CMS-2786U Fire Safety Survey Report - ASC & ESRD Medicare

DEPARTMENT OF HEALTH & HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

2000 CODE

FIRE SAFETY SURVEY REPORT - AMBULATORY SURGICAL CENTERS & END
STAGE RENAL DISEASE (ESRD) Medicare

Form Approved
OMB No. 0938-0242

1. (A) PROVIDER NUMBER

1. (B) MEDICAID I.D. NO.

K1

K2

Identifying information as shown in applicable records. Enter changes, if any, alongside each item, giving date of change.
2. (A) MULTIPLE CONSTRUCTION (BLDGS.)

A. BUILDING _________________

B. WING
_________________

C. FLOOR
_________________

2. NAME OF FACILITY

2. (B) ADDRESS OF FACILITY (STREET, CITY, STATE, ZIP CODE) A. Fully Sprinklered
(All required areas are sprinklered)
B. Partially Sprinklered
(Not all required areas are sprinklered)
C.

K0180

K3

Initial Survey

Resurvey

3. DATE OF SURVEY
K4

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 Accredited

New
DATE OF BLDG. PERMIT OR
PLAN APPROVAL:

None

(No sprinkler system)

Number of Stations in ESRD

Existing

DATE FIRST OCCUPIED AS
AMBULATORY SURGICAL CTR.

If facility is located in a hospital or hospital owned/operated, was facility surveyed as part of Hospital LSC Survey?

YES

NO

A.
The facility MEETS based upon:

1.
Compliance with all provisions

2.
Acceptance of a Plan of Correction

3.
Recommended waivers
B.
The facility DOES NOT MEET THE STANDARD.

5.

Performance Based Design

K9

SURVEYOR (SIGNATURE)

TITLE

OFFICE

DATE

TITLE

OFFICE

DATE

SURVEYOR ID
K10

REVIEW AUTHORITY OFFICIAL (SIGNATURE)

According to the Paperwork Reduction Act to 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0242.
The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review
the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard,
Baltimore, Maryland 21244-1850.
Form CMS-2786U (10/08) 

Page 1

ID
PREFIX

MET

CONSTRUCTION

K12

Buildings two or more stories in height and of Type II(000),III (200)
V (000) construction are equipped throughout with a supervised
approved automatic sprinkler system in accordance with section
9.7. 20.1.6.3, 21.1.6.3

Number of stories in the building__________________________

K13

NOT
MET

N/A

REMARKS

2000 CODE

Construction Type_ ____________________________________
EXITS

K32

At least two exits, located remote from each other are provided for
each floor or fire section of the building. 20.2.4.1, 21.2.4.1, 7.5.1.4

K42

Rooms or suites of rooms of more than 2,500 sq. ft. have at least
two exit access doors located remote from each other. 20.2.4.2,
21.2.4.2

K37

Dead-end corridors do not exceed 50 ft.
(Note: A common path of travel for the first 25 ft. is permitted.)
39.2.5.1, 39.2.5.2, 39.2.5.3

K36

Travel distance between any room door required as exit access
and an exit does not exceed 100 ft. The travel distance between
any point in a room and an exit does not exceed 150 ft.
(Note: In approved automatic sprinklered buildings, the travel
distances may be increased by 50 ft.). 20.2.6.2, 21.2.6.2

K112

At least 50 percent of the required exit capacity from upper floors
discharges directly to the exterior of the building in accordance
with section 7.7, 38.2.7, 39.2.7, 21.1.6.1, 20.1.6.1

K113

Designated aisles, corridors, passageways, and exitways are provided
with illumination in accordance with section 7.8. 20.2.8, 21.2.8

K46

Emergency illumination is provided in accordance with section 7.9.
20.2.9.1, 21.2.9.1

K47

Exits and ways of travel thereto are marked in accordance with
section 7.10. 20.2.10, 21.2.10

K43

Doors of patient treatment, diagnostic, or recovery rooms arranged
to provide a clear width of not less than 32 inches and existing
34 inch door. 20.2.3.3, 21.2.3.3

K40

Exit and exit access doors are at least 34 inches wide. 20.2.3.3, 21.2.3.3

Form CMS-2786U (10/08) 

Page 2

ID
PREFIX

MET

K31

LABORATORIES
Laboratories employing quantities of flammable, combustible, or
hazardous materials that are considered a severe hazard shall be
protected in accordance with NFPA 99. (Laboratories that are not
considered to be a severe hazard shall meet the provision of K29.)
Laboratories in health care occupancies and medical and dental
offices shall be in accordance with NFPA 99, Standard for Health
Care Facilities and NFPA101. Ventilating Systems shall comply
with NFPA 101. 20.3.2.1, 21.3.2.1, 8.4.4, 9.2.4

K136

Procedures for laboratory emergencies shall be developed. Such
procedures shall include alarm actuation, evacuation, and equipment
shutdown procedures, and provisions for control of emergencies
that could occur in the laboratory, including specific detailed plans
for control operations by an emergency control group within the
organization or a public fire department in accordance with
NFPA 99 and NFPA 101. 10.2.1.3.1, 20.3.2.1, 21.3.2.1

K131

Emergency procedures established for controlling chemical spills
shall be in accordance with NFPA 99. 10.2.1.3.2

K132

Continuing safety education and supervision shall be provided,
incidents shall be reviewed monthly, and procedures reviewed
annually shall be in accordance with NFPA 99. 10.2.1.4.2

K133

Fume hoods shall be in accordance with NFPA 99. 5.4.3, 5.6.2

K134

Emergency Shower:
Where the eyes or body of any person can be exposed to injurious
corrosive materials, suitable fixed facilities for quick drenching or
flushing of the eyes and body shall be provided within the work
area for immediate emergency use. Fixed eye baths shall be
designed and installed to avoid injurious water pressure shall be
in accordance with NFPA 99. 10.6

K135

Flammable and combustible liquids used from and stored in
approved containers shall be in accordance with NFPA 30,
Flammable and Combustible Liquids Code, and NFPA 45,
Standard on Fire Protection for Laboratories Using Chemicals.
Storage cabinets for flammable and combustible liquids shall be
constructed in accordance with NFPA 30, Flammable and
Combustible Liquids Code, NFPA 99. 4.3, 10.7.2.1

K39

Corridors for exit access are at least 44 inches wide. 20.2.3.2, 21.2.3.2

Form CMS-2786U (10/08) 

NOT
MET

N/A

REMARKS

2000 CODE

Page 3

ID
PREFIX

K105

MET

EMERGENCY POWER

NOT
MET

N/A

REMARKS

2000 CODE

Where general anesthesia or life support equipment is used, an
emergency power system is provided in accordance with NFPA 99.
20.2.9.2, 21.2.9.2
Indicate type__________________________________________
VERTICAL OPENING PROTECTION

K20

Vertical openings such as stairways, elevator shaftways,
escalators, and building service shaftways are enclosed in
accordance with section 8.2.5, 8.2.5.2, 38.3.1, 39.3.1
(Note: Some exceptions are permitted in 38.3.1.)

K21

Any door with a required fire protection rating, such as stairways,
exit passageways, horizontal exits, smoke barriers, or hazardous
areas enclosures, if held open, is arranged to close automatically
by the actuation of the manual fire alarm system and either smoke
detectors arranged to detect smoke on either side of the opening
or a complete automatic sprinkler system. 20.2.2.3, 21.2.2.3
HAZARDOUS AREA PROTECTION

K29

Hazardous areas separated from other parts of the building by fire
barriers have at least one hour fire resistance rating or such areas
are enclosed with partitions and doors and the area is provided with
an automatic sprinkler system. High hazard areas are provided
with both fire barriers and sprinkler systems 38.3.2, 39.3.2

Area
Automatic Sprinkler Separation N/A
General Storage
Boiler Rooms
Furnace Rooms
Storage Rooms
Maintenance Shops
Paint Shops
Laundries (over 100 square feet)
_________________________________________________________________________________
Chemical Storage Room
_________________________________________________________________________________

Form CMS-2786U (10/08) 

Page 4

ID
PREFIX

MET

NOT
MET

N/A

REMARKS

2000 CODE

K211 2000 EXISTING

Where Alcohol Based Hand Rub (ABHR) dispensers are

installed:

o The corridor is at least 6 feet wide

o The maximum individual fluid dispenser capacity shall be
1.2 liters (2 liters in suites of rooms)

o The dispensers shall have a minimum spacing of 4 ft from
each other

o Not more than 10 gallons are used in a single smoke
compartment outside a storage cabinet.

o Dispensers are not installed over or adjacent to an ignition
source.

o If the floor is carpeted, the building is fully sprinklered. 19.3.2.7,
CFR 416.44

2000 NEW

Where Alcohol Based Hand Rub (ABHR) dispensers are

installed:

o The corridor is at least 6 feet wide

o The maximum individual fluid dispenser capacity shall be
1.2 liters (2 liters in suites of rooms)

o The dispensers shall have a minimum spacing of 4 ft from
each other

o Not more than 10 gallons are used in a single smoke
compartment outside a storage cabinet.

o Dispensers are not installed over or adjacent to an
ignition source.

o If the floor is carpeted, the building is fully sprinklered. 18.3.2.7,
CFR 416.44
Medical Gases, and Anesthetizing Areas
K76
Medical gas storage and administration areas shall be protected

in accordance with NFPA 99, Standards for Health Care Facilities,

and NFPA 101.
(a) Oxygen storage locations of greater than 3,000 cu. ft. are
enclosed by a one hour separation.
(b) Locations for supply systems of greater than 3,000 cu. ft.
are vented to the outside.
4.3.1.1.2, 20.3.2.4, 21.3.2.4
K77

Piped in medical gas systems comply with NFPA 99.

Form CMS-2786U (10/08) 

Page 5

ID
PREFIX

MET

K78
Anesthetizing locations shall be protected in accordance with

NFPA 99, Standard for Health Care Facilities and NFPA 101.
(a) Shutoff valves are located outside each anesthetizing
location and arranged so that shutting off one room or
location will not affect others.
(b) Relative humidity is maintained equal to or greater
than 35%.

NFPA 99 4.3.1.2.3(n) and 5.4.1.1, 18.3.2.3, 19.3.2.3

NOT
MET

N/A

REMARKS

2000 CODE

K140 (a) Master alarm panels are in two separate locations and have
audible and visible signals.
(b) There are high/low alarms for +/- 20% operating pressure.
This section shall be in accordance with NFPA 99, 4.3.1.2.2
(c) Where a level 1 gas system is used, one alarm panel that
complies with 4.3.1.2.2(b) 3 a, b, c and d and with 4.3.1.2.2(c)
2 and 5 shall be permitted. (4.4.1 exception No. 4).
K141

Non-smoking and no smoking signs in areas where oxygen is
used or stored shall be in accordance with NFPA 99. 8.6.4.2

K142

All occupancies containing hyperbaric facilities shall comply with
NFPA 99, Standard for Health Care Facilities, Chapter 19.

K143
Transferring of oxygen shall be:

o (a) separated from any portion of a facility wherein patients are
housed, examined, or treated by a separation of a fire
barrier of one hour fire-resistive construction; and

o (b) the area that is mechanically ventilated, sprinklered, and
has ceramic or concrete flooring; and

o (c) in an area that is posted with signs indicating that
transferring is occurring, and that smoking in the immediate
area is not permitted in accordance with NFPA 99 and
Compressed Gas Association. 8.6.2.5.2
Electrical
K106

The ASC with life support equipment has a Type I Essential
Electrical System powered by a generator with a transfer switch
and separate power supply. The EES is in accordance with
NFPA 99. 3.4.2.2, 3.4.2.1.4 Required emergency shall be tested
and maintained in accordance with NFPA 110 Standard for
Emergency and Standby Power Supplies.

K144

Generators are inspected weekly and exercised under load for 30
minutes per month and shall be in accordance with NFPA 99.
3.4.4.1, NFPA110, 8.4.2

Form CMS-2786U (10/08)

Page 6

ID
PREFIX

MET

K145

The Type I EES is divided into the critical branch, life safety
branch and the emergency system and shall be in accordance
with NFPA 99. 3.4.2.2.2

K147

Electrical wiring and equipment shall be in accordance with
NFPA 70, National Electrical Code 9.1.2, 20.5.1

K146

REMARKS

2000 CODE

INTERIOR FINISH

Interior finish on walls and ceilings of exits, enclosed corridors,
and exit access furnishing shall be Class A or B (offices Class A,
B, or C) 38.3.3.2, 39.3.3.2

K51

A manual fire alarm system, not a pre-signal type, is provided to
automatically warn the building occupants. Fire alarm system has
initiation notification and control function. The fire alarm system is
arranged to automatically transmit an alarm to summon the fire
department. 20.3.4.1, 21.3.4.1

K17

Corridors used as access to exit are separated from use areas by
partitions with a fire resistance rating of at least one hour. Fire
resistance rating not required if building fully sprinklered. Doors
have at least one 20 minute fire protection rating and are equipped
with a positive latch and closing device. Vision panels, if provided,
in partitions or doors therein are not to exceed 20 inches and
install at or below half distance from floor to room ceiling.
20.3.6.2, 38.3.6.1

K114

N/A

The ASC with no life support equipment shall have an alternate
source of power separate and independent from the normal
source that will be effective for minimum of 11/2 hour after loss
of normal source NFPA 99. 3.6

K14

NOT
MET

FIRE ALARM SYSTEMS

CORRIDOR SEPARATION

(Indicate N/A for existing occupancies, open floor areas with
available exits, corridors in a space occupied by a single tenant,
and buildings provided with complete automatic sprinkler systems.)
OCCUPANCY SEPARATION

Ambulatory health care occupancies are separated from other
tenants and occupancies by fire barriers with at least a 1 hour fire
resistance rating. Doors in such barriers are solid bonded core
wood of 13/4 inches or equivalent and are equipped with a positive
latch and closing device. Vision panels, if provided in fire barriers
or doors shall be of fixed fire window assemblies in accordance
with 8.2.3.2.2.

Form CMS-2786U (10/08)

Page 7

ID
PREFIX

MET

smoke barriers

K115

Ambulatory health care facilities are divided into at least two
smoke compartments with smoke barriers having at least 1 hour
fire resistance rating. Doors in smoke barriers are equipped with
positive latcher. Doors shall be constructed of not less than 13/4
inch thick solid bonded core wood or equivalent. Vision panels are
provided and are of fixed wire glass limited to 1,296 sq. inch
per panel.

(Indicate N/A for facilities of less than 5,000 sq. ft. with an
approved smoke detection system, and less than 10,000 sq. ft.
with an approved supervicsed sprinkler system in accordance
with 9.7.) 20.3.7.1, 20.3.7.2, 20.3.7.3, 21.3.7.1, 21.3.7.2, 21.3.7.2

NOT
MET

N/A

REMARKS

2000 CODE

portable fire extinguishers
K64

Portable fire extinguishers are provided. 20.3.5.2, 21.3.5.2
High rise buildings

K116

Buildings over 75 ft. in height housing ambulatory health care
facilities are provided with a complete approved automatic
sprinkler system shall be in accordance with 11.8.
building services

K117

Utilities shall comply with section 9.1 Electrical Wiring and
Equipment and shall be in accordance with NFPA 70 National
Electrical Code. 20.5.1, 21.5.1, 9.1, See also K-147

K67

Heating, ventilating, and air-conditioning shall comply with the
manufacturer’s specifications and section 9.2. 20,5.2.1, 21.5.2.1

K70

Portable space heating devices are prohibited except portable
space heating devices shall be permitted to be used in nonsleeping staff and employee areas where the heating elements
of such devices do not exceed 212oF (100oC). 20.7.8, 21.7.8

K118

Elevators, dumbwaiters, and vertical conveyors shall comply with
section 9.4. 20.5.3, 21.5.3

K71

Rubbish chutes, incinerators, and laundry chutes shall comply
with section 7.5. 20.5.4, 21.5.4

Form CMS-2786U (10/08)

Page 8

ID
PREFIX

MET

emergency plan, fire drills

K48

There is a written plan for the protection of all patients and for
their evacuation in the event of an emergency. 20.7.1.1, 21.7.1.1

K50

Fire drills are held at unexpected times under varying conditions,
at least quarterly on each shift. The staff is familiar with procedures
and is aware that drills are part of established routine. 20.7.1.2,
21.7.1.2
SMOKING REGULATIONS

K66

Smoking regulations are adopted, and include the posting of
“NO SMOKING” signs or shall be posted with the international
symbol for no smoking in any room, ward, or compartment where
flammable liquids, combustible gases or oxygen are used or
stored, and in any other hazardous location. 20.7.4, 21.7.4

K72

FURNISHINGS AND DECORATIONS
Draperies, curtains and other loosely hanging fabrics and films
serving as furnishings, except curtains at shower, shall be in
accordance with NFPA 701. 20.7.5.1, 21.7.5.1

K73

Newly introduced upholstered furniture shall be in accordance
with NFPA 260, 261 unless building is fully sprinklered. 20.7.5.2,
21.7.5.2

K74

Newly introduced mattresses shall meet NFPA 267. 20.7.5.3,
21.7.5.3
Combustible decorations shall be flame retardant. 20.7.5.4, 21.7.5.4

K75

Solid linen or trash collection receptacles shall not exceed 32 gallons
(121L) in capacity. The average density of container capacity in a room
or space shall not exceed 0.5 gal/ft2 (20.4L/m2). A capacity of 32 gal
(121L) shall not be exceeded with any 64 ft2 (5.9m2) area.

Mobile soiled linen or trash collection receptacles with capacity
greater than 32 gallons (121L) shall be located in a room
protected as a hazardous area when not attended. 20.7.5.3, 21.7.5.5

NOT
MET

N/A

REMARKS

2000 CODE

MISCELLANEOUS
K130

List in the REMARKS section, any items that are not listed
previously, but are deficient. This information along with the
applicable Life Safety Code or NFPA Standard citation, should
be included on Form CMS-2567.

Form CMS-2786U (10/08) 

Page 9

RECOMMENDATION FOR WAIVER OF SPECIFIC LIFE SAFETY CODE PROVISIONS
For each item of the Life Safety Code recommended for waiver, list the survey report form item number and state the reason
for the conclusion that: (a) the specific provision of the code, if rigidly applied, would result in unreasonable hardship on the
facility, and (b) the waiver of such unmet provisions will not adversely affect the health and safety of the patients. (If additional
space is required, use additional sheet.)
JUSTIFICATION

PROVISION NUMBER(S)

Surveyor

(Signature)

Fire Authority Official
Form CMS-2786U (10/08) 

(Signature)

Title

Office

Date

Title

Office

Date
Page 10

Date of Plan
Approval
NUMBER OF THIS BUILDING

K56:

A4.

B.

Form CMS-2786U (10/08)

* MANDATORY

FACILITY DOES NOT MEET LSC

BUILDING
WING
FLOOR
APARTMENT UNIT

Fully Sprinklered

A.

Partially Sprinklered

B.
(All required areas are sprinklered) (Not all required areas are sprinklered)

K0180

(COMP. WITH
(ACCEPTABLE POC)
(WAIVERS)
(FSES)
ALL PROVISIONS)

A3.

A2.

e.g. 2.5

A1.

FACILITY MEETS LSC BASED ON (Check all that apply)

K29:

K5:

ENTER E – SCORE HERE

7 PROMPT
8 SLOW
9 IMPRACTICAL

APARTMENT HOUSE

K8:

4 PROMPT
5 SLOW
6 IMPRACTICAL

1 PROMPT
2 SLOW
3 IMPRACTICAL

K8:

LARGE

(16 BEDS OR LESS)

SMALL

*K9:

A
B
C
D

* K4

SURVEY DATE

None

Page 11

(No sprinkler system)

C.

(Performance
BAseD Design)

A5.

COMPLETE IF ICF/MR IS SURVEYED UNDER CHAPTER 21

____________

K8:
SELECT NUMBER OF FORM USED FROM ABOVE

ICF/MR Form
2786V, W, X 2000 existing
2786V, W, X 2000 new

ASC / ESRD Form
2786U
2000 EXISTING
2786U
2000 NEW

(Check if K29 or K56 are marked as not applicable
in the 2786 M, R, T, U, V, W, X and Y.)

* K7

16
17

14
15

12
13

MULTIPLE CONSTRUCTION

TOTAL NUMBER OF BUILDINGS ____________

K3

FACILITY NAME

Health Care Form
2786R
2000 Existing
2786R
2000 new

LSC FORM INDICATOR

K6

K1

PROVIDER NUMBER

FIRE SAFETY SURVEY REPORT
CRUCIAL DATA EXTRACT
(TO BE USED WITH CMS-2786 FORMS)