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

2. 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

3. 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.

4. 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

5. SPARE
SPRINKLER
HEADS &
WRENCH

6. 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

7. 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

8. 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

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

10. 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

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

12. 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

14. 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

15. 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

16. 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.

17. 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 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

18. 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

19. BLOCKING
THE
ELECTRICAL
PANEL
NOTHING
ALLOWED
WITHIN
3 FEET

20. 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)

21. 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

22. 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

23. 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.

24. 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

25. 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

26. DAMAGED
FIRE DOOR

27. PORTABLE FIRE EXTINGUISHERS
INSPECTED EVERY 30 DAYS

28. HIGH RISE BUILDINGS
MUST BE PROTECTED THROUGHOUT BY A SPRINKLER SYSTEM

29. 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

30. TOO
MUCH TRASH
IN THIS SPACE

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

32. 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

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

34. 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

35. THE END
IF YOU NEED HELP MEETING THE REQUIREMENTS, PLEASE CONSIDER CALLING US AT RITEWAY SERVICES ASCQS
DEBBIE COMERFORD
BILL COMERFORD