CMS SOM App. E, Tag I-118

The organization satisfies the following requirements:

(1) It complies with all applicable State and local building, fire, and safety

codes.

(2) Permanently attached automatic fire-extinguishing systems of adequate

capacity are installed in all areas of the premises considered to have

special fire hazards. Fire extinguishers are conveniently located on

each floor of the premises. Fire regulations are prominently posted.

(3) Doorways, passageways and stairwells negotiated by patients are:

(i) Of adequate width to allow for easy movement of all patients

(including those on stretchers or in wheelchairs),

(ii) free from obstruction at all times, and

(iii) in the case of stairwells, equipped with firmly attached handrails

on at least one side.

(4) Lights are placed at exits and in corridors used by patients and are

supported by an emergency power source.

(5) A fire alarm system with local alarm capability and, where applicable,

an emergency power source, is functional.

(6) At least two persons are on duty on the premises of the organization

whenever a patient is being treated.

(7) No occupancies or activities undesirable or injurious to the health and

safety of patients are located in the building.

Interpretive Guidelines §485.723(a)

A – General

Areas of the organization considered to pose a degree of hazard higher than that normal

to the general use areas are to be equipped with a State fire authority approved,

permanently attached, automatic fire extinguishing system; or shall be separated from the

rest of the building by 1-hour rated fire resistant barrier. These hazardous areas may

include, but are not limited to, areas used for storage or use of: a) combustibles or

flammables; b) toxic, noxious or corrosive materials; or c) heat producing appliances. It

is not CMS’s intent that rooms used to store routine office supplies have sprinklers.

All areas occupied or accessible to the organization for use during emergency or non-emergency activity, including corridors and stairwells, are to be protected by easily

accessible fire extinguishers. Extinguishers should be distributed throughout every

rehabilitation agency so that the distance between extinguishers is no more than 75 feet.

Extinguishers should be installed, inspected, and maintained in a fully charged and

operable condition, and kept in their designated places at all times when they are not

being used. Extinguishers should be conspicuously located where they are readily

accessible; preferably located along normal paths of travel to exits. State or local laws

should define what type of fire extinguisher is considered to be easily accessible and

appropriate for the organization’s building.

Extinguishers should be securely installed on brackets or placed in cabinets or wall

recesses, and installed so the top of the extinguisher is no more than five feet above the

floor. Extinguisher operating instructions should be located on the front of the

extinguisher and clearly visible. Maintenance, servicing, and recharging of the

extinguishers should only be performed by specially trained personnel. However,

monthly “quick checks” or inspections can be performed by agency personnel with basic

knowledge of fire extinguishers. Extinguishers should be inspected when initially placed

in service and thereafter at approximately 30-day intervals. The inspection should

include the following:

• the extinguisher is located in a designated space;

• there is no obstruction to access or visibility;

• the operating instructions on the nameplate are legible and facing outward;

• safety seals and tamper indicators are not broken or missing;

• fullness of the extinguisher is determined by weighing or lifting;

• examination for obvious damage, corrosion, leakage, or clogged nozzle; and

• observation of the pressure gauge reading or indicator to ensure it’s in the

operable range or position.

Personnel making the inspections should keep records of all inspections which include

the date the inspection was performed and the initials of the person performing the

inspection. The records should be kept on a tag or label attached to the fire extinguisher,

on an inspection checklist maintained on file, or in an electronic system that provides a

permanent record. In addition, all employees shall be periodically instructed in the use

of portable fire extinguishers. Documentation of the instruction should include the

personnel that received instruction and the date.

The doorways and passageways shall be free of obstruction to allow for ease in patient

movement (into and within the organization), and shall be wide enough to accommodate

wheelchairs, gurneys or stretchers, etc. Stairwells should include handrails on at least one

side, and should be free from obstruction at all times.

During emergency operation, an emergency power source (e.g., battery or auxiliary

generator) is available to assure adequate lighting within the treatment areas and those

passageways, stairwells, and exits (as noted above) that are accessible to the organization.

In cases of power outage, the emergency power source should respond either

automatically or require only minimal activation effort.

A fire alarm system with local alarm capability must be available in every Rehabilitation

Agency to alert personnel in time to permit safe evacuation of the building. Initiation of

the fire alarm system may occur by manual means (i.e., pull box), smoke detection, or

extinguishing system operation, as applicable. Once initiated, the fire alarm system

should notify facility occupants of the fire or other emergency by activation of the

system’s audible and visible devices (e.g., flashing lights). In the absence of State or

local requirements, the above system must be approved by the State Fire Marshal’s

Office. The electrical power supply for the fire alarm system should be provided by both

normal and emergency power. Emergency power may be supplied by the building’s

emergency power or battery power to ensure the fire alarm system remains operational

in the event of normal power failure.

CMS has become aware that some Rehabilitation Agencies are utilizing hand-held air

horns in lieu of a fire alarm system. The word “system” was intentionally included in the

regulatory language and is intended to require a fire alarm system which is integrated

into the building. Use of an air horn in lieu of a fire alarm system is not acceptable.

Fire regulations are prominently posted and facilities must have a fire protection plan

that is an integral part of the organization’s disaster plan.

The building housing the organization should be free of hazardous occupancies or

activities such as the manufacturing of combustible materials.

Verify that applicable State and local building, fire, and safety codes are met and review

available reports of State and local personnel responsible for enforcement of the above.

Anytime a patient is being treated by the organization, at least two organization staff will

be on duty on the premises. This requirement is for the safety of the patients. It is not a

new requirement, but is sometimes overlooked, at either the primary site of the

rehabilitation agency or the rehab agency’s extension location(s).

This duty requirement can be verified by requesting staff or personnel time cards. The

staff time cards can be compared against patient sign-in sheets if there are concerns

regarding the two person duty requirement.

B – Major Sources of Information

• State/local building, fire and safety code; and

• Staff schedules and patient logs.