CMS SOM App. H, Tag V400

Interpretive Guidance §494.60

This Condition addresses the requirements related to the building and equipment of the dialysis

facility and incorporates by reference the ambulatory health care occupancy provisions of the

2012 edition of the Life Safety Code of the National Fire Protection Association and the

Tentative Interim Amendments (TIA 12-1 through TIA 12-6).

The primary survey task used to assess compliance with this Condition is the observation of the

environment and equipment maintenance. A survey of the requirements found at V400-V407 of

this Condition will be conducted by the health and safety surveyors who conduct the usual ESRD

surveys. A survey of the requirements related to Life Safety Code (LSC), found at V417-V418,

will be done by specific surveyors trained as fire specialists and may be conducted at a separate

time.

Noncompliance at the Condition level should be considered if identified deficient practices are

pervasive, serious in nature, and/or a potential risk to health and safety. For example, serious

deficient practices in the construction or maintenance of the physical environment and/or

equipment that have or are likely to have an impact on the health and safety of patients, staff or

the public should be considered as noncompliance at the Condition level. Such triggering

situations may occur simultaneously, and their degree of noncompliance should be considered

based on the nature of the events.