THROUGH A SURVEYOR’S EYES LIFE SAFETY THROUGH A SURVEYOR’S EYES

19 AREAS TO BE REVIEWED 1. FACILITY INFORMATION 2. GENERAL CONSTRUCTION 3. MEANS OF EGRESS 4. LABORATORY RELATED REQUIREMENTS 5. VERTICAL OPENING PROTECTION 6. HAZARDOUS AREA PROTECTION 7. MEDICAL GASES 8. ELECTRICAL SYSTEM 9. INTERIOR FINISHES 10. FIRE ALARM SYSTEMS 11. CORRIDOR SEPARATION 12. SMOKE & FIRE PROTECTION 13. PORTABLE FIRE EXTINGUISHERS 14. HIGH RISE BUILDINGS 15. BUILDING SERVICES 16. VERTICAL CONVEYORS 17. FIRE EMERGENCY PLAN 18. SMOKING 19. FURNISHINGS & DECORATIONS

FACILITY INFORMATION EXISTING NEW PERMITS WERE APPROVED OR CONSTRUCTION WAS STARTED BEFORE JULY 5, 2016 PERMITS WERE APPROVED OR CONSTRUCTION WAS STARTED AFTER JULY 5, 2016 REQUIREMENTS VARY DEPENDING ON WHETHER A FACILITY IS “NEW” OR EXISTING. NEW PROJECTS HAVE MORE STRINGENT REQUIREMENTS FOR LIFE SAFETY SYSTEMS. NEED TO KNOW THE SQUARE FOOTAGE OF THE FACILITY & WHETHER THE WHOLE BUILDING IS SPRINKLERED.

GENERAL CONSTRUCTION HAVE “AS BUILT” BLUEPRINTS AVAILABLE FOR SURVEYOR. SEPARATION OF ASC SPACE FROM OTHER TENANTS IN BUILDING: 2HOURS NO PENETRATIONS SUPERVISED AUTOMATIC SPRINKLER SYSTEMS: STOCK OF SPARE SPRINKLER HEADS & WRENCH FOR EACH TYPE (6) 18 INCHES OF CLEARANCE FROM TOP OF STORAGE TO ALLOW SHOWER OF SPRINKLERS ONE HEAD IS INSTALLED IN EVERY ROOM OR SPACE THROUGHOUT SPRINKLERS AND STANDPIPES ARE INSPECTED AND MAINTAINED ACCORDING TO NFPA 25: DAILY, WEEKLY, MONTHLY, QUARTERLY, AND 5 YEAR FREQUENCIES (MORE LATER ON THIS) DESIGNATED IMPAIRMENT COORDINATOR IS APPOINTED ACTS WHEN THE FIRE SPRINKLER SYSTEM IS IMPAIRED FOR MOR THAN 10 HOURS EVACUATES THE ASC ESTABLISH A FIRE WATCH

SPARE SPRINKLER HEADS & WRENCH

MEANS OF EGRESS THERE MUST BE 2 EXITS FROM THE ASC THERE MUST BE 2 EXITS FROM EACH SMOKE COMPARTMENT DOORS SWING IN THE DIRECTION OF EGRESS IF EXTERIOR DOOR HAS A KEY OPERATED LOCK, IT MUST HAVE A SIGN WITH 1 INCH HIGH LETTERS STATING “THIS DOOR TO REMAIN UNLOCKED WHEN THE BUILDING IS OCCUPIED” ALL PORTIONS OF THE EXIT PATHWAY ARE AT ALL TIMES KEPT FREE OF PHYSICAL AND VISUAL OBSTRUCTIONS

EGRESS LIGHTING EGRESS PATH MUST BE CONTINUOUSLY LIGHTED WHILE THE FACILITY IS OCCUPIED UNDER NORMAL POWER DO YOU HAVE KEYS IN SWITCHES SO THEY CAN’T BE TURNED OFF? FIXTURES THAT STAY ON WHEN THE SWITCH TO THE AREA IS SHUT OFF? IF YOU CAN TURN ALL OF THE LIGHTS OFF AND IT GETS DARK IN THE AREA, YOU ARE NOT MEETING THIS REQUIREMENT. EMERGENCY LIGHTING IN MEANS OF EGRESS IS PROVIDED FOR AT LEAST 90 MINUTES TEST FOR 30 SECONDS EVERY MONTH TEST FOR 90 MINUTES ONCE PER YEAR IDENTIFY THE BREAKERS THAT ENERGIZE THE EMERGENCY LIGHTING. TURN OFF BREAKER AND CHECK THE LIGHTING IS ON

EGRESS INDENTIFICATION EXIT SIGNAGE ALL EXIT DOORS ARE IDENTIFIED WITH SIGNS DIRECTIONAL EXIT SIGNS ARE PROVIDED TO DIRECT PERSONS TO THE EXIT. THE CHEVRONS POINT THE WAY OUT, IF IT IS NOT STRAIGHT EXIT SIGNAGE ILLUMINATION IS INSPECTED FOR PROPER ILLUMINATION AT LEAST EVERY 30 DAYS

NOTE THE CHEVRON IS POINTING DOWN THE HALL NOT DOWN THE STAIRS

VERTICAL OPENING PROTECTION STAIRS & ESCALATORS ELEVATORS HAVE THEIR OWN CHAPTER OPTIONS FOR COMPLIANCE: STAIRS PROTECTED WITH FIRE DOORS AND FIRE BARRIERS UNENCLOSED STAIRS WITH SPRINKLER SYSTEM MORE REQUIREMENTS, BUT THESE ARE THE 2 BIG ONES

HAZARDOUS AREA PROTECTION TRASH ROOM, BIOHAZARDOUS WASTE ROOM, SPRINKLERED OR WINDOWLESS 1HOUR RATED WALLS

ALCOHOL BASED HAND RUB CORRIDOR IS AT LEAST 6 FEET WIDE DISPENSER CAPACITY IS NO MORE THAN 38.4 OZ AEROSOL CAPACITY IS NOT MORE THAN 18 OZ. DISPENSERS ARE AT LEAST 4 FEET APART NO MORE THAN 10 GALLONS ALLOWED IN A SMOKE COMPARTMENT 5 GALLONS OR MORE MUST BE STORED IN FLAME PROOF CABINET DISPENSERS ARE LOCATED AT LEAST 1 INCH CLEAR FROM ANY SWITCH OR RECEPTACLE PLATE IF DISPENSERS ARE INSTALLED OVER CARPET, THE AREA MUST BE FULLY SPRINKLERED ABHR MUST BE PROTECTED FROM INAPPROPRIATE ACCESS

ALCOHOL BASED HAND RUBS OPERATION: DISPENSERS DO NOT RELEASE THEIR CONTENTS WITHOUT ACTIVATION TOUCH FREE ACTIVATION DOES NOT OCCUR UNTIL AN OBJJECT IS WITHIN 4 INCHES OF THE SENSING DEVICE THE PROPER AMOUNT IS DELIVERED EACH DISPENSER IS TESTED PER MANUFACTURERS INSTRUCTIONS EACH TIME IT IS REFILLED

MEDICAL GASES- SIGNAGE ON DOOR STORAGE AREA HAS A SIGN VISIBLE FROM 5 FEET AWAY THAT STATES: CAUTION: OXIDIZING GASES STORED WITHIN NO SMOKING IF JUST OXYGEN OR MEDICAL AIR IS STORED: MEDICAL GASES NO SMOKING OR OPEN FLAME IF COMPRESSED GAS STORAGE FOR OTHER THAN OXYGEN & MEDICAL AIR: POSTIVE PRESSURE GASES ROOM MAY HAVE INSUFFICIENT OXYGEN OPEN DOOR AND ALLOW ROOM TO VENTILATE BEFORE ENTERING

MEDICAL GASES ROOM IS FULLY ENCLOSED IN 1 HOUR RATED WALLS FREQUENTLY SEE PENETRATIONS FROM BANGING TANKS AND CHAINS INTERIOR LOCATIONS ARE VENTED NATURAL VENTILATION PROVIDED BY TWO NON- CLOSABLE LOUVERED OPENINGS MECHANICAL VENTILATION IS PROIDED THROUGH AN EXHAUST SYSTEM VERIFY IT IS WORKING BY TESTING MONTHLY TANKS ARE SECURED IN RACKS OR BY CHAINS – NO LONGER REQUIRED TO BE INDIVIDUALLY CHAINED.

MEDICAL GASES AND VACUUM PUMP MAINTENANCE AND TESTING NEED THE INITIAL VERIFICATION AND TESTING DOCUMENTS FOR THE MEDICAL GAS SYSTEM. KEEP IT FOR EVERY SURVEY PIPING IS TO BE LABELED WITH GAS NAME AND VISIBLE EVERY 20 FEET NFPA 99 2012 INDICATES TESTING IS BASED ON RISK ASSESSMENT AND MFG INSTRUCTIONS FOR SYSTEM HIGH RISK AREA IF GAS SYSTEM MONITORING FAILS. REQUIRES FREQUENT TESTING AND MONITORING BY STAFF RECOMMEND MONTHLY

ELECTRICAL SYSTEM PATIENT CARE-RELATED EQUIPMENT IS TESTED BEFORE BEING PUT INTO SERVICE FOR THE FIRST TIME AND AFTER ANY REPAIR OR MODIFICATION. ADDITIONAL TYPE OF TESTS AND INTERVALS OF TESTS OF PATIENT CARE-RELATED EQUIPMENT IS ESTABLISHED BY THE ASC AND WRITTEN INTO THE POLICIES & PROCEDURES NON- WET LOCATION RISK ASSESSMENT O.R.s ARE WET LOCATIONS REQUIRING EITHER GFI OF LIM IF NOT WET AND NOT PROTECTED WITH GIF OR LIM, A RISK ASSESSMENT NEEDS TO BE PERFORMED EACH YEAR AND APPROVED BY THE BOARD OUTLET TESTING HOSPITAL GRADE OUTLETS MUST BE TESTED IMMEDIATELY FOLLOWING INSTALLATION, SERVICING AND REPLACEMENT NON HOSPITAL GRADE OUTLETS IN PATIENT CARE AREAS MUST BE TESTED EVERY 12 MONTHLS CIRCUIT BREAKERS THAT ARE SPARE MUST BE IN “OFF” POSITION

BLOCKING THE ELECTRICAL PANEL NOTHING ALLOWED WITHIN 3 FEET

EMERGENCY ELECTRICAL SYSTEM TYPE I EES – DEEP SEDATION OR GENERAL ANESTHESIA GENERATOR TYPE 2 EES – LOCAL ANESTHESIA AND MODERATE SEDATION SEPSS (STORED ENERGY EMERGENCY POWER SUPPLY SYSTEM)

FREQUENT GENERATOR FINDINGS TWO SETS OF INSTRUCTION MANUALS ARE REQUIRED TO BE ON SITE ONE NEAR EQUIPMENT ONE IN A SEPARATE LOCATION REMOTE ANNUNCIATOR STATION READILY OBSERVED BY STAFF – OFTEN BLOCKED BY PAPERS BATTERY POWERED EMERGENCY LIGHTING INSIDE OF THE GENERATOR REMOTE SHUT OFF SWITCH OUTSIDE OF THE CABINET TRANSFER SWITCH(ES) EXERCISED MONTHLY GENERATOR EXERCISED FOR 30 MINUTES MONTHLY UNDER LOAD ACHIEVE 30% OF NAMEPLATE RATING OR DO A 90 MINUTE LOAD TEST ANNUALLY READINGS OF OUTPUT OIL PRESSURE BATTERY FUNCTION TEMPERATURE OF EXHAUST EVERY 36 MONTHS UNDERGO A 4 HOUR LOAD TEST GENERATOR IS INSPECTED WEEKLY AND DOCUMENTED

TYPE I EES BRANCHES THREE DISTINCT BRANCHES LIFE SAFETY BRANCH- ONLY CONTAIN LS ITEMS CRITICAL BRANCH- ONLY CONTAIN SPECIFIC ITEMS LISTED IN NFPA EQUIPMENT BRANCH

INTERIOR FINISHES PROVIDE THE FLAME SPREAD INFORMATION FOR FLOORING, WALL COVERING, CURTAINS, DECORATIONS POSTERS AND BULLETING BOARDS CANNOT COVER MORE THAN 20% OF THE WALL IT’S MOUNTED ON.

FIRE ALARM SYSTEMS MUST HAVE THE INITIAL DOCUMENTATION AND CERTIFICATION PULL STATION IS LOCATED INSIDE THE ASC ADJACENT TO EACH EXIT DISCHARGE OPENING THROUGH THE FIRE WALL SEPARATING THE ASC FROM NON ASC SPACE TECHNICIANS MUST BE QUALIFIED AND CERTIFIED. DOCUMENTATION REQUIRED POLICY FOR A FIRE WATCH OR EVACUATION WHEN THE SYSTEM IS OUT FOR MORE THAN 4 HOURS

SMOKE & FIRE PROTECTION #1 FINDING IS PENETRATIONS OF SMOKE AND FIRE WALLS FIRE DOORS MUST BE INSPECTED ANNUALLY BY INDIVIDUAL WITH DEMONSTRATED KNOWLEDGE & UNDERSTANDING OF REQUIREMENTS AND FUNCTIONAL COMPONENTS OF THE RATED ASSEMBLIES BEING EVALUATED REPAIRS MUST BE MADE ASAP SMOKE & FIRE DAMPERS ARE TESTED UPON INSTALLATION AFTER 1 YEAR EVERY 4 YEARS THEREAFTER SIGNAL TRANSMISSION VERIFICATION REQUIRED W/ DRILLS

DAMAGED FIRE DOOR

PORTABLE FIRE EXTINGUISHERS INSPECTED EVERY 30 DAYS

HIGH RISE BUILDINGS MUST BE PROTECTED THROUGHOUT BY A SPRINKLER SYSTEM

BUILDING SERVICES UTILITIES ARE INSTALLED IN A SAFE MANNER AND DO NOT POSE A HAZARD TO LIFE SMOKE & FIRE DAMPERS ARE INSPECTED AND TESTED ONE YEAR AFTER INSTALLATION, AND EVERY 4 YEARS THEREAFTER

TOO MUCH TRASH IN THIS SPACE

VERTICAL CONVEYORS FANCY TALK FOR ELEVATOR THE FIREMAN RECALL TEST MUST BE PERFORMED MONTHLY VERIFY THAT THE CERTIFICATE IS CURRENT IN THE CAB

FIRE EMERGENCY PLAN THE WRITTEN FIRE PLAN IS AVAILABLE AT THE MAIN TELEPHONE (FRONT DESK) FIRE DRILLS INCLUDE TRANSMISSION OF A FIRE ALARM SIGNAL AND SIMULATION OF EMERGENCY FIRE CONDITIONS

SMOKING NO SMOKING SIGNS ARE POSTED AT THE MAJOR ENTRANCES, EVEN IF IT IS A NON SMOKING BUILDING

FURNISHINGS & DECORATIONS IF YOU HAVE A SMALL SOILED HOLDING ROOM THAT IS LESS THAN 64 SQ FT, YOU CANNOT HAVE TRASH AND SOILED LINEN RECEPTACLES THAT EXCEED 32 GAL

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