Fire Safety Survey Report Abulatory Surgical Centers Medicare {CMS-2786U}

DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICE 2012 LIFE SAFETY CODE Form Approved OMB Exempt FIRE SAFETY SURVEY REPORT 1. (A) PROVIDER NUMBER K1 1. (B) MEDICAID I.D. NO. K2 PART I 227 Life Safety Code, New and ExistingPART II 227 Health Care Facilities Code, New and ExistingPART III 227 Recommendation for WaiverPART IV 226 Crucial Data Extract Identifying information as shown in applicable records. Enter changes, if any, alongside each item, giving date of change. 2. NAME OF FACILITY 2. (A) MULTIPLE CONSTRUCTION (BLDGS.) A.BUILDINGB.WINGC.FLOORK32. (B) ADDRESS OF FACILITY (STATE, CITY, ZIPCODE) A. Fully Sprinklered (All required areas are sprinklered) B. Partially Sprinklered (Not all required areas are sprinklered) C. None (No sprinkler system) K0180 Initial SurveyResurveyDate of Survey K4New Existing Number of Stations in ESRD CHECK ONE Facility is: Physically located in a hospital Free-standing: only occupancy in building Located in an Office Occupancy Located in a Mercantile/Business Occupancy Indicate Occupancy Other (specify) Accredited by Non AccreditedDATE OF BLDG. PERMIT OR PLAN APPROVALK6DATE FIRST OCCUPIED AS AMBULATORY SURGICALCTR.If facility is located in a hospital or hospital owned/operated, was facility surveyed as part of Hospital LSC Survey?YesNoA The facility MEETS based upon: 1.Compliance with all provisions2.Acceptance of a Plan of Correction3.Recommended waivers4.Performance Based D esignBThe facility DOES NOT MEET THE STANDARD Page 1 K9SURVEYOR (Signature)SURVEYOR IDK10TITLEOFFICEDATEREVIEW AUTHORITY OFFICIAL (Signature)TITLEOFFICEDATECMS FORMS SHALL BE COMPLETED AND RETAINED AS PART OF THE SURVEY RECORD. American LegalNet, Inc. www.FormsWorkFlow.com Name of Facility 2012 LIFE SAFE TY CODE Page 2 ID PREFIX METNOT METN/AREMARKS PART I 226 NFPA 101 LSC REQUIREMENTS (Items in italics relate to the FSES) SECTION 1 226 GENERAL REQUIREMENTS K100 General Requirements 226 Other List in the REMARKS section any LSC Section 20.1 and 20.1 General Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. K111 Building Rehabilitation Repair, Renovation, Modification, or Reconstruction Any building undergoing repair, renovation, modification, or reconstruction complies with both of the following: Requirements of Chapter 21Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.620.1.1.4.3, 21.1.1.4.3, 4.6.7, 43.1.2.1Change of Use or Change of OccupancyAny building undergoing change of use or change of occupancy classification complies with the requirements of Section 43.7, unless permitted by 20.1.1.4.2 or 21.1.1.4.2 20.1.1.4.2, 21.1.1.4.2, 43.1.2.2 (43.7) Additions Any building undergoing an addition shall comply with the requirements of Section 43.8. If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a 2 hour fire resistance rating constructed of materials as required for the addition. 20.1.1.4.1, 21.1.1.4.1, 4.6.5, 4.6.7, 43.1.2.3 (43.8) American LegalNet, Inc. www.FormsWorkFlow.com Page 3 Name of Facility 2012 LIFE SAFE TY CODE ID PREFIX METNOT METN/AREMARKS K131 Multiple Occupancies 226 Sections of Ambulatory Health Care Facilities Multiple occupancies shall be in accordance with 6.1.14. Sections of ambulatory health care facilities shall be permitted to be classified as other occupancies, provided they meet both of the following: The occupancy is not intended to serve ambulatory health careoccupants for treatment or customary accessThey are separated from the ambulatory health care occupancy by a 1hour fire resistance ratingAmbulatory health care facilities shall be separated from other tenants and occupancies and shall meet all of the following: Walls have not less than 1 hour fire resistance rating and extend fromfloor slab to roof slabDoors are constructed of not less than 1-3/4 inches thick, solid-bondedwood core or equivalent and is equipped with positive latches.Doors are self-closing and are kept in the closed position, except whenin use.Windows in the barriers are of fixed fire window assemblies per 8.3.Per regulation, ASCs are classified as Ambulatory Health CareOccupancies, regardless of the number of patients served.20.1.3.2, 21.1.3.3, 20.3.7.1, 21.3.7.1,42 CFR 416.44 American LegalNet, Inc. www.FormsWorkFlow.com Name of Facility 2012 LIFE SAFETY CODE Page 4 ID NOT METN/AREMARKSPREFIXMETBuilding Construction Type and Height K161 Building construction type and stories meet Table 20.1.6.1 or Table 21.1.6.1, respectively. Construction Type I (442), I (332), II (222), Any number of stories 1 II (111), III (211), IV (2HH), non-sprinklered or sprinklered V (111) One story non-sprinklered 2 II (000), III (200), V (000) Any number of stories sprinklered Any level below the level of exit discharge shall be separated by Type II (111), Type III (211), or Type V (111) construction unless both of the following are met: 1.Such levels are under the control of the ambulatory health careoccupancy.2.Hazardous spaces are protected per section 8.7.Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 20.3.5 or 21.3.5, respectively) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate. 20.1.6.1, 20.1.6.2, 21.1.6.1, 21.1.6.2 K163 Interior Nonbearing Wall Construction Interior nonbearing walls in Type I or II construction are constructed of noncombustible or limited-combustible materials. Interior nonbearing walls required to have a minimum 2 hour fire resistance rating arefire-retardant-treated wood enclosed within noncombustible or limited-combustible materials, provided they are not used as shaft enclosures. 20.1.6.3, 20.1.6.4, 21.1.6.3, 21.1.6.4 American LegalNet, Inc. www.FormsWorkFlow.com Name of Facility 2012 LIFE SAFETY CODE Page 5 ID NOT METN/AREMARKSPREFIXMETSECTION 2 226 MEANS OF EGRESS REQUIREMENTS Means of Egress Requirements 226 Other K200 List in the REMARKS section any LSC Section 20.2 and 21.2 Means of Egress Requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. 20.2, 21.2 Means of Egress 226 General K211 Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full instant use in case of emergency, unless modified by 20/21.2.2 through 20/21.2.11. 20.2.1, 21.2.1, 7.1.10.1 Egress Doors K222 Special locking arrangements are in accordance with section 7.2.1.6 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 20.2.2.2, 21.2.2.2, 7.2.1.6.1 through 7.2.1.6.3 American LegalNet, Inc. www.FormsWorkFlow.com Name of Facility 2012 LIFE SAFETY CODE Page 6 ID PREFIX METNOT METN/AREMARKSK223 Doors with Self-Closing Devices Doors required to be self-closing are permitted to be held open by a release device complying with 7.2.1.8.2 that automatically closes all such doors througho