Form Cms-2786u - Fire Safety Survey Report - Asc & Esrd 2012 Life Safety Code Page 29
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39Name of Facility
2012 LIFE SAFETY CODE
ID
NOT
MET
N/A
REMARKS
PREFIX
MET
Gas and Vacuum Piped Systems – Information and Warning Signs
K909
Piping is labeled by stencil or adhesive markers identifying the gas or
vacuum system, including the name of system or chemical symbol, color
code (Table 5.1.11), and operating pressure if other than standard. Labels
are at intervals not more than 20 feet, are in every room, at both sides of
wall penetrations, and on every story traversed by riser. Piping is not
painted. Shutoff valves are identified with the name or chemical symbol of
the gas or vacuum system, room or area served, and caution to not use the
valve except in emergency.
5.1.14.3, 5.1.11.1, 5.1.11.2, 5.2.11, 5.3.13.3, 5.3.11 (NFPA 99)
Gas and Vacuum Piped Systems – Modifications
K910
Whenever modifications are made that breach the pipeline, any necessary
installer and verification test specified in 5.1.2 is conducted on the
downstream portion of the medical gas piping system. Permanent records
of all tests required by system verification tests are maintained.
5.1.14.4.1, 5.1.14.4.6, 5.2.13, 5.3.13.4.3 (NFPA 99)
Electrical Systems – Other
K911
List in the REMARKS section, any NFPA 99 Chapter 6 Electrical Systems
requirements that are not addressed by the provided K-Tags, but are
deficient. This information, along with the applicable Life Safety Code or
NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)
Electrical Systems – Receptacles
K912
Power receptacles have at least one, separate, highly dependable
grounding pole capable of maintaining low-contact resistance with its
mating plug. In pediatric locations, receptacles in patient rooms,
bathrooms, play rooms, and activity rooms, other than nurseries, are listed
tamper-resistant or employ a listed cover.
If used in patient care room, ground-fault circuit interrupters (GFCI) are
listed.
6.3.2.2.6.2 (F), 6.3.2.4.2 (NFPA 99)
Form CMS-2786U (10/2016)
Page 29
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