This regulation establishes fire and life safety construction requirements for buildings undergoing repair, renovation, modification, reconstruction, change of use/occupancy, or additions, referencing the 2012 Life Safety Code (NFPA 101) chapters and sections. Facility operators must ensure that any physical changes to their building comply with the applicable Life Safety Code chapters (18, 19, 43) governing fire barriers, fire resistance ratings, and self-closing fire doors. This is a CMS survey tag (K111) applied during inspections of healthcare facilities.
View official sourceK111 Building Rehabilitation Repair, Renovation, Modification, or Reconstruction Any building undergoing repair, renovation, modification, or reconstruction complies with both of the following: Requirements of Chapter 18 and 19. Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6. 18.1.1.4.3, 19.1.1.4.3, 43.1.2.1 Change of Use or Change of Occupancy Any building undergoing change of use or change of occupancy classification complies with the requirements of Section 43.7, unless permitted by 18.1.1.4.2 or 19.1.1.4.2. 18.1.1.4.2 (4.6.7 and 4.6.11), 19.1.1.4.2 (4.6.7 and 4.6.11), 43.1.2.2 (43.7) Additions Any building undergoing an addition shall comply with the requirements of Section 43.8. If the building has a common wall with a nonconforming building, the common wall is a fire barrier having at least a two hour fire resistance rating constructed of materials as required for the addition. Communicating openings occur only in corridors and are protected by approved self-closing fire doors with at least a 1-1/2 hour fire resistance rating. Additions comply with the requirements of Section 43.8. 18.1.1.4.1 (4.6.7 and 4.6.11), 18.1.1.4.1.1 (8.3), 18.1.1.4.1.2, 18.1.1.4.1.3, 19.1.1.4.1 (4.6.7 and 4.6.11), 19.1.1.4.1.1 (8.3), 19.1.1.4.1.2, 19.1.1.4.1.3, 43.1.2.3(43.8) Form CMS-2786R (07/2018) Page 2 Name of Facility 2012 LIFE SAFETY CODE ID PREFIX MET NOT MET N/A REMARKS