Life Safety Inspection Report

**VA State Veterans Per Diem Program**

# Existing Nursing Home Care Facilities

(All Code References are NFPA 101-1997 unless otherwise noted)

This checklist is a summation of the requirements found in Chapter 13
"Existing Healthcare Occupancies" of the Life Safety Code. The user is
cautioned to consult the code prior to answering the following
questions.

Facility Name: [     ]{.underline}

Facility Address: [     ]{.underline}

Date Inspected: [     ]{.underline}

+---+-----------------------------------------+----------+---+---+---+
| I | Standard                                | R        | Y | N | N |
| t |                                         | eference | e | o | / |
| e |                                         |          | s |   | A |
| m |                                         |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 1 | Does the building construction meet the | 13-1.6   |   |   |   |
| - | basic requirements of NFPA 101,         |          |   |   |   |
| 1 | paragraph 13-1.6?                       |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 2 | Are exit stair enclosure doors and      | 5-2.1.8  |   |   |   |
| - | horizontal exit (if provided) doors     |          |   |   |   |
| 1 | self-closing?                           | 13-3.1.2 |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 2 | Are doors and associated hardware in    | 1-3.1.1  |   |   |   |
| - | good repair?                            |          |   |   |   |
| 2 |                                         |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 2 | Do exit access doors swing in the       | 5-2.1.4  |   |   |   |
| - | direction of exit travel?               |          |   |   |   |
| 3 |                                         |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 2 | Are doors to hazardous areas equipped   | 13-3.2.1 |   |   |   |
| - | with self-closing devices and kept      |          |   |   |   |
| 4 | closed?                                 |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 2 | Are exit stairs, which continue beyond  | 5-7.3    |   |   |   |
| - | the level of exit discharge interrupted |          |   |   |   |
| 5 | at the level of exit discharge by       |          |   |   |   |
|   | partitions, doors, gates, or other      |          |   |   |   |
|   | effective means?                        |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 2 | Are corridor doors equipped with a      | 13       |   |   |   |
| - | suitable means to keep the door closed  | -3.6.3.2 |   |   |   |
| 6 | when a force of 5 pounds is applied at  |          |   |   |   |
|   | the latch edge of the door? (Note:      |          |   |   |   |
|   | Roller latches are prohibited on        |          |   |   |   |
|   | corridor doors in buildings not fully   |          |   |   |   |
|   | protected by an approved automatic      |          |   |   |   |
|   | sprinkler system.)                      |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 2 | Do all patient rooms have an outside    | 13-3.8.1 |   |   |   |
| - | window or door and are the windowsills  |          |   |   |   |
| 7 | within 44 inches of the floor? (Note:   |          |   |   |   |
|   | Windowsill height in ICU's, CCU's and   |          |   |   |   |
|   | hemodialysis areas may be not higher    |          |   |   |   |
|   | than 60 inches.)                        |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 2 | Are all corridors serving patient       | 13-2.3.3 |   |   |   |
| - | sleeping rooms a minimum of 48 inches   |          |   |   |   |
| 8 | wide and kept free and clear of         | 2-4      |   |   |   |
|   | obstructions?                           |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 2 | Area all doors in a means of egress at  | 13-2.3.4 |   |   |   |
| - | least 32 inches wide?                   |          |   |   |   |
| 9 |                                         |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 2 | Are there two remote exits for each     | 13-2.4.1 |   |   |   |
| - | floor or fire/smoke area?               |          |   |   |   |
| 1 |                                         |          |   |   |   |
| 0 |                                         |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 2 | Does each habitable room have an exit   | 13-2.5.1 |   |   |   |
| - | access door leading directly to an exit |          |   |   |   |
| 1 | access (or otherwise meeting the        |          |   |   |   |
| 1 | exceptions of 13-2.5.1)?                |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 2 | Does every corridor provide access to   | 13-2.5.9 |   |   |   |
| - | at least two approved exits?            |          |   |   |   |
| 1 |                                         |          |   |   |   |
| 2 |                                         |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 2 | Is the travel distance between any      | 13       |   |   |   |
| - | point in a patient sleeping room and    | -2.6.2.3 |   |   |   |
| 1 | the door to the room 50 feet or less?   |          |   |   |   |
| 3 |                                         |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 2 | Are all exit discharges arranged and    | 5-7.3    |   |   |   |
| - | marked to clearly indicate direction of |          |   |   |   |
| 1 | egress?                                 |          |   |   |   |
| 4 |                                         |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 2 | Is emergency lighting provided          | 5-9.1.1  |   |   |   |
| - | throughout the means of egress?         |          |   |   |   |
| 1 |                                         | 13-2.9   |   |   |   |
| 5 |                                         |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+

VA FORM 10-3567b-1 (Test)

+---+-----------------------------------------+----------+---+---+---+
| I | Standard                                | R        | Y | N | N |
| t |                                         | eference | e | o | / |
| e |                                         |          | s |   | A |
| m |                                         |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 2 | Are exit discharge doorways kept free   | 2-4      |   |   |   |
| - | of ice, snow and other obstructions?    |          |   |   |   |
| 1 |                                         |          |   |   |   |
| 6 |                                         |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 2 | Are doors within a means of egress      | 13       |   |   |   |
| - | equipped with hardware which will open  | -2.2.2.4 |   |   |   |
| 1 | without the use of a key from the       |          |   |   |   |
| 7 | inside (or which meet the exceptions of |          |   |   |   |
|   | 13-2.2.2.4)?                            |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 2 | Are stairwells kept free of             | 5        |   |   |   |
| - | obstructions and storage?               | -1.3.2.3 |   |   |   |
| 1 |                                         |          |   |   |   |
| 8 |                                         |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 3 | Is a manual fire alarm station provided | 7-6.3.2  |   |   |   |
| - | in the natural path of egress near each |          |   |   |   |
| 1 | required exit?                          | 13-3.4.2 |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 3 | Are all manual fire alarm stations      | 7-6.2.4  |   |   |   |
| - | located so that the travel distance is  |          |   |   |   |
| 2 | no more than 200 feet, visible,         | 7-6.2.5  |   |   |   |
|   | unobstructed, and of the same general   |          |   |   |   |
|   | type?                                   |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 3 | Is occupant notification accomplished   | 13       |   |   |   |
| - | automatically by means of an internal   | -3.4.3.1 |   |   |   |
| 3 | audible alarm (or which meet the        |          |   |   |   |
|   | exceptions of 13-3.4.3.1)?              |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 3 | Are waiting areas open to the corridor  | 13-3.6.1 |   |   |   |
| - | less than 600 sq ft in size;            |          |   |   |   |
| 4 | [and]{.underline} in line of sight of   |          |   |   |   |
|   | the nurses station (or provided with    |          |   |   |   |
|   | smoke detection if the zone is          |          |   |   |   |
|   | sprinkler protected); [and]{.underline} |          |   |   |   |
|   | provided with smoke detection if the    |          |   |   |   |
|   | zone is not sprinklered;                |          |   |   |   |
|   | [and]{.underline} arranged not to       |          |   |   |   |
|   | obstruct exit access?                   |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 3 | Are smoke detectors located at corridor | 5-2.1.8  |   |   |   |
| - | smoke doors for the automatic release   |          |   |   |   |
| 5 | of smoke doors and activation of the    |          |   |   |   |
|   | fire alarm system?                      |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 3 | In facilities which are classified as   | 13       |   |   |   |
| - | "Limited Care" are smoke detectors      | -3.4.5.1 |   |   |   |
| 6 | located in the corridors or patient     |          |   |   |   |
|   | sleeping rooms (not required if the     |          |   |   |   |
|   | building is sprinkler protected)?       |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 3 | Does the fire alarm system              | 7-6.4    |   |   |   |
| - | automatically transmit an alarm to the  |          |   |   |   |
| 7 | fire department or other emergency      | 13       |   |   |   |
|   | forces immediately upon activation of a | -3.4.3.2 |   |   |   |
|   | system device (pull box, smoke          |          |   |   |   |
|   | detector, flow switch, etc) or does the |          |   |   |   |
|   | facility conform to Circular 10-83-94?  |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 3 | Are emergency lighting systems tested   | 5-9.3    |   |   |   |
| - | monthly?                                |          |   |   |   |
| 8 |                                         |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 3 | Are 100% of smoke detectors,            | NFPA     |   |   |   |
| - | audible/visual alarms, and smoke        | 72-1996  |   |   |   |
| 9 | barrier doors tested functionally at    |          |   |   |   |
|   | least annually?                         | 7-3.2 &  |   |   |   |
|   |                                         | Table    |   |   |   |
|   |                                         |          |   |   |   |
|   |                                         | 7-3.2    |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 4 | Are all exit stairs enclosed by one     | 5        |   |   |   |
| - | hour or greater rated construction for  | -1.3.1.2 |   |   |   |
| 1 | buildings 3 stories or less, or by 2    |          |   |   |   |
|   | hour fire resistive construction where  |          |   |   |   |
|   | the exit connects 4 or more stories?    |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 4 | Are all other vertical openings         | 13-3.1.1 |   |   |   |
| - | (shafts, chutes, elevator shafts, etc.) |          |   |   |   |
| 2 | enclosed by 1 hour or greater rated     |          |   |   |   |
|   | construction (or do they meet the       |          |   |   |   |
|   | exceptions noted in 13-3.1.1)?          |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 4 | Are all hazardous areas (including      | 13-3.2.1 |   |   |   |
| - | boiler rooms, laundries, repair or      |          |   |   |   |
| 3 | craft shops, soiled linen rooms,        |          |   |   |   |
|   | storage rooms, and trash rooms)         |          |   |   |   |
|   | enclosed by 1 hour fire rated           |          |   |   |   |
|   | construction and ¾ hour self closing    |          |   |   |   |
|   | doors --or-protected by an automatic    |          |   |   |   |
|   | sprinkler system and smoke resisting    |          |   |   |   |
|   | partitions and self closing doors?      |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 4 | Do all wall and ceiling finishes have a | 13-3.3.2 |   |   |   |
| - | Class A or Class B flame spread rating  |          |   |   |   |
| 4 | (Class C is permitted within a room     |          |   |   |   |
|   | separated from exit access corridors in |          |   |   |   |
|   | fully sprinkler protected buildings)?   |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 4 | Are sprinkler systems supervised by the | 13-3.5.3 |   |   |   |
| - | fire alarm system to monitor water flow |          |   |   |   |
| 5 | and valve tamper alarms?                |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+

+---+-----------------------------------------+----------+---+---+---+
| I | Standard                                | R        | Y | N | N |
| t |                                         | eference | e | o | / |
| e |                                         |          | s |   | A |
| m |                                         |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 4 | Are sprinkler systems water flow alarms | NFPA     |   |   |   |
| - | and main drain tests performed          | 25-1998  |   |   |   |
| 6 | quarterly and are records maintained?   |          |   |   |   |
|   |                                         | 2-1      |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 4 | Are fire pumps churn tested weekly and  | NFPA     |   |   |   |
| - | flow tested annually?                   | 25-1998  |   |   |   |
| 7 |                                         |          |   |   |   |
|   |                                         | 5-1-1    |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 4 | Is a minimum of 18 inches clearance     | NFPA     |   |   |   |
| - | maintained between the top of all       | 13-1996  |   |   |   |
| 8 | storage and ceiling sprinkler           |          |   |   |   |
|   | deflectors?                             | 4-2.5.1  |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 4 | Does the facility have contingency      | 7-7.6    |   |   |   |
| - | plans to address the sprinkler system   |          |   |   |   |
| 9 | or fire alarms systems being out of     |          |   |   |   |
|   | service, such as establishing a fire    |          |   |   |   |
|   | watch, prohibiting hot work, and        |          |   |   |   |
|   | notifying the fire department?          |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 4 | Is each floor housing more than 30      | 13-3.7.1 |   |   |   |
| - | patients divided into at least two      |          |   |   |   |
| 1 | smoke compartments?                     |          |   |   |   |
| 0 |                                         |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 4 | Is the maximum smoke compartment area   | 13-3.7.1 |   |   |   |
| - | 22,500 sq ft or less, and the travel    |          |   |   |   |
| 1 | distance to reach a smoke barrier door  |          |   |   |   |
| 1 | 200 feet or less?                       |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 4 | Are all doors in smoke zone separations | 13-3.7.6 |   |   |   |
| - | self or automatic closing?              |          |   |   |   |
| 1 |                                         |          |   |   |   |
| 2 |                                         |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 4 | Do all smoke barrier doors have at      | 13-3.7.5 |   |   |   |
| - | least a 20 minute fire rating and if    |          |   |   |   |
| 1 | they contain a vision panel, is it      |          |   |   |   |
| 3 | wired or fire rated glass in a steel    |          |   |   |   |
|   | frame?                                  |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 4 | Is the clearance around smoke barrier   | 6-3.4.1  |   |   |   |
| - | doors limited to 1/8 inch or less?      |          |   |   |   |
| 1 |                                         |          |   |   |   |
| 4 |                                         |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 4 | Are penetrations in smoke barrier walls | 6-3.6.1  |   |   |   |
| - | properly sealed to resist the passage   |          |   |   |   |
| 1 | of smoke?                               |          |   |   |   |
| 5 |                                         |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 4 | Are grease producing appliances in the  | NFPA     |   |   |   |
| - | Kitchen protected by an automatic fire  | 96-1994  |   |   |   |
| 1 | suppression system?                     |          |   |   |   |
| 6 |                                         | 7-1.2    |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 4 | Does the automatic fire extinguishing   | NFPA     |   |   |   |
| - | system cover the cooking surface of the | 96-1994  |   |   |   |
| 1 | range, griddle, fryers and duct system  |          |   |   |   |
| 7 | above the filters (protection not       | 7-1.2    |   |   |   |
|   | required above the filters if an        |          |   |   |   |
|   | approved and listed grease extraction   |          |   |   |   |
|   | system has been installed)?             |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 4 | Does the operation of the automatic     | NFPA     |   |   |   |
| - | extinguishing system over the cooking   | 96-1994  |   |   |   |
| 1 | surfaces automatically shut off all     |          |   |   |   |
| 8 | sources of fuel and heat the equipment  | 7-3.1.3  |   |   |   |
|   | protected by the system?                |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 4 | Are shut down devices of the type that  | NFPA     |   |   |   |
| - | require manual resetting prior to fuel  | 96-1994  |   |   |   |
| 1 | or power restoration?                   |          |   |   |   |
| 9 |                                         | 7-3.1.3  |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 4 | Is a readily accessible means available | NFPA     |   |   |   |
| - | to manually activate the automatic      | 96-1994  |   |   |   |
| 2 | extinguishing system (in the path of    |          |   |   |   |
| 0 | egress from the kitchen) over the       | 7-3.1.1  |   |   |   |
|   | cooking equipment?                      |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 4 | Are hoods, grease removal devices, fans | NFPA     |   |   |   |
| - | and ducts cleaned on a scheduled basis? | 96-1994  |   |   |   |
| 2 |                                         |          |   |   |   |
| 1 | *\[Cleaning frequencies will vary       | 8-3.1    |   |   |   |
|   | depending upon use and the types of     |          |   |   |   |
|   | foods being prepared. Cleanings must be |          |   |   |   |
|   | at least semiannual but more frequent   |          |   |   |   |
|   | cleanings may be required.\]*           |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 4 | Are fuse links located over cooking     | NFPA     |   |   |   |
| - | appliances and within plenums replaced  | 96-1994  |   |   |   |
| 2 | at least annually?                      |          |   |   |   |
| 2 |                                         | 8-2.1.2  |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 4 | Are deep fat fryers installed with at   | NFPA     |   |   |   |
| - | least a 16-inch space between the       | 96-1994  |   |   |   |
| 2 | fryers and flames from adjacent cooking |          |   |   |   |
| 3 | equipment?                              | 9-1.2.2  |   |   |   |
+---+-----------------------------------------+----------+---+---+---+

+---+-----------------------------------------+----------+---+---+---+
| I | Standard                                | R        | Y | N | N |
| t |                                         | eference | e | o | / |
| e |                                         |          | s |   | A |
| m |                                         |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 4 | Is the automatic fire extinguishing     | NFPA     |   |   |   |
| - | system protecting cooking equipment     | 96-1994  |   |   |   |
| 2 | inspected and serviced by a properly    |          |   |   |   |
| 4 | trained and qualified company on at     | 8-2.1    |   |   |   |
|   | least a semiannual basis?               |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 5 | Is emergency power available to operate | NFPA     |   |   |   |
| - | all required electrical systems?        | 99-1996  |   |   |   |
| 1 |                                         |          |   |   |   |
|   |                                         | 3        |   |   |   |
|   |                                         | -4.2.2.2 |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 5 | If a generator set is utilized for      | NFPA     |   |   |   |
| - | emergency power, is it inspected weekly | 99-1996  |   |   |   |
| 2 | and tested under load, for at least 30  |          |   |   |   |
|   | minutes, on a monthly basis?            | 3        |   |   |   |
|   |                                         | -6.2.4.1 |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 5 | Are all receptacles installed on 15 amp | NFPA     |   |   |   |
| - | and 20 amp branch circuits of the       | 70-1997  |   |   |   |
| 3 | grounding type?                         |          |   |   |   |
|   |                                         | 21       |   |   |   |
|   |                                         | 0-7\[a\] |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 5 | Are all receptacles in patient care     | NFPA     |   |   |   |
| - | areas tested for correct polarity and   | 99-1996  |   |   |   |
| 4 | retention force (not less than 4        |          |   |   |   |
|   | ounces) annually?                       | 3        |   |   |   |
|   |                                         | -5.2.2.1 |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 5 | Are 125 volt, single phase, 15 and 20   | NFPA     |   |   |   |
| - | amp receptacles located with 6 feet of  | 70-1997  |   |   |   |
| 5 | a water source provided with GFCI       |          |   |   |   |
|   | protection?                             | 210-8\[  |   |   |   |
|   |                                         | a\]\[1\] |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 5 | Are there sufficient receptacles in the | NFPA     |   |   |   |
| - | patient care areas so as to avoid the   | 99-1996  |   |   |   |
| 6 | use of extension cords or multiple      |          |   |   |   |
|   | outlet devices?                         | 3-4.1.   |   |   |   |
|   |                                         | 2.4\[b\] |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 5 | If provided, are laundry chute openings | 13-5.4.1 |   |   |   |
| - | into the corridors protected by 1 hour  |          |   |   |   |
| 7 | fire rated, self closing doors with     |          |   |   |   |
|   | approved and listed frames?             |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 5 | If provided, are laundry chute rooms    | 13-3.2.1 |   |   |   |
| - | and terminal rooms protected by either  |          |   |   |   |
| 8 | 1-hour fire rated construction or       |          |   |   |   |
|   | sprinkler protected with walls and      |          |   |   |   |
|   | doors, which resist the passage of      |          |   |   |   |
|   | smoke?                                  |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 5 | If provided, is the laundry chute       | 13-5.4.2 |   |   |   |
| - | provided with sprinkler protection at   |          |   |   |   |
| 9 | the top, bottom and every other floor   |          |   |   |   |
|   | between?                                |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 5 | If provided, is the (commercial type)   | 13-3.2.1 |   |   |   |
| - | laundry separated by 1-hour fire rated  |          |   |   |   |
| 1 | construction or is it sprinkler         |          |   |   |   |
| 0 | protected with walls and doors, which   |          |   |   |   |
|   | will resist the passage of smoke?       |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 5 | Are soiled linen room doors equipped    | 13-3.2.1 |   |   |   |
| - | with either self or automatic closing   |          |   |   |   |
| 1 | devices?                                | 13-2.2.6 |   |   |   |
| 1 |                                         |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 5 | Is the boiler or furnace room protected | 13-3.2.1 |   |   |   |
| - | by either 1-hour fire rated             |          |   |   |   |
| 1 | construction or a sprinkler system and  |          |   |   |   |
| 2 | smoke barrier partitions, with doors to |          |   |   |   |
|   | the room equipped with self or          |          |   |   |   |
|   | automatic closing devices?              |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 5 | Do elevators, which have a travel       | 7-4.5    |   |   |   |
| - | distance of 25 feet or more, equipped   |          |   |   |   |
| 1 | with automatic elevator (Phase I and    | ANSI     |   |   |   |
| 3 | II) recall?                             | 17.3     |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 6 | Does the facility have a written fire   | 13-7.1.1 |   |   |   |
| - | emergency plan, and is a copy available |          |   |   |   |
| 1 | in the nurse's station and other        |          |   |   |   |
|   | locations staffed 24 hours per day?     |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 6 | Are all facility personnel instructed   | 13-7.2.3 |   |   |   |
| - | in the use of, and response to, fire    |          |   |   |   |
| 2 | alarms and on the use of any code       |          |   |   |   |
|   | phrase used during fire emergencies?    |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 6 | Does documentation exist showing that   | 13-7.2.1 |   |   |   |
| - | quarterly fire drills are conducted on  |          |   |   |   |
| 3 | all shifts?                             |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 6 | Is smoking prohibited in all areas      | 13-7.4   |   |   |   |
| - | where flammable liquids, combustible    |          |   |   |   |
| 4 | gases, or oxygen is stored or used?     |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 6 | Is smoking prohibited by patients       | 13-7.4   |   |   |   |
| - | classified as not responsible?          |          |   |   |   |
| 5 |                                         |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 6 | Are portable space heating devices      | 13-7.7   |   |   |   |
| - | prohibited?                             |          |   |   |   |
| 6 |                                         |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+

+---+-----------------------------------------+----------+---+---+---+
| I | Standard                                | R        | Y | N | N |
| t |                                         | eference | e | o | / |
| e |                                         |          | s |   | A |
| m |                                         |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 6 | In patient rooms protected by           | NFPA     |   |   |   |
| - | sprinklers are privacy curtains         | 13-1996  |   |   |   |
| 7 | provided with minimum ½ inch mesh or    |          |   |   |   |
|   | are sprinklers located such that these  | 4        |   |   |   |
|   | curtains do not obstruct sprinkler      | -4.1.3.3 |   |   |   |
|   | discharge.                              |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 6 | Are fire extinguishers inspected on a   | NFPA     |   |   |   |
| - | monthly and serviced annually?          | 10-1996  |   |   |   |
| 8 |                                         |          |   |   |   |
|   |                                         | 4-1.2    |   |   |   |
|   |                                         |          |   |   |   |
|   |                                         | 4-3.1    |   |   |   |
+---+-----------------------------------------+----------+---+---+---+
| 7 | Are trash and linen receptacles limited | 13-7.5.5 |   |   |   |
| - | to 32-gallon capacity, or less, with    |          |   |   |   |
| 1 | not more than one 32-gallon capacity    |          |   |   |   |
|   | receptacle in a 64 square foot area?    |          |   |   |   |
|   | (Note: mobile soiled linen or trash     |          |   |   |   |
|   | collection receptacles with capacities  |          |   |   |   |
|   | greater than 32 gallons shall be        |          |   |   |   |
|   | located in a room protected as a        |          |   |   |   |
|   | hazardous area.)                        |          |   |   |   |
+---+-----------------------------------------+----------+---+---+---+

Recommendations:

     

Inspected By: