Healthcare Facilities

patient and her doctorThe OSFM is sub-contracted through the Kansas Department of Health and Environment and the Kansas Department on Aging to conduct the Fire and Life Safety Surveys for Centers for Medicare and Medicaid.

The OSFM is required to follow the CMS guidelines for conducting inspections.


Frequently Asked Questions

Doors and Door Locks

What are the requirements for posting codes next to the keypads?

As long as you have a method of providing cognitively aware residents, staff, and visitors the code you should not be cited for this deficiency. Posting of the code by the keypad is not the only method to achieve compliance with this, although it has been widely used by the providers. Some other approved methods:

  • Post code on the entrance to all doors
  • Create badges with the code on back for all visitors

What are the requirements for delayed egress posting?

Provider must post appropriate signage reading “Push until alarm sounds door will open in 15 seconds”

Can we prop open resident room doors?

You cannot use a wooden wedge, kick down, or other items like a trash can to prop open doors. However, nonrated resident room doors may be equipped with a magnetic or friction hold-open device that would allow the door to remain open but still meet the requirement for a single-motion to close. Rated doors such as your smoke barrier, fire barrier, and hazardous room doors must remain closed. If they are equipped with a hold-open device, those devices must be tied into the fire alarm system.


How much area must be kept clear around the electrical panels?

A three foot area around the panel needs to be clear so that there is easy access to the panel. NFPA Standard: Sufficient space shall be provided and maintained about electric equipment to permit ready and safe operation and maintenance of such equipment. Where energized parts are exposed, the minimum clear work space shall not be less than 6½ feet high or less than 3 feet wide. In all cases, the work space shall be adequate to permit at least a 90 degree opening of doors or hinged panels. 1999 NFPA 70, Article 110-32

Emergency Lights

If you have a generator where is additional battery-powered emergency lighting required?

If the generator supplies emergency power, then battery powered emergency lighting is required at the following locations:

  • At the generator – If located inside
  • At the generator – If located outside and not accessible by vehicle
  • Surgery Suite – New or Major renovated

Is emergency lighting required in a med room if you have a generator?

Not if the med room lights are powered by the generator.

Can emergency lights be on a keyed-switch?

No. Emergency lighting cannot require manual operation (such as being switched)

Fire Alarms

Does our alarm vendor have to use the annual inspection forms shown in NFPA 72?

They do not have to use the exact forms but all of the information shown in NFPA 72 must be provided on the vendor forms.

Fire Drills

What is the definition of unexpected times? And why do we have to document a scenario?

OSFM will cite providers for similar times if you hold a fire drill the first day of the month every quarter and if you do not vary your time more than 2-3 hours. Drills should be conducted throughout shifts and should not show a pattern (same time of day, same day of the month). Scenarios ensure that drills are performed under varying conditions – such as the size, type and location of the fire. NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. When a coded announcement is used, transmission of the alarm MUST occur the following morning. 2012 NFPA 101, 18/19.7.1.-18/

Fire Place

What are the requirements for a wood burning or gas fireplace?

They are both considered a fireplace and fall under the same codes (New: Existing: Electric/Plug in fireplaces are considered portable space heaters and must adhered to space-heating requirements (New: 18.7.8 Existing: 19.7.8)


What are the testing and maintenance schedule/requirements for generators?

The requirements for testing and maintenance of generators are somewhat lengthy so we’ve created a Fire Fact.

Where do annunciator panels need to be if following 2012 code?

A remote annunciator must be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. However, the panel itself is not required to be at a 24/7 monitored station. You can place the panel somewhere else, as long as it’s remote from the generator. If the location you chose to place the annunciator is not monitored 24/7, you will need to install an audible and visible trouble indicator (clearly labeled for the generator annunciator) at a 24/7 monitored location so they know to go look at the panel if signaled. If a provider is installing a new generator or undergoing a major upgrade they would need to follow the 2012 LSC, 2011 NFPA 70, 2010 NFPA 110, 2012 NFPA 99 - otherwise they would follow the code when their generator was installed. The requirement for a remote annunciator at an attended location can be tracked back to 1965.

Kitchen Hood Suppression Systems

We were cited for being late on our 6 month service on our kitchen system. Is there any leeway?

Per CMS, inspectors will give you a week or so after the 6 month date before citing the system. This leeway is only applicable to kitchen systems.

Does kitchen hood suppression need to be connected to fire alarm system?


Sprinkler System

Does the 2013 sprinkler requirement apply to assisted living and residential board and care type facilities?

No. The 2013 sprinkler requirement only applies to long-term care facilities. See below for more information and a link to the final ruling that applies to the long-term care facilities. NOTE: Keep in mind that this applies to ALL long-term care facilities, regardless of construction type, number of floors, prior approved compensatory measures, etc.

ALL Long-term Care Facilities must be FULLY-SPRINKLERED

What about previously waivered conditions?

No waivers (new or previous) or FSES’s (new or previous) will be accepted. If not incompliance by the August date they will be denied payment and be terminated from the CMS program.

What are the requirements for storage within 18 inches of a sprinkler head?

The 18-in. (0.46-mm) dimension is not intended to limit the height of shelving on a wall or shelving against a wall in accordance with 5-6.6. Where shelving is installed on a wall and is not directly below sprinklers, the shelves, including storage thereon, can extend above the level of a plane located 18 in. (0.46 mm) below ceiling sprinkler deflectors. Shelving, and any storage thereon, directly below the sprinklers cannot extend above a plane located 18 in. (0.46 mm) below the ceiling sprinkler deflectors.

Is there a minimum size requirement for a closet to be sprinklered?

Yes. Sprinklers shall not be required in clothes closets of patient sleeping rooms in hospitals where the area of the closet does not exceed 6 ft2 (0.55 m2), provided that the distance from the sprinkler in the patient sleeping room to the back wall of the closet does not exceed the maximum distance permitted by NFPA 13, Standard for the Installation of Sprinkler Systems. 2012 LSC 18/

How many spare sprinkler heads must we keep on site?

A supply of spare sprinklers (never fewer than six) shall be maintained on the premises so that any sprinklers that have operated or been damaged in any way can be promptly replaced. These sprinklers shall correspond to the types and temperature ratings of the sprinklers in the property. The sprinklers shall be kept in a cabinet located where the temperature to which they are subjected will at no time exceed 100°F (38°C).

A special sprinkler wrench shall also be provided and kept in the cabinet to be used in the removal and installation of sprinklers.

The stock of spare sprinklers shall include all types and ratings installed and shall be as follows:

  • For systems having less than 300 sprinklers, not fewer than six sprinklers
  • For systems with 300 to 1000 sprinklers, not fewer than 12 sprinklers
  • For systems with over 1000 sprinklers, not fewer than 24 sprinklers

Does our sprinkler vendor have to use the annual inspection forms shown in NFPA 25?

They do not have to use the exact forms but all of the information shown in NFPA 25 must be provided on the vendor forms.

Please clarify at what point will OSFM cite a sprinkler head for being corroded or dirty?

CMS and OSFM will only cite facilities if the corrosion, paint, dust, or lint is heavy and would prevent proper operation. NFPA Standard: Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. 1998 NFPA 25, 2-2.1.1