FACILITY NAME: CMS CATEGORICAL WAIVER CHECKLIST Page 1 of 7 Waiver Topic, description & location: CITY: If the facility desires to use any of the CMS categorical waivers listed below, it should follow the guides on the last page of this checklist Lauzon Life Safety Consulting, LLC Waiver adopted/approved (date) by q 1-Unoccupied Opening in Exit Enclosures K-033 LS02.01.20 EP 32 13-58 8/30/13 101-2000 unoccupied mech equip 7.1.3.2.1(d) rooms cannot open into exit enclosures REQUIREMENT CODE REF SUMMARY 7.1.3.2(9)c) existing unoccupied mech equip spaces (without fuel-fired equip & no storage) with fire-rated doors may open into exit enclosures (stairs & exit passageways) q Apply only to existing stairwell openings q Existing door must be properly rated q Used solely for non-fuel fired mechanical equip q Bldg has full supervised sprinkler sys q No storage of combustibles q 2-Door Locking K-038 LS02.01.20 13-58 8/30/13 101-2000 doors may be locked only 1014-2012 18/19.2.2.2 when the clinical needs of 18/19.2.2.2.5 patients require special security measures doors may be locked only when the clinical, security, safety. Or other special needs of patients require special security measures Can lock if Clinical Need: q The clinical need of patient requires specialized security measures or patient poses a security staff AND q All staff can readily unlock at all times with keys they carry at all times or via remote control or other reliable means available to all staff, AND q Only one lock on the door Can lock if Special Need: q The patient special needs requires specialized protective measures for their own safety, AND q All staff can readily unlock at all times with keys they carry at all times or via remote control or other reliable means available to all staff, AND q Only one lock on the door, AND (continued next col) q Complete smoke detection in locked space; or locked doors remotely unlockable from an approved & constantly attended location within the space, AND q Building fully sprinkled, AND q Electric locks open on loss of power, AND q Locks release by independent, activity of the smoke detector system or water flow of the sprinkler system
CMS CATEGORICAL WAIVER CHECKLIST Page 2 of 7 q 3-Delayed Egress Locking, single K-038 LS02.01.20 13-58 8/30/13 101-2000 only a single delayed 18/19.2.2.2 egress lock may be in a.4 path of egress REQUIREMENT CODE REF SUMMARY 18/19.2.2.2.4 (4) more than one delayed egress lock may be in a path of egress Follow 7.2.1.6.1: qlisted locking sys qlow/ordinary haz content q Irreversible release in 15 sec after opening attempt q 30 sec release if AHJ ok (no longer a limit of 1 per path of egress) q Bldg Full supervised sprinkled or full smoke detector q Unlock with power loss q Relock by manual only q Egress side of door has emerg lighting per LSC 7.9 Unlock with one of following: q Supervised sprinkler, or q Single heat detector, or q Two heat detectors q Readily visible sign w/1" hi letters with contrasting background q "Push until Alarm sounds, Door can be opened in 15 seconds" q Audible signal by door q 4-Suite size and travel distance K-042 LS02.01.20 8 13-58 8/30/13 101-2000 18/19.2.5 all required egress from suites must be to a corridor, rather than into another suite; sleeping suites max 5,000 sq. ft. 18/19.2.5.7 first egress means may be to a corridor, stair, or exterior. second egress from one suite may be into another suite; sleeping suites may be up to 10,000 sq. ft. q Suite enclosed with same walls as a corridor q Haz Areas enclosed per 18/19.3.2.1 qhaz suites okay if 1-hr enclosed & suite is mostly haz q OR Sterile Mtls exempt from enclosure if only a 1-day supply q Non-rated walls within suite must be made of non/limited combustible mtls or fire-retard wood covered with non/limited mtls q Travel Distance max 100' to corridor door q Exit Travel Distance from within suite max 150' if bldg not fully spkled q Exit Travel Distance from within suite max 200' if bldg fully spkled Sleeping Suites: q Must have a door to corridor or horiz exit q If >1,000 sf need two remote doors to corridor; but one can be into another suite if enclosed w/corridor type walls qmust have constant staff supervision in suite q Sleep rms must have direct staff supervision by normally attended location within suite OR complete smoke detection q Max 5,000 sf, unless: q Max 7,500 sf if fully sprinkled smoke comp has all QR sprinklers, OR full sprinkler + complete smoke detection q Max 10,000 sf if direct visual supervision + full QR sprinkling + complete smoke detection Non-Sleeping Patient Care Suites: q Must have a door to corridor or horiz exit q If >2,500 sf need two remote doors to corridor; but one can be into another suite if enclosed w/corridor type walls q Max 10,000 sf Non-Patient Care Suites: q Follow Travel Distance egress requirements of occupancy of primary use of space (no size limit) q 5-Sprinkler Testing K-062 EC02.03.05 EP 6 13-58 8/30/13 25-1998 2-3.3 quarterly testing of water flow alarms 25-2011 5.3.3.2 semi-annual testing of water flow alarms q Mechanical water flow tested quarterly q Vane-type & Pressure-Switch Type tested semi-annually
CMS CATEGORICAL WAIVER CHECKLIST Page 3 of 7 q 6-Fire Pump Testing K-062 EC02.03.05 EP 2 13-58 8/30/13 25-1998 5-3.2 REQUIREMENT CODE REF SUMMARY weekly no-flow testing of electric fire pumps 25-2011 8.3.1.2 monthly no flow testing of electric fire pumps q Electric motor fire pump noflow monthly operation q Diesel driven operated weekly q Start pump automatically or auto-timer q Run for at least 10 min with no flow q Must have safety valve to permit water discharge q Qualified operator in attendance when pump is operating q Fill out specified visual checklist q 7-Relative Humidity in Anesthetic area K-067 LS02.01.30 EP 25 13-25 4/19/13 99-99 5-4.1.1 min 35% RH where inhalation anesthetics used 99-2012 9.3.1.1 min 20% RH where inhalation anesthetics used; recommend comply with ASHRAE 170, 20-60% RH q comply with ASHRAE 170-2008 q comply with ASHRAE 90.1-2010 q 8-Fireplace, Direct-Vent q 9-Fireplace, Solid Fuel K-067 LS02.01.50 K-067 LS02.01.50 12-21 3/9/12 101-2000, no fireplaces in sleeping 18/19.5.2.2 compartments (except 2) 12-21 3/9/12 101-2000, no fireplaces in sleeping 18/19.5.2.2 compartments (except 2) 18/19.5.2.3 18/19.5.2.3 direct-vent fireplaces in common areas & solid fuel fireplaces in areas other than sleeping compartments direct-vent fireplaces in common areas & solid fuel fireplaces in areas other than sleeping compartments q Fireplace complies with NFPA 54-Nat Fuel Gas code q Installed, maintained & used per LSC 9.2.2, which references NFPA 54 & 211 qseparated from sleeping rooms with 1-hr rated walls q Carbon Monoxide in rm; electrically supervised qnot in a sleeping room q Smoke Compartment is fully sprinkled with Quick Response heads q Installed, maintained & used per LSC 9.2.2, which references NFPA 54 & 211 q Hearth min 4" high q Fireplace has sealed glass front with wire mesh panel or screen q Controls are locked or in a restricted location q Carbon Monoxide in same room & is electrically supervised q Enclosure made of heat treated tempered glass q Enclosure guaranteed against breakage up to 650 F q 10-Kitchens in Corridors K-069 LS02.01.35 4 12-21 13-58 3/9/12 8/30/13 101-00 18/19.3.2.6 9.2.3 no cooking in the corridor; warming only is permitted 18/19.3.2.5 kitchens for cooking for less than 31 residents can be open to corridors, with restrictions; warming is permitted q smk compart has <30 patients q hood as wide as cook surface q hood has grease baffles q hood has min 500 cfm q hood exhausts to exterior or has charcoal filter q cooking surfaces protected with UL 300 extinguishing sys q deactivation switch of cooktop q NFPA 96 chap 11 followed for use, has restricted access inspection & maintenance q deactivation switch used when q min 2 ac interconnected photoelectric kitchen isn't supervised smoke alarms located at least 20' from q deactivation switch max 2-hr cook surface timer to auto turn off q smoke detector located at least 20' from qextinguishing sys has manual cook surface release qsolid fuel cooking prohibited q exting sys activates fuel shutdown interlock
CMS CATEGORICAL WAIVER CHECKLIST Page 4 of 7 q 11-Corridor Obstruction K-072 LS02.01.20 3 12-21 13-58 3/9/12 8/30/13 101-00 7.1.10 REQUIREMENT CODE REF SUMMARY nothing in the corridor that reduces required egress width, other than permitted projections 18/19.2.3.4 1. permits certained wheeled equip in corridor 2. permits permanent seating groupings of furniture in corridor Furniture: q corr min 8' wide q furn fixed to floor or wall q all furn on one side of corr q max 50 sf per furn group q furn groups min 10' apart Furniture: q no obstruction to bldg service or fire protection devices q corr smoke detection or direct nrs sta supervision Wheeled Equip: q Leaves min 5' unostructed width q Fire response plan requires removal during an emergency q Limited to equip in use, carts in use, med emerg equip not in use (crash cart), pt lift equip, pt transport equip q 12-Decoration, Combustible K-073 LS02.01.70 12-21 13-58 3/9/12 8/30/13 101-00 18/19.7.5 no combustible decorations 18/19.7.5.6 increased wall space covered with combustible decorations qflame-retardant or Fireretardant treated listed for material q or Meet NFPA 701 q or Heat Release 100KW or less per NFPA 289 with 20 Kw ignition source Art, photos, paintings on walls: q Not interfere with door latching Not exceed max % of ceiling, wall & door areas: (see next column) q Max 20% surface area in non-sprinkled space q Max 30% surface area in fully sprinkled smoke compartment q Max 50% surface area of pt room in fully sprinkled smoke compart. q 13-Waste Container sizes K-075 LS02.01.70 EP 2 13-58 8/30/13 101-2000 max 32 gal container 18/19.7.5.7 outside of haz storage when not attended 18/19.7.5.7.2 recycling containers for clean waste may be up to 96 gal q Containers used solely for recycling clean waste or patient records waiting for destruction q Max 96 gal capacity outside of hazardous room q No limit on size if stored in hazardous room when not attended q Containers for combustibles shall be labeled to satisfy FM 6921 or equal
CMS CATEGORICAL WAIVER CHECKLIST Page 5 of 7 q 14-Med Gas Master Alarm K-140 EC02.05.01 13-58 8/30/13 99-1999 4-3.1.2.2 REQUIREMENT CODE REF SUMMARY master alarms must be provided in two separate locations and does not permit use of central computer monitoring in lieu of a panel 99-2012 5.1.9.4 central computer monitoring may be substituted for one of the required med gas master alarms Computer Sys: q Be in continuous uninterrupted operation q Powered to ensure reliability q Be continuously attended by a responsible person or Remotely signal responsible parities via pager, auto-dialer, etc. q Interface devices supervised to alarm any failure q Signal switch/sensors must be powered by the computer sys or by Life Safety ATS q Computer communicates directly with signal switch/ sensors & comply with same 10 requirements as med gas panels q Computer connections with signal switch/sensors are supervised so failure generates alarm q Audio alert loud enough to inform system operator q Communication devices do not use elec wiring for signals q Transmission is supervised so failures initiate an alarm Computer Program: q Med Gas alarm must have Life Safety priority signal q Med Gas alarm must interrupt all lower priority alarms q Program includes audible alert, remote signaling, display of specific alarm condition q Must separately display each condition monitored, remain in alarm until problem resolved, be cancelable, visual/audible alarm if communication with any device is disrupted; reinitiate alarm signals even if audible is silenced during prior alarm q 15-Generator Load Bank Exercising K-144 EC02.05.07 EP 5 13-58 8/30/13 110-1999 6-4.2.2 diesel generators may use the 2-hr load bank exercise in lieu of the monthly 30% loading 110-2010 8.4.2.3 diesel generators may use a 1- q Applies to Diesel only 1/2 hrs load bank exercise in q Run monthly at avail load lieu of the monthly 30% loading q Annual Load bank for min 1-1/2 hr, and: q @Min 50% load for 30 min q @Min 75% load for 60 min
CMS CATEGORICAL WAIVER CHECKLIST Page 6 of 7 q 16-Strip Plugs K-147 EC.02.06.01 (Safe Envir) 14-46 9/26/14 99-1999: 7-5.1.2.6 7-6.2.1.5 12-4.1.2.5(b) NEC 70-1999: art 307-6(a) and (b)2 REQUIREMENT CODE REF SUMMARY 1. Cord shall meet the requirements of 9-2.1.2.2 2. Exten.Cords may be used. Wiring must be periodically tested for physical integrity, polarity, and continuity of grounding 3. Prohibited on light fixtures in anesthetizing locations 4. No permanent use of extension cords in lieu of permanent wiring. If used temporarily, must be fed by GFIC or written program of an assured grounding conductor inspection program 99-2010 10.2.3.6 10.5.2 10.5.2.5-.7 1. Strip plugs permitted on rack, table, or cart-mounted equip if permanently attached & sum of amps of all appliances is less than 75% of the ampacity of the cord AND methods are used to ensure more devices can't be plugged in 2. Exten.Cords may be used. Wiring must be periodically tested for physical integrity, polarity, and continuity of grounding 3. Such sys must be demonstrated to comply with the code as a complete system LTC facilities that do not use line-operated devices for therapeutic treatment are not subject to NFPA 99 requirements and do not need to use this Categorical Waiver. GENERAL REQUIREMENTS q Facility has policy on use & testing of all electrical devices & cords q Facility has policy for control of devices not supplied by the facility q Strip plugs powered by a GFIC; or part of a documented testing program of the strip plug for physical integrity, polarity, and grounding. q Outlets that provide power to the strip plug must be properly grounded per its listing. q Cords cannot be a trip hazard; be 'daisy' chained together; have tension on plug; be walked on, be overloaded, or be near combustibles q Strip plug must be installed & maintained per manufacturer instructions. q Facility complies with all requirements of 2012 NFPA 99 on strip plugs (6.3.2.2.6, 10.2, 10.5, etc) q Facility complies with all requirements of 1999 NFPA 99 and NFPA 70, including article 715. NON-PT CARE VICINITY Strip plugs may be used outside the patient care vicinity for both patient care and non-patient care equipment, provided all the following are satisfied: q 1-Strip Plug used for nonpatient care equipment must be UL listed 1363, "Relocatable Power Tap" q Extension cords not used in lieu of permanent wiring, except for a 90 day period for construction or holiday decoration. PATIENT CARE VICINITY Strip plugs may be used hospitals or nursing homes in the patient care vicinity (within 6' of a bed/stretcher) for rack, table, pedestal, or cart mounted line-operated patient care equipment, provided all the following are satisfied: q 1-Strip Plug must be UL listed 1363A or UL 60601-1, "Special Purpose Relocatable Power Tap" q 2-Strip plug must be permanently attached to the equipment assembly q 3-Mounting of the plug strip must be performed by qualified personnel q 4-Sum of Amp rating of all attached devices adds up to less than 75% of the cord rating q 5-Ampacity of the cord satisfied the current edition of the NFPA 70 q 6-A method is used to prevent added devices being plugged into the plug strip q 7-Equip does not need to be an intragal component of a mfgr assembly of equipment q 8-Non-pt care equipment cannot be plugged into a power strip in the pt care vicinity.
CMS CATEGORICAL WAIVER CHECKLIST Page 7 of 7 q 17-Damper Inspection, 6 yr frequency (hospital) K-067 EC02.03.05 8 10-04 10/30/ 2009 90A-1999 3-4.7 REQUIREMENT CODE REF SUMMARY Dampers shall be maintained every 4 yrs 90A-2007 3-4.7 80-2007 19.4 &.5 105-2007 6-5 &.6 Inspection every 4 yrs by all occupancies but hospitals, which are not 6 yrs; Expanded the detail of what inspections should include, but nothing added q Inspector must wear PPE q Test for full unobstructed access to damper q Remove fuseable link (if any), ensure full closure & ability to lock in place q Check for blockage to closing q Check for interferences, bent or misaligned parts, damaged frame, defective hinge q Dry lubricate per mfr requirements q Reinstall link unless damaged or painted; replace with same size, temp, load rating If the facility desires to use any of the CMS categorical waivers listed below, it must 1. Officially adopt the waiver decision, with written approval of the facility Environment of Care/Safety Committee, or other designee of the board of directors or owner. Approval shown in minutes. Best to have a separate letter for each waiver topic. Best to show the specific location of each occurrence with a "keynote" on the Life Safety Plans 2. Have documentation to show compliance with each of the new code requirements (see below at right side of this checklist for each topic), 3. Notify (in writing & verbal) surveyors at the start of a survey which waivers have been adopted by the facility (show official adoption documentation from step 1) 4. Cautions: a). Facility must also ensure compliance with the Wis Building Codes (IBC, IMC, etc) for any new work. The CMS waivers do NOT apply to those requirements. b). These categorical waives do NOT affect any continuing/annual CMS waivers, which must still be adhered to. 5. Recommendation: For the sake of organization, it is highly recommended that ALL facility waivers & variances documentation be kept in a single location, such as a "WAVIER" binder, with a separate "tab" for each waiver topic. If the facility is Joint Commission surveyed, documentation of categorical waivers MUST be shown in the "additional comments" field of the on-line Basic Building Information (BBI). Best to attach the official adoption documentation from step 1. Also list each situation in the on-line Statement of Conditions (SOC), with the wavier as the Plan for Improvement (PFI).