.2.418.3.2.4

18.5.1.218.5.1.221.3.2.121.3.2.121.3.2.221.3.2.2

The Primary Support CodesThe Primary Support CodesThe Primary Support CodesThe Primary Support CodesNFPA 10 NFPA 10 -- Portable Fire ExtinguishersPortable Fire ExtinguishersNFPA 25 NFPA 25 -- Inspection, Testing, and Maintenance of WaterInspection, Testing, and Maintenance of Water--Based Fire Protection SystemsBased Fire Protection SystemsNFPA 70 NFPA 70 –– National Electrical CodeNational Electrical CodeNFPA 72 NFPA 72 –– National Fire Alarm CodeNational Fire Alarm CodeNFPA 80 NFPA 80 -- Fire Doors and Other Opening ProtectivesFire Doors and Other Opening ProtectivesNFPA 96NFPA 96 -- Ventilation Control and Fire Protection ofVentilation Control and Fire Protection ofNFPA 96 NFPA 96 -- Ventilation Control and Fire Protection of Ventilation Control and Fire Protection of Commercial Cooking OperationsCommercial Cooking OperationsNFPA 110 NFPA 110 –– Emergency Power and Standby SystemsEmergency Power and Standby SystemsNFPA 111NFPA 111 Stored Electrical Energy Emergency andStored Electrical Energy Emergency andNFPA 111 NFPA 111 -- Stored Electrical Energy Emergency and Stored Electrical Energy Emergency and Standby Power SystemsStandby Power Systems

NFPA 101 Health Care FacilitiesNFPA 101 Health Care FacilitiesPurposePurpose

To provide minimum requirements, with To provide minimum requirements, with due regard to function for the designdue regard to function for the designdue regard to function, for the design, due regard to function, for the design, operation, and maintenance of buildings operation, and maintenance of buildings and structures for safety to life from fireand structures for safety to life from fireand structures for safety to life from fire.and structures for safety to life from fire.

NFPA 99 Health Care FacilitiesNFPA 99 Health Care FacilitiesPurposePurpose

To provide minimum requirements for: To provide minimum requirements for: P fP f–– PerformancePerformance

–– MaintenanceMaintenance–– TestingTesting–– Safe PracticesSafe Practices

** No installation criteria except for piped gasNo installation criteria except for piped gas

True or False?True or False?True or False?True or False?

NFPA 99 applies to all new construction?NFPA 99 applies to all new construction?

NFPA 99 applies to existing facilities?NFPA 99 applies to existing facilities?

Application of NFPA 99Application of NFPA 99Application of NFPA 99Application of NFPA 99

“This document shall apply to all healthcare facilities Construction and equipmentfacilities. Construction and equipment requirements shall be applied only to new construction and new equipment, except asconstruction and new equipment, except as modified in individual chapters…”

Patient Care AreaPatient Care AreaPatient Care AreaPatient Care Area

Patient Care AreaPatient Care AreaAny portion of a healthcare facility wherein Any portion of a healthcare facility wherein patients are intended to be examined orpatients are intended to be examined orpatients are intended to be examined or patients are intended to be examined or treated.treated.

General Care AreaGeneral Care AreaGeneral Care AreaGeneral Care Area

General Care AreaGeneral Care AreaGeneral Care AreaGeneral Care AreaPatient bedrooms, examining rooms, Patient bedrooms, examining rooms, treatment rooms clinics and similar areas intreatment rooms clinics and similar areas intreatment rooms, clinics and similar areas in treatment rooms, clinics and similar areas in which it is intended that the patient will come which it is intended that the patient will come in contact with ordinary appliances such asin contact with ordinary appliances such asin contact with ordinary appliances such as in contact with ordinary appliances such as nurse call system, electric beds, examining nurse call system, electric beds, examining lamps telephones and entertainmentlamps telephones and entertainmentlamps, telephones, and entertainment lamps, telephones, and entertainment devices.devices.

Critical Care AreaCritical Care AreaCritical Care AreaCritical Care Area

Critical Care AreaCritical Care AreaCritical Care AreaCritical Care AreaThose special care units, intensive care Those special care units, intensive care units operating rooms and similar areas inunits operating rooms and similar areas inunits, operating rooms…and similar areas in units, operating rooms…and similar areas in which patients are intended to be subjected which patients are intended to be subjected to invasive procedures and connected toto invasive procedures and connected toto invasive procedures and connected to to invasive procedures and connected to lineline--operated patientoperated patient--carecare--related electrical related electrical appliancesappliancesappliances.appliances.

Wet Location or Not?Wet Location or Not?Wet Location or Not?Wet Location or Not?

Description of AreaDescription of Area Wet Location?Wet Location?Description of AreaDescription of Area Wet Location?Wet Location?

Operating RoomOperating Room

Patient RoomPatient Room

ICU RoomICU Room

Emergency Exam RoomEmergency Exam Room

Ph i l ThPh i l ThPhysical TherapyPhysical Therapy

KitchenKitchen

Wet Location or Not?Wet Location or Not?Wet Location or Not?Wet Location or Not?

Description of AreaDescription of Area Wet Location?Wet Location?Description of AreaDescription of Area Wet Location?Wet Location?

Operating RoomOperating Room MaybeMaybe

Patient RoomPatient Room No No

ICU RoomICU Room NoNo

Emergency Exam RoomEmergency Exam Room NoNo

Ph i l ThPh i l Th M bM bPhysical TherapyPhysical Therapy MaybeMaybe

KitchenKitchen NoNo

The CMS SurveyThe CMS SurveyThe CMS SurveyThe CMS Survey

Life Safety Code requirementsLife Safety Code requirementsLife Safety Code requirementsLife Safety Code requirements

–– Building ConstructionBuilding ConstructionInterior FinishInterior Finish–– Interior FinishInterior Finish

–– Corridor Walls and DoorsCorridor Walls and Doors–– Vertical OpeningsVertical Openings

Smoke Compartmentation and ControlSmoke Compartmentation and Control–– Smoke Compartmentation and ControlSmoke Compartmentation and Control–– Hazardous AreaHazardous Area–– Exit and AccessExit and Access

Exit and EgressExit and Egress–– Exit and EgressExit and Egress


Life Safety Code requirementsLife Safety Code requirementsLife Safety Code requirementsLife Safety Code requirements–– Illumination and Emergency PowerIllumination and Emergency Power–– Emergency Plan and Fire DrillsEmergency Plan and Fire Drills

Automatic Sprinkler SystemsAutomatic Sprinkler Systems–– Automatic Sprinkler SystemsAutomatic Sprinkler Systems–– Smoking RegulationsSmoking Regulations–– Building Service EquipmentBuilding Service Equipment

Furnishings and DecorationsFurnishings and Decorations–– Furnishings and DecorationsFurnishings and Decorations–– LaboratoriesLaboratories–– Medical Gases and Anesthetizing AreasMedical Gases and Anesthetizing Areas

ElectricalElectrical–– ElectricalElectrical


Building ConstructionBuilding ConstructionBuilding ConstructionBuilding Construction–– K11 requires a 2 hr FRR barrier for any common occupancy separation K11 requires a 2 hr FRR barrier for any common occupancy separation

wallswalls–– K12 sets requirements for acceptable construction typesK12 sets requirements for acceptable construction typesK12 sets requirements for acceptable construction typesK12 sets requirements for acceptable construction types

NewNew–– I (443), I (332), II (222) any height with complete AASSI (443), I (332), II (222) any height with complete AASS–– II (111) not over three stories with complete AASSII (111) not over three stories with complete AASS

III (211) V (111) IV (2HH) II (000) t t ith l t AASSIII (211) V (111) IV (2HH) II (000) t t ith l t AASS–– III (211) V (111) IV (2HH) II (000) not over one story with complete AASSIII (211) V (111) IV (2HH) II (000) not over one story with complete AASS–– III (200) V (000) NOT ACCEPTABLEIII (200) V (000) NOT ACCEPTABLE

ExistingExisting–– I (443), I (332), II (222) any height I (443), I (332), II (222) any height –– II (111) One story only when nonII (111) One story only when non--sprinkleredsprinklered–– II (111) Not over three stories with complete AASSII (111) Not over three stories with complete AASS–– III (211) V (111) IV (2HH) II (000) III (211) V (111) IV (2HH) II (000) not over two stories with complete AASSnot over two stories with complete AASS–– III (200) V (000) not over one story with complete AASS III (200) V (000) not over one story with complete AASS ( ) ( ) y p( ) ( ) y p

The CMS SurveyThe CMS SurveyThe CMS SurveyThe CMS SurveyBuilding Construction (cont)Building Construction (cont)–– K103 requires interior walls and partitions in buildings of Type I or Type K103 requires interior walls and partitions in buildings of Type I or Type

II construction shall be noncombustible or limitedII construction shall be noncombustible or limited--combustible materialscombustible materialsInterior FinishInterior Finish–– K14 K14

Existing interior finish for corridors and exitways, including exposed interior Existing interior finish for corridors and exitways, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and surfaces of buildings such as fixed or movable walls, partitions, columns, and ceilings has a flame spread rating ofceilings has a flame spread rating ofCl A Cl BCl A Cl BClass A or Class BClass A or Class BNewNew iinterior finish for corridors and exitways, including exposednterior finish for corridors and exitways, including exposedinterior surfaces of buildings such as fixed or movable walls,interior surfaces of buildings such as fixed or movable walls,partitions, columns, and ceilings has a flame spread rating ofpartitions, columns, and ceilings has a flame spread rating ofCl A Cl B L ti f id ll bCl A Cl B L ti f id ll bClass A or Class B. Lower portion of corridor walls can beClass A or Class B. Lower portion of corridor walls can beClass CClass C

The CMS SurveyThe CMS SurveyThe CMS SurveyThe CMS SurveyInterior FinishInterior Finish–– K15 K15

Existing interior finish for rooms and spaces not used for corridors or Existing interior finish for rooms and spaces not used for corridors or exitways, including exposed interior surfaces of buildings such as fixed or exitways, including exposed interior surfaces of buildings such as fixed or movable walls partitions columns and ceilings has a flame spread rating ofmovable walls partitions columns and ceilings has a flame spread rating ofmovable walls, partitions, columns, and ceilings has a flame spread rating of movable walls, partitions, columns, and ceilings has a flame spread rating of Class A or Class B. (In fully sprinklered buildings, flame spread rating of Class A or Class B. (In fully sprinklered buildings, flame spread rating of Class A, Class B, or Class C may be continued in use within rooms Class A, Class B, or Class C may be continued in use within rooms separated in accordance with 19.3.6 from the access corridors.)separated in accordance with 19.3.6 from the access corridors.)New interior finish for rooms and spaces not used for corridors or exitways,New interior finish for rooms and spaces not used for corridors or exitways,New interior finish for rooms and spaces not used for corridors or exitways, New interior finish for rooms and spaces not used for corridors or exitways, including exposed interior surfaces of buildings such as fixed or movable including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and ceilings has a flame spread rating of Class A walls, partitions, columns, and ceilings has a flame spread rating of Class A or Class B. (Rooms not over 4 persons in capacity may have a flame spread or Class B. (Rooms not over 4 persons in capacity may have a flame spread rating of Class A, Class B, or Class C). rating of Class A, Class B, or Class C).

–– K16 K16 Newly installed interior floor finish complying with 10.2.7 shall be permitted in Newly installed interior floor finish complying with 10.2.7 shall be permitted in corridors and exits if Class I. (In smoke compartments protected throughout corridors and exits if Class I. (In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with by an approved, supervised automatic sprinkler system in accordance with 19.3.5.2, no interior floor finish requirements shall apply19.3.5.2, no interior floor finish requirements shall apply

The CMS SurveyThe CMS SurveyThe CMS SurveyThe CMS SurveyCorridor Walls and DoorsCorridor Walls and Doors–– K17 K17

Existing Corridors are separated from use areas by walls constructed with at Existing Corridors are separated from use areas by walls constructed with at least 1/2 hour fire resistance rating. least 1/2 hour fire resistance rating.

–– In sprinklered buildings, partitions are only required to resist the passage of smoke In sprinklered buildings, partitions are only required to resist the passage of smoke and may terminate at the underside of ceilings where specifically permitted by and may terminate at the underside of ceilings where specifically permitted by Code) . Code) .

–– In nonIn non--sprinklered buildings, walls properly extend above the ceiling.. sprinklered buildings, walls properly extend above the ceiling.. Ch ti d l i l t ti iti di i d ti itCh ti d l i l t ti iti di i d ti it–– Charting and clerical stations, waiting areas, dining rooms, and activity spaces Charting and clerical stations, waiting areas, dining rooms, and activity spaces may be open to corridor under certain conditions specified in the Code. may be open to corridor under certain conditions specified in the Code.

–– Gift shops may be separated from corridors by nonGift shops may be separated from corridors by non--fire rated walls if the gift shop fire rated walls if the gift shop is fully sprinklered.)is fully sprinklered.)

Ne corridor alls shall form a barrier to limit the transfer of smoke S chNe corridor alls shall form a barrier to limit the transfer of smoke S chNew corridor walls shall form a barrier to limit the transfer of smoke. Such 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 walls shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke. constructed to limit the transfer of smoke. No fire resistance rating is No fire resistance rating is required for the corridor walls.required for the corridor walls.


Existing corridor doors, other than hazardous area, shall be:Existing corridor doors, other than hazardous area, shall be:–– Substantial doors, such as those constructed of 1 3/4 inch soldSubstantial doors, such as those constructed of 1 3/4 inch sold--bonded bonded

core wood, or capable of resisting fire for at least 20 minutescore wood, or capable of resisting fire for at least 20 minutes–– Doors in sprinklered buildings are only required to resist the passage of Doors in sprinklered buildings are only required to resist the passage of

smoke. smoke. –– There is no impediment to the closing of the doorsThere is no impediment to the closing of the doorsThere is no impediment to the closing of the doors. There is no impediment to the closing of the doors. –– Doors shall be provided with a means suitable for keeping the door Doors shall be provided with a means suitable for keeping the door

closed. closed. –– Dutch doors meeting 19.3.6.3.3 are permitted. Dutch doors meeting 19.3.6.3.3 are permitted.

New corridor doors shall be:New corridor doors shall be:–– Constructed to resist the passage of smoke. Constructed to resist the passage of smoke. –– Doors shall be provided with positive latching hardware. Doors shall be provided with positive latching hardware.

Dutch doors meeting 18 3 6 3 6 are permittedDutch doors meeting 18 3 6 3 6 are permitted–– Dutch doors meeting 18.3.6.3.6 are permitted.Dutch doors meeting 18.3.6.3.6 are permitted.


Vision panels in corridor walls or doors shall be fixed window assemblies in Vision panels in corridor walls or doors shall be fixed window assemblies in approved frames. (In fully sprinklered buildings, there are no restrictions in approved frames. (In fully sprinklered buildings, there are no restrictions in th d fi i t f l d f )th d fi i t f l d f )the area and fire resistance of glass and frames.) the area and fire resistance of glass and frames.) Access to exits shall be marked by approved, readily visible signs in all cases Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the where the exit or way to reach exit is not readily apparent to the

Vertical Openings Between FloorsVertical Openings Between FloorsVertical Openings Between FloorsVertical Openings Between Floors–– K20 K20

Existing vertical Openings shall be protected with a 1 hr FRRExisting vertical Openings shall be protected with a 1 hr FRRNew vertical openings shall be protected with 1 hr FRR for 3 stories or lessNew vertical openings shall be protected with 1 hr FRR for 3 stories or lessNew vertical openings shall be protected with 1 hr FRR for 3 stories or less New vertical openings shall be protected with 1 hr FRR for 3 stories or less and 2 hr FRR for 4 or more stories and 2 hr FRR for 4 or more stories An atrium may be used in accordance with 8.2.2.3.5An atrium may be used in accordance with 8.2.2.3.5

The CMS SurveyThe CMS SurveyThe CMS SurveyThe CMS SurveyVertical Openings Between FloorsVertical Openings Between Floorsp gp g–– K21 K21

Any door in an exit passageway, stairway enclosure, horizontal exit, smoke Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier or hazardous area enclosure shall be permitted to be held open only barrier or hazardous area enclosure shall be permitted to be held open only b d i d t t ti ll l ll h d bb d i d t t ti ll l ll h d bby devices arranged to automatically close all such doors by zone or by devices arranged to automatically close all such doors by zone or throughout the facility upon activation of:throughout the facility upon activation of:

–– (a) The required manual fire alarm system (a) The required manual fire alarm system andand–– (b) Local smoke detectors designed to detect smoke(b) Local smoke detectors designed to detect smoke

passing through the opening passing through the opening or or a required smokea required smokedetection system detection system andand

–– (c) The automatic sprinkler system, if installed(c) The automatic sprinkler system, if installed

The CMS SurveyThe CMS SurveyThe CMS SurveyThe CMS SurveyVertical Openings Between FloorsVertical Openings Between Floorsp gp g–– K33K33

Existing EXIT components (such as stairways) are enclosed with Existing EXIT components (such as stairways) are enclosed with construction having a fire resistance rating of at least one hour, are arranged construction having a fire resistance rating of at least one hour, are arranged t id ti th f d id t ti i t fit id ti th f d id t ti i t fito provide a continuous path of escape, and provide protection against fire or to provide a continuous path of escape, and provide protection against fire or smoke from other parts of the buildingsmoke from other parts of the buildingNew EXIT components (such as stairways) in buildings four stories or more New EXIT components (such as stairways) in buildings four stories or more are enclosed with construction having a fire resistance rating of at least two are enclosed with construction having a fire resistance rating of at least two hours, are arranged to provide a continuous path of escape, and provide a hours, are arranged to provide a continuous path of escape, and provide a protection against fire and smoke from other parts of the building. In all protection against fire and smoke from other parts of the building. In all buildings less than four stories, the enclosure is at least one hour. buildings less than four stories, the enclosure is at least one hour.

The CMS SurveyThe CMS SurveyThe CMS SurveyThe CMS SurveySmoke Compartmentation and ControlSmoke Compartmentation and Controlpp–– K23K23

Existing Existing -- Smoke barriers shall be provided to form at least two smoke compartments on Smoke barriers shall be provided to form at least two smoke compartments on every sleeping room floor for more than 30 patients.every sleeping room floor for more than 30 patients.NewNew Smoke barriers shall be provided to form at least two smoke compartments onSmoke barriers shall be provided to form at least two smoke compartments onNew New -- Smoke barriers shall be provided to form at least two smoke compartments on 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 every floor used by inpatients for sleeping or treatment, and on every floor with an occupant load of 50 or more persons, regardless of use. Smoke barriers shall also be occupant load of 50 or more persons, regardless of use. Smoke barriers shall also be provided on floors that are usable, but unoccupiedprovided on floors that are usable, but unoccupied

–– K24K24K24K24The smoke compartments shall not exceed 22,500 square feet and the travel distance to The smoke compartments shall not exceed 22,500 square feet and the travel distance to and from any point to reach a door in the required smoke barrier shall not exceed 200 and from any point to reach a door in the required smoke barrier shall not exceed 200 feet.feet.

The CMS SurveyThe CMS SurveyThe CMS SurveyThe CMS SurveySmoke Compartmentation and ControlSmoke Compartmentation and Controlpp–– K25K25

Smoke barriers shall be constructed to provide:Smoke barriers shall be constructed to provide:–– At least a one half hour in existing, (one hour in new) fire resistance rating and At least a one half hour in existing, (one hour in new) fire resistance rating and

d i d i h 8 3d i d i h 8 3constructed in accordance with 8.3. constructed in accordance with 8.3. –– Smoke barriers shall be permitted to terminate at an atrium wall. Smoke barriers shall be permitted to terminate at an atrium wall. –– Windows shall be protected by fireWindows shall be protected by fire--rated glazing or by wired glass panels and steel rated glazing or by wired glass panels and steel

frames. frames. f ff f–– A minimum of two separate compartments shall be provided on each floor. A minimum of two separate compartments shall be provided on each floor.

–– Dampers shall not be required in duct penetrations of smoke barriers in fully Dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air conditioning systems.ducted heating, ventilating, and air conditioning systems.

–– K26K26Space shall be provided on each side of smoke barriers to adequately Space shall be provided on each side of smoke barriers to adequately accommodate those occupants served.accommodate those occupants served.

The CMS SurveyThe CMS SurveyThe CMS SurveyThe CMS SurveySmoke Compartmentation and ControlSmoke Compartmentation and Control–– K27K27

Existing door openings in smoke barriers have:Existing door openings in smoke barriers have:–– At least a 20 minute fire protection rating or are at least 1 3/4 inch thick solid At least a 20 minute fire protection rating or are at least 1 3/4 inch thick solid

bonded core wood bonded core wood NonNon--rated protective plates that do not exceed 48 inches from the bottom of therated protective plates that do not exceed 48 inches from the bottom of the–– NonNon--rated protective plates that do not exceed 48 inches from the bottom of the rated protective plates that do not exceed 48 inches from the bottom of the door are permitted. door are permitted.

–– Horizontal sliding doors comply with 7.2.1.14. Horizontal sliding doors comply with 7.2.1.14. –– Doors shall be selfDoors shall be self--closing or automaticclosing or automatic--closing in accordance with 19.2.2.2.6. closing in accordance with 19.2.2.2.6. –– Swinging doors are not required to swing with egressSwinging doors are not required to swing with egress

P iti l t hi i t i dP iti l t hi i t i d–– Positive latching is not requiredPositive latching is not requiredNew Door openings in smoke barriers have:New Door openings in smoke barriers have:

–– At least a 20 minute fire protection rating or are at least 1 3/4 inch thick solid At least a 20 minute fire protection rating or are at least 1 3/4 inch thick solid bonded core wood. bonded core wood.

–– NonNon--rated protective plates that do not exceed 48 inches from the bottom of the rated protective plates that do not exceed 48 inches from the bottom of the door are permitted. door are permitted.

–– Horizontal sliding doors comply with 7.2.1.14. Horizontal sliding doors comply with 7.2.1.14. –– Swinging doors shall be arranged so that each door swings in an opposite Swinging doors shall be arranged so that each door swings in an opposite

direction. direction. –– Doors shall be selfDoors shall be self--closing and rabbets, bevels or astragals are required at the closing and rabbets, bevels or astragals are required at the

meeting edges. meeting edges. –– Positive latching is not requiredPositive latching is not required


Smoke Compartmentation and ControlSmoke Compartmentation and ControlSmoke Compartmentation and ControlSmoke Compartmentation and Control–– K28K28

Discusses clear widths and vision panel requirements.Discusses clear widths and vision panel requirements.–– K104K104

Penetrations of smoke barriers by ducts are protected Penetrations of smoke barriers by ducts are protected by smoke dampers in accordance with 8 3 5by smoke dampers in accordance with 8 3 5by smoke dampers in accordance with 8.3.5.by smoke dampers in accordance with 8.3.5.

The CMS SurveyThe CMS SurveyThe CMS SurveyThe CMS SurveySmoke Compartmentation and ControlSmoke Compartmentation and ControlSmoke Compartmentation and ControlSmoke Compartmentation and Control–– K29K29

Existing hazardous areas are: Existing hazardous areas are: –– Protected by 1 hr FRR (with ¾ hr doors) or automatic fire Protected by 1 hr FRR (with ¾ hr doors) or automatic fire

extinguishment system and resistant to the passage of smoke, extinguishment system and resistant to the passage of smoke, –– Be without windowsBe without windows–– Self closing or automatic closing doorsSelf closing or automatic closing doors

New hazardous areas are:New hazardous areas are:–– Protected by a 1 hr FRR (with ¾ hr door)Protected by a 1 hr FRR (with ¾ hr door)y ( )y ( )–– Without windowsWithout windows–– SelfSelf--closing or automatic closing doorsclosing or automatic closing doors


Smoke Compartmentation and ControlSmoke Compartmentation and ControlSmoke Compartmentation and ControlSmoke Compartmentation and Control–– K30K30

Gift shops shall be protected as hazardous areas when Gift shops shall be protected as hazardous areas when p pp pused for storage or display of combustibles in quantities used for storage or display of combustibles in quantities considered hazardous. Nonconsidered hazardous. Non--rated walls may separate rated walls may separate gift shops that are not considered hazardous, have gift shops that are not considered hazardous, have g p ,g p ,separate protected storage and that are completely separate protected storage and that are completely sprinkled. sprinkled. Gift shops may be open to the corridor if they are notGift shops may be open to the corridor if they are notGift shops may be open to the corridor if they are not Gift shops may be open to the corridor if they are not considered hazardous, have separate protected considered hazardous, have separate protected storage, are completely sprinklered and do not exceed storage, are completely sprinklered and do not exceed 500 square feet500 square feet500 square feet.500 square feet.

The CMS SurveyThe CMS SurveyThe CMS SurveyThe CMS SurveyExit and Exit AccessExit and Exit Accessa d ccessa d ccess–– K32K32

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

–– K34K34K34K34Stairways and smoke proof towers used as exits are in Stairways and smoke proof towers used as exits are in accordance with 7.2. 18.2.2.4, 19.2.2.3, 19.2.2.4accordance with 7.2. 18.2.2.4, 19.2.2.3, 19.2.2.4

–– K35K35Capacity of exits in number of persons per unit of exit Capacity of exits in number of persons per unit of exit width is in accordance with 7 3 18 2 3 1 19 2 3 1width is in accordance with 7 3 18 2 3 1 19 2 3 1width is in accordance with 7.3. 18.2.3.1, 19.2.3.1width is in accordance with 7.3. 18.2.3.1, 19.2.3.1


Existing travel distances:Existing travel distances:100 ft from an exit access door to an exit (150 ft if AASS)100 ft from an exit access door to an exit (150 ft if AASS)150 ft from anywhere in a room (or suite of rooms) to an exit (200 ft 150 ft from anywhere in a room (or suite of rooms) to an exit (200 ft if AASS)if AASS)

K37K37–– K37K37Existing deadExisting dead--end corridors shall be permitted to be continued to be end corridors shall be permitted to be continued to be used if it is impractical and unfeasible to alter them so that exists are used if it is impractical and unfeasible to alter them so that exists are accessible in not less than two different directions from all points inaccessible in not less than two different directions from all points inaccessible in not less than two different directions from all points in accessible in not less than two different directions from all points in aisles, passageways, and corridors.aisles, passageways, and corridors.New deadNew dead--end corridors shall not exceed 30 ft.end corridors shall not exceed 30 ft.


Exit access is so arranged that exits are readily accessible at all Exit access is so arranged that exits are readily accessible at all ti i d ith 7 1 18 2 1 19 2 1 ( h t )ti i d ith 7 1 18 2 1 19 2 1 ( h t )times in accordance with 7.1. 18.2.1, 19.2.1 (egress chapter)times in accordance with 7.1. 18.2.1, 19.2.1 (egress chapter)

–– K39K39Existing Existing -- Width of aisles or corridors (clear and unobstructed) Width of aisles or corridors (clear and unobstructed)

i it h ll b t l t 4 f ti it h ll b t l t 4 f tserving as exit access shall be at least 4 feet.serving as exit access shall be at least 4 feet.New New -- Width of aisles or corridors (clear and unobstructed) serving Width of aisles or corridors (clear and unobstructed) serving as exit access in hospitals and nursing homes shall be at least 8 as exit access in hospitals and nursing homes shall be at least 8 feet In limited care facility and psychiatric hospitals width of aislesfeet In limited care facility and psychiatric hospitals width of aislesfeet. In limited care facility and psychiatric hospitals, width of aisles feet. In limited care facility and psychiatric hospitals, width of aisles or corridors shall be at least 6 feet. or corridors shall be at least 6 feet.

–– K40K40Exit access doors and exit doors used by health care occupants areExit access doors and exit doors used by health care occupants areExit access doors and exit doors used by health care occupants are Exit access doors and exit doors used by health care occupants are of the swinging type and have a clear width per 18/19.2.3.5of the swinging type and have a clear width per 18/19.2.3.5


All sleeping rooms have a door leading to a corridor providing All sleeping rooms have a door leading to a corridor providing t it h d l di di tl t dt it h d l di di tl t daccess to an exit or have a door leading directly to grade.access to an exit or have a door leading directly to grade.

–– K42K42Any room or suite of rooms of more than 1,000 sq. ft. has at least 2 Any room or suite of rooms of more than 1,000 sq. ft. has at least 2

it d t f h thit d t f h thexit access doors remote from each otherexit access doors remote from each other

–– K43K43Patient room doors are arranged such that the patients can open the Patient room doors are arranged such that the patients can open the door from inside without using a key. (Special door locking door from inside without using a key. (Special door locking arrangements are permitted in facilities. 18.2.2.2.4, 18.2.2.2.5)arrangements are permitted in facilities. 18.2.2.2.4, 18.2.2.2.5)

The CMS SurveyThe CMS SurveyThe CMS SurveyThe CMS SurveyIllumination and Emergency PowerIllumination and Emergency Poweru a o a d e ge cy o eu a o a d e ge cy o e–– K45K45--K47K47

Illumination of means of egress, including exit discharge and exit Illumination of means of egress, including exit discharge and exit dischargedischargedischargedischarge

–– K105K105--108 108 Requirements for life support systems, alarm detection, Requirements for life support systems, alarm detection, communications etc be on emergency powercommunications etc be on emergency powercommunications, etc. be on emergency powercommunications, etc. be on emergency power

–– K48K48Written Fire PlanWritten Fire Plan

–– K50K50Fire Drill requirementsFire Drill requirements

The CMS SurveyThe CMS SurveyThe CMS SurveyThe CMS SurveyIllumination and Emergency PowerIllumination and Emergency Powerg yg y–– K51, 52, 155, 53, 54, and 55K51, 52, 155, 53, 54, and 55

Fire Alarm System RequirementsFire Alarm System Requirements–– K56, 154, and 60K56, 154, and 60--64 64

Fire Sprinkler RequirementsFire Sprinkler Requirements

Smoking regulationsSmoking regulations–– K66K66

Smoking regulations shall be adopted and shall include not lessSmoking regulations shall be adopted and shall include not lessthan the following provisions: 18.7.4, 19.7.4 than the following provisions: 18.7.4, 19.7.4

–– Smoking shall be prohibited in any room, ward, orSmoking shall be prohibited in any room, ward, orcompartment where flammable liquids, combustible gases, or oxygen is used or stored compartment where flammable liquids, combustible gases, or oxygen is used or stored i th h d l ti d h h ll b t d ith i th t d NOi th h d l ti d h h ll b t d ith i th t d NOin any other hazardous location, and such area shall be posted with signs that read NO 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. SMOKING or shall be posted with the international symbol for no smoking.

–– Smoking by patients classified as not responsible shall be prohibited, except when under Smoking by patients classified as not responsible shall be prohibited, except when under direct supervision. direct supervision.

–– Ashtrays of noncombustible material and safe design shall be provided in all areas Ashtrays of noncombustible material and safe design shall be provided in all areas h ki i itt dh ki i itt dwhere smoking is permitted.where smoking is permitted.

–– Metal containers with selfMetal containers with self--closing cover devices into which ashtrays can be emptied closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. shall be readily available to all areas where smoking is permitted.

The CMS SurveyThe CMS SurveyThe CMS SurveyThe CMS SurveyBuilding Services EquipmentBuilding Services Equipmentu d g Se ces qu p eu d g Se ces qu p e–– K67 K67

Heating, ventilating, and air conditioning shall comply with 9.2 and shall be installed in Heating, ventilating, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications.accordance with the manufacturer’s specifications.

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

–– K69 K69 Cooking facilities shall be protected in accordance with 9.2.3.Cooking facilities shall be protected in accordance with 9.2.3.18.3.2.6, 19.3.2.6, NFPA 96 18.3.2.6, 19.3.2.6, NFPA 96

–– K70 K70 Portable space heating devices shall be prohibited in all health care occupanciesPortable space heating devices shall be prohibited in all health care occupanciesPortable space heating devices shall be prohibited in all health care occupancies. Portable space heating devices shall be prohibited in all health care occupancies. Except it shall be permitted to be used in nonExcept it shall be permitted to be used in non--sleeping staff and employee areas where sleeping staff and employee areas where the heating elements of such devices do not exceed 212 F (100 C). the heating elements of such devices do not exceed 212 F (100 C).

The CMS SurveyThe CMS SurveyThe CMS SurveyThe CMS SurveyBuilding Services EquipmentBuilding Services Equipmentu d g Se ces qu p eu d g Se ces qu p e–– K71K71

Linen ChutesLinen Chutes

–– K160K160All existing elevators, having a travel distance of 25 ft or more above or below the level All existing elevators, having a travel distance of 25 ft or more above or below the level that best serves the needs of emergency personnel for fire fighting purposes, conform that best serves the needs of emergency personnel for fire fighting purposes, conform with Firefighter’s Service Requirements of ASME/ ANSI A17.3, Safety Code for Existing with Firefighter’s Service Requirements of ASME/ ANSI A17.3, Safety Code for Existing Elevators and Escalators.Elevators and Escalators.All existing escalators, dumbwaiters, and moving walks conform to the requirements of All existing escalators, dumbwaiters, and moving walks conform to the requirements of ASME/ ANSI A17.3, Safety Code for Existing Elevators and Escalators. 19.5.3, 9.4.2.2 ASME/ ANSI A17.3, Safety Code for Existing Elevators and Escalators. 19.5.3, 9.4.2.2 Includes escalator emergency stop buttons and automatic skirt obstruction stop. For Includes escalator emergency stop buttons and automatic skirt obstruction stop. For power dumbwaiters includes hoistway door locking to keep doors closed except for floor power dumbwaiters includes hoistway door locking to keep doors closed except for floor where car is being loaded or unloadedwhere car is being loaded or unloadedwhere car is being loaded or unloaded.where car is being loaded or unloaded.All new elevators, escalators, and conveyors comply with ASME/ ANSI A17.1, Safety All new elevators, escalators, and conveyors comply with ASME/ ANSI A17.1, Safety Code for Elevators and Escalators (Includes car emergency signaling, firefighters Code for Elevators and Escalators (Includes car emergency signaling, firefighters service phase I key and smoke detector automatic recall, firefighters service phase II service phase I key and smoke detector automatic recall, firefighters service phase II emergency inemergency in--car operation, machine room smoke detectors, elevator lobby smoke car operation, machine room smoke detectors, elevator lobby smoke detectors). detectors).

The CMS SurveyThe CMS SurveyThe CMS SurveyThe CMS SurveyBuilding Services EquipmentBuilding Services Equipmentu d g Se ces qu p eu d g Se ces qu p e–– K72K72

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

–– K160K160All existing elevators, having a travel distance of 25 ft or more above or below the levelAll existing elevators, having a travel distance of 25 ft or more above or below the level

–– K73K73--7474Requirements for draperies, mattresses, etc.Requirements for draperies, mattresses, etc.

–– K75K75Soiled linen or trash collection receptacles shall not exceed 32 gal (121 L) inSoiled linen or trash collection receptacles shall not exceed 32 gal (121 L) inSoiled linen or trash collection receptacles shall not exceed 32 gal (121 L) in Soiled linen or trash collection receptacles shall not exceed 32 gal (121 L) in capacity. The average density of container capacity in a room or space shall not capacity. The average density of container capacity in a room or space shall not exceed .5 gal/ft2 (20.4 L/m2). A capacity of 32 gal (121 L) shall not be exceeded exceed .5 gal/ft2 (20.4 L/m2). A capacity of 32 gal (121 L) shall not be exceeded within any 64within any 64--ft2 (5.9ft2 (5.9--m2) area. Mobile soiled linen or trash collection receptacles m2) area. Mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) shall be located in a room protected as with capacities greater than 32 gal (121 L) shall be located in a room protected as a hazardous area when not attended.a hazardous area when not attended.


Laboratory RequirementsLaboratory RequirementsLaboratory RequirementsLaboratory Requirements–– K31, 136, and 131K31, 136, and 131--134134

If high hazardIf high hazardEmergency ProceduresEmergency ProceduresSpill ProceduresSpill ProceduresSafety EducationSafety EducationFume HoodsFume HoodsEmergency ShowerEmergency Showerg yg yFlammable Liquid StorageFlammable Liquid Storage

–– K 76K 76--78,14078,140--141, and 142141, and 142--143143Medical Gas SystemsMedical Gas SystemsAnesthesia Locations 35% HumidityAnesthesia Locations 35% HumidityAnesthesia Locations 35% HumidityAnesthesia Locations 35% HumidityMaster alarm panels are in two separate locations and have audible and visible signals. Master alarm panels are in two separate locations and have audible and visible signals. There are high/low alarms for +/There are high/low alarms for +/-- 20% operating pressure.20% operating pressure.Hyperbaric facilitiesHyperbaric facilities

Gas & Vacuum SystemsGas & Vacuum SystemsGas & Vacuum SystemsGas & Vacuum Systems

Storage between 300 cubic feet & 3000 cubic feetStorage between 300 cubic feet & 3000 cubic feet–– Outdoor spaceOutdoor space–– Interior spaceInterior space

Noncombustible or limitedNoncombustible or limited--combustible construction combustible construction Secured DoorsSecured DoorsVented (but not into corridor)Vented (but not into corridor)


Greater than 3,000 cubic feetGreater than 3,000 cubic feet–– OutdoorsOutdoors–– If indoors, be constructed and use interior finishes of noncombustible orIf indoors, be constructed and use interior finishes of noncombustible orIf indoors, be constructed and use interior finishes of noncombustible or If indoors, be constructed and use interior finishes of noncombustible or

limitedlimited--combustible materials such that all walls, floors, ceilings and combustible materials such that all walls, floors, ceilings and doors are of a minimum 1doors are of a minimum 1--hour fire resistance ratinghour fire resistance rating

–– Shall be provided with dedicated mechanical ventilation systems that Shall be provided with dedicated mechanical ventilation systems that draw air from within 300 mm (1 ft) of the floor and operate continuouslydraw air from within 300 mm (1 ft) of the floor and operate continuouslydraw air from within 300 mm (1 ft) of the floor and operate continuously. draw air from within 300 mm (1 ft) of the floor and operate continuously. A means of makeup air shall be provided.A means of makeup air shall be provided.


Oxidizing gases, such as oxygen and nitrous oxide:Oxidizing gases, such as oxygen and nitrous oxide:–– shall not be stored with any flammable gas, liquid, or vapor.shall not be stored with any flammable gas, liquid, or vapor.

5 f t f b tibl t i l i i kl d5 f t f b tibl t i l i i kl d–– 5 feet from combustible materials in sprinklered areas5 feet from combustible materials in sprinklered areas–– 20 feet from combustible materials in non20 feet from combustible materials in non--sprinklered areas orsprinklered areas or–– An enclosed cabinet of noncombustible construction having a minimum An enclosed cabinet of noncombustible construction having a minimum

fire protection rating of ½ hourfire protection rating of ½ hourfire protection rating of ½ hourfire protection rating of ½ hour

Gas & Vacuum SystemsGas & Vacuum SystemsGas & Vacuum SystemsGas & Vacuum SystemsCentralized manifold systems interior roomCentralized manifold systems interior room–– 1 hr FRR room & door1 hr FRR room & door–– Vented to exteriorVented to exterior–– Not located in or have direct access to areas involved in critical patient Not located in or have direct access to areas involved in critical patient

carecare–– Not located in or have direct access to anesthetizing procedures Not located in or have direct access to anesthetizing procedures –– Not located near areas storing flammable materials or liquids or Not located near areas storing flammable materials or liquids or

combustible liquidscombustible liquids–– Not located near areas with open flames (e g kitchen & mechanicalNot located near areas with open flames (e g kitchen & mechanicalNot located near areas with open flames (e.g., kitchen & mechanical Not located near areas with open flames (e.g., kitchen & mechanical

room)room)–– Not located in area with sparkNot located in area with spark--generating equipment (e.g., emergency generating equipment (e.g., emergency

generator)generator)

The CMS SurveyThe CMS SurveyThe CMS SurveyThe CMS SurveyElectrical SystemsElectrical Systemsyy–– K106 K106

The hospital and all nursing homes and hospices with life support equipment has a Type The hospital and all nursing homes and hospices with life support equipment has a Type I Essential Electrical System powered by a generator with a transfer switch and separate I Essential Electrical System powered by a generator with a transfer switch and separate power supply. power supply. p pp yp pp y

–– K144 K144 Generators are tested monthly and exercised under load for 30 minutes per month Generators are tested monthly and exercised under load for 30 minutes per month

–– K146 K146 The Type I EES is divided into the critical branch, life safety branch and the emergency The Type I EES is divided into the critical branch, life safety branch and the emergency systemsystem

–– K147 K147 Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical g q p ,g q p ,Code. Code.

–– And last, but not least, K130 And last, but not least, K130 Miscellaneous items that are not listed previously, but are deficient. Miscellaneous items that are not listed previously, but are deficient.

Electrical Systems Electrical Systems 110110NFPA 110NFPA 110

EPS installed in separate room for Level One installationsEPS installed in separate room for Level One installationsEPSS equipment allowed in same roomEPSS equipment allowed in same roomRoom must be 2Room must be 2--hour rated or in an adequate enclosure hour rated or in an adequate enclosure outside the building capable of resisting the entry of snow or outside the building capable of resisting the entry of snow or rainrainNo other equipment, except that serving the space, permitted No other equipment, except that serving the space, permitted in roomin room

Electrical SystemsElectrical Systems&&Maintenance & TestingMaintenance & Testing

Maintain to meet 10Maintain to meet 10--second criteriasecond criteriaInterval 20 to 40 daysInterval 20 to 40 days12 tests per year12 tests per yearMust meet 30% rated load or load bankMust meet 30% rated load or load bank36 M th t t t b t i i f 3% f th f ll 436 M th t t t b t i i f 3% f th f ll 436 Month test must be at a minimum of 3% for the full 4 36 Month test must be at a minimum of 3% for the full 4 hours.hours.

Summary of Hot ItemsSummary of Hot ItemsSummary of Hot ItemsSummary of Hot ItemsCorridor ObstructionsCorridor ObstructionsExits not locked/obstructedExits not locked/obstructedItems on Sprinkler lines and supportsItems on Sprinkler lines and supportsO JO J BBOpen JOpen J--BoxesBoxesAir Pressure RelationshipsAir Pressure RelationshipsFire DrillsFire DrillsFire DrillsFire DrillsEPSS TestingEPSS TestingDocumentation ErrorsDocumentation Errors

QuestionsQuestionsQuestionsQuestions

Ken GregoryKen Gregory

Vice President of AccreditationVice President of AccreditationVice President of AccreditationVice President of AccreditationTSIG ConsultingTSIG Consulting1001 Olivia Court1001 Olivia Court1001 Olivia Court1001 Olivia Court

Mount Juliet, TN 37122Mount Juliet, TN 37122(615) 598(615) 598--26522652

[email protected]@tsigconsulting.com

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CMS Issue Affecting theCMS Issue Affecting the … Issue Affecting theCMS Issue Affecting the ... Ventilation Control and Fire Protection ofVentilation Control and Fire Protection