ASF ASC Medicare LSC Surveyor User Manual

AAAASF MEDICARE

ASC

Life Safety Code Section

Surveyors Handbook

Version 7.0

AMERICAN ASSOCIATION FOR

ACCREDITATION OF

AMBULATORY SURGERY FACILITIES, INC.

Medicare LSC Checklist for Accreditation of Ambulatory Surgery Facilities

Version 7.0 ● Published December 2018 ● Implement February 2019 ● Approved by CMS

November 2018

American Association for Accreditation of Ambulatory Surgery
Facilities, Inc. Content provided by Department of Health and
Human Services, Centers for Medicare and Medicaid Services

Notice

The materials included in this handbook are provided to assist the surveyor in

assessing the ASC’s compliance with all applicable codes and requirements. This

manual is intended as a survey guide to facilitate the documentation of surveyor
findings. The Life Safety Code surveyor must consider all applicable National Fire
Protection Association (NFPA) Life Safety Code (LSC), Health Care Facilities Code
(HCFC), and reference document requirements when conducting the survey.

ASC Application pg 289

9999.005

Fire Safety

9999

LIFE SAFETY CODE/ HEALTH CARE FACILITY CODES

9999.000.005

9999.005.005

9999.005.025 Compliant Deficient A,B,C-M,C

9999.005.050 Compliant Deficient A,B,C-M,C

___ Compliant ______ Deficient

416.44 Condition

Compliant

The operating room and recovery room have an emergency power source—such
as a generator or battery-powered inverter—with capacity to operate adequate
monitoring, anesthesia, surgical equipment, cautery, and lighting for a minimum of
2 hours. If 2 or more operation and recovery rooms are used simultaneously, an
adequate emergency power source must be available for each room.).

Sufficient electrical outlets are available, labeled and grounded to suit the
location
(e.g. wet locations, cystoscopy-arthroscopy) and connected to emergency
power supplies where appropriate.

All flammable and combustible materials and supplies are stored and
handled in a safe manner with appropriate ventilation according to the
most stringent requirements from among the LSC and HCFC
requirements, State or local authorities.

Deficient

B,C-M,C

9999.005.060 Compliant Deficient A,B,C-M,C

Except as otherwise provided in section 42 CFR 416.44, the ASC
must meet the provisions applicable to Ambulatory Health Care
Occupancies, regardless of the number of patients served, and
must proceed in accordance with the Life Safety Code (NFPA
101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA
12-3, and TIA 12-4).

416.44.b.1

9999.005.065 Compliant Deficient A,B,C-M,C

In consideration of a recommendation by the State survey agency, CMS may
waive, for periods deemed appropriate, specific provisions of the Life Safety
Code which, if rigidly applied, would result in unreasonable hardship upon an
ASC, but only if the waiver will not adversely affect the health and safety of the
patients.

416.44.b.2

Standard

Standard

ASC Application pg 299

9999.005.070 Compliant Deficient A,B,C-M,C
The provisions of the Life Safety Code do not apply in a State if CMS finds that a fire

and safety code imposed by State law adequately protects patients in an ASC.

416.44.b.3

Standard

9999.005.075

Compliant Deficient A,B,C-M,C

When a sprinkler system is shut down for more than 10 hours, the
ASC must:

i)

Evacuate the building or portion of the building affected by the system outage until the
system is back in service, or

ii)

Establish a fire watch until the system is back in service.

416.44.b.5

Standard

416.44.b.5.i Standard

416.44.b.5.ii Standard

9999.005.080 Compliant Deficient A,B,C-M,C

An ASC may place alcohol-based hand rub dispensers in its facility if the dispensers are
installed in a manner that adequately protects against inappropriate access.

416.44.b.4 Standard

9999.005.085 Compliant Deficient A,B,C-M,C

Beginning July 5, 2017, an ASC must be in compliance with Chapter 21.3.2.1,
Doors to hazardous areas.

416.44.b.6 Standard

ASC Application pg 291

9999.005.090 Compliant Deficient A,B,C-M,C
Except as otherwise provided in section 42 CFR 416.44, the ASC must meet the

applicable provisions and must proceed in accordance with the 2012 edition of the
Health Care Facilities Code (NFPA 99, and Tentative Interim Amendments TIA
12-2, TIA 12-3, TIA 12-4, TIA 12-5 and TIA 12-6).

416.44.c Standard

9999.005.095 Compliant Deficient A,B,C-M,C

Chapters 7, 8, 12, and 13 of the adopted Health Care Facilities Code do not
apply to an ASC.

416.44.c.1

Standard

9999.005.100 Compliant Deficient A,B,C-M,C

If application of the Health Care Facilities Code required under paragraph (c)
of this section would result in unreasonable hardship for the ASC, CMS may
waive specific provisions of the Health Care Facilities Code, but only if the
waiver does not adversely affect the health and safety of patients.

416.44.c.2

Standard

9999.010

Reference Section

9999.010.010

A,B,C-M,C

The standards incorporated by reference in this section are approved for incorporation by
reference by the Director of the Office of the Federal Register in accordance with 5
U.S.C.

552(a) and 1 CFR part 51. You may inspect a copy at the CMS Information

Resource Center,

7500 Security Boulevard, Baltimore, MD or at the National

Archives and Records

Administration (NARA). For information on the availability of this

material at NARA, call

202-741-6030, or go to:
http://www.archives.gov/federal_register/
code_of_federal_regulations/ibr_locations.html. If any changes in this edition of the Code
are incorporated by reference, CMS will publish a document in the Federal Register to
announce the changes.

(1)

National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02169,

www.nfpa.org, 1.617.770.3000.
(i)

NFPA 99, Standards for Health Care Facilities Code of the National Fire

Protection

Association 99, 2012 edition, issued August 11, 2011.

(ii)

TIA 12-2 to NFPA 99, issued August 11, 2011.

(iii)

TIA 12-3 to NFPA 99, issued August 9, 2012.

(iv) TIA 12-4 to NFPA 99, issued March 7, 2013.
(v) TIA 12-5 to NFPA 99, issued August 1, 2013.
(vi) TIA 12-6 to NFPA 99, issued March 3, 2014.
(vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011;
(viii) TIA 12-1 to NFPA 101, issued August 11, 2011.
(ix) TIA 12-2 to NFPA 101, issued October 30, 2012.
(x) TIA 12-3 to NFPA 101, issued October 22, 2013.
(xi) TIA 12-4 to NFPA 101, issued October 22, 2013.

416.44.f Standard

Statement of Deficiency

Official Forms Only Please

Surveyor:

Facility ID:

Date:

□ Condition Level Deficiency

Standard #:

□ Standard Level Deficiency

Approved: June 5, 2014

Implemented: June 5, 2014

Instructions:
Include the facts and findings relevant to the deficient practice must answer the
questions: who, what, where, when, and how. Illustrate the entity’s noncompliance with
the requirement. The deficiency citation must explain how the entity fails to comply with
the regulatory requirements, not how it fails to comply with the guidelines for the
interpretation of those requirements. Refer to the CMS Principles of Documentation for
further instruction.

This standard was NOT MET as evidenced by… (Describe the deficient practice
and identify relevant findings and facts that substantiate the failure of compliance.)

Findings include: (Describe each item of non-compliance as observed during the
survey relative to the requirement being cited as not met. Remember to quantify findings
where possible, i.e.
4/20 records.)

Statement of Deficiency

Official Forms Only Please

Surveyor:

Facility ID:

Date:

□ Condition Level Deficiency

Standard #:

□ Standard Level Deficiency

Approved: June 5, 2014

Implemented: June 5, 2014

Instructions:
Include the facts and findings relevant to the deficient practice must answer the

questions: who, what, where, when, and how. Illustrate the entity’s noncompliance with

the requirement. The deficiency citation must explain how the entity fails to comply with
the regulatory requirements, not how it fails to comply with the guidelines for the
interpretation of those requirements. Refer to the CMS Principles of Documentation for
further instruction.

This standard was NOT MET as evidenced by… (Describe the deficient practice
and identify relevant findings and facts that substantiate the failure of compliance.)

Findings include: (Describe each item of non-compliance as observed during the
survey relative to the requirement being cited as not met. Remember to quantify findings
where possible, i.e. 4/20 records.)

Statement of Deficiency

Official Forms Only Please

Surveyor:

Facility ID:

Date:

□ Condition Level Deficiency

Standard #:

□ Standard Level Deficiency

Approved: June 5, 2014

Implemented: June 5, 2014

Instructions:
Include the facts and findings relevant to the deficient practice must answer the
questions: who, what, where, when, and how. Illustrate the entity’s noncompliance with
the requirement. The deficiency citation must explain how the entity fails to comply with
the regulatory requirements, not how it fails to comply with the guidelines for the
interpretation of those requirements. Refer to the CMS Principles of Documentation for
further instruction.

This standard was NOT MET as evidenced by… (Describe the deficient practice
and identify relevant findings and facts that substantiate the failure of compliance.)

Findings include: (Describe each item of non-compliance as observed during the
survey relative to the requirement being cited as not met. Remember to quantify findings
where possible, i.e. 4/20 records.)

Statement of Deficiency

Official Forms Only Please

Surveyor:

Facility ID:

Date:

□ Condition Level Deficiency

Standard #:

□ Standard Level Deficiency

Approved: June 5, 2014

Implemented: June 5, 2014

Instructions:
Include the facts and findings relevant to the deficient practice must answer the

questions: who, what, where, when, and how. Illustrate the entity’s noncompliance with

the requirement. The deficiency citation must explain how the entity fails to comply with
the regulatory requirements, not how it fails to comply with the guidelines for the
interpretation of those requirements. Refer to the CMS Principles of Documentation for
further instruction.

This standard was NOT MET as evidenced by… (Describe the deficient practice
and identify relevant findings and facts that substantiate the failure of compliance.)

Findings include: (Describe each item of non-compliance as observed during the
survey relative to the requirement being cited as not met. Remember to quantify findings
where possible, i.e. 4/20 records.)

Page 1

Life Safety Code Survey Guide (10/2016)

PART I — Life Safety Code, New and Existing

PART II — Health Care Facilities Code, New and Existing

PART III — Recommendation for Waiver

PART IV – Crucial Data Extract

Identifying information as shown in applicable records. Enter changes, if any, alongside each item, giving date of change.

2012 LIFE SAFETY CODE

Content provided by the Centers for
Medicare & Medicaid Services

2. NAME OF FACILITY

2. (A) MULTIPLE

CONSTRUCTION (BLDGS.)

2. (B) ADDRESS OF FACILITY
CODE)

(STATE,

CITY,

ZIP

A. Fully Sprinklered

(All required areas are sprinklered)

B. Partially Sprinklered

(Not all required areas are
sprinklered)

C. None (No sprinkler system)

K0180

A. BUILDING
B. WING
C. FLOOR

K3

Initial Survey Resurvey

Date of Survey

K4

New Existing Number of Stations in ESRD

CHECK ONE
Facility is:

DATE OF BLDG. PERMIT OR PLAN APPROVAL

DATE FIRST OCCUPIED AS AMBULATORY SURGICAL
CTR.

Physically located in a hospital
Free-standing: only occupancy in building

K6

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

Yes No

Located in an Office Occupancy

Located in a Mercantile/Business Occupancy

Indicate Occupancy

Other (specify)
Accredited by
Non Accredited

A

The facility MEETS based upon:

1. Compliance with all provisions

2. Acceptance of a Plan of Correction

3. Recommended waivers

4. Performance Based Design

B

The facility DOES NOT MEET THE STANDARD

K9

SURVEYOR (Signature)

TITLE

OFFICE

DATE

SURVEYOR ID

K10

REVIEW AUTHORITY OFFICIAL (Signature)

TITLE

OFFICE

DATE

FORMS SHALL BE COMPLETED AND RETAINED AS PART OF THE SURVEY RECORD.

FIRE SAFETY SURVEY REPORT – AMBULATORY SURGICAL

CENTERS (ASC) & END STAGE RENAL DISEASE (ESRD)

MEDICARE

1. (A) PROVIDER NUMBER

K1

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

K2

Name of Facility

2012 LIFE SAFETY CODE

Life Safety Code Survey Guide (10/2016)

Page 2

ID

PREFIX

MET

NOT
MET

N/A

REMARKS

PART I – NFPA 101 LSC REQUIREMENTS

(Items in italics relate to the FSES)

SECTION 1

–

GENERAL REQUIREMENTS

K100

General Requirements – 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 21

•

Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6

20.1.1.4.3, 21.1.1.4.3, 4.6.7, 43.1.2.1

Change of Use or Change of Occupancy

Any 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)

Name of Facility

2012 LIFE SAFETY CODE

Life Safety Code Survey Guide (10/2016)

Page 3

ID

PREFIX

MET

NOT
MET

N/A

REMARKS

K131

Multiple Occupancies – 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 care
occupants for treatment or customary access

•

They are separated from the ambulatory health care occupancy by a
1-hour fire resistance rating

Ambulatory 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 from
floor slab to roof slab

•

Doors are constructed of not less than 1-3/4 inches thick, solid-bonded
wood core or equivalent and is equipped with positive latches.

•

Doors are self-closing and are kept in the closed position, except when
in use.

•

Windows in the barriers are of fixed fire window assemblies per 8.3.

Per regulation, ASCs are classified as Ambulatory Health Care
Occupancies, 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

Name of Facility

2012 LIFE SAFETY CODE

Life Safety Code Survey Guide (10/2016)

Page 4

ID

PREFIX

MET

NOT
MET

N/A

REMARKS

K161

Building Construction Type and Height

Building construction type and stories meet Table 20.1.6.1 or Table

21.1.6.1, respectively.

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 care
occupancy.

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 are fire-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

Construction Type

1

I (442), I (332), II (222),
II (111), III (211), IV (2HH),
V (111)

Any number of stories
non-sprinklered or sprinklered

2

II (000), III (200), V (000)

One story non-sprinklered
Any number of stories sprinklered