s): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2000 CODE DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICESForm Approved OMB No. 0938-0242THE PEOPLE OF THE STATE OF NEW YORK TO1. (B) MEDICAID I.D. NO.1. (A) PROVIDER NUMBERFIRE SAFETY SURVEY REPORT 2000 CODE -HEALTH CAREMedicare MedicaidK1K2PART I Life & Safety Code, New and ExistingPART IV Waiver Recommendation FormIdentifying information as shown in applicable records. Enter changes, if any, alongside each item, giving date of change.GREETINGS:2. NAME OF FACILITY2. (B) ADDRESS OF FACILITY (STREET, CITY, STATE, ZIP CODE)2. (A) MULTIPLE CONSTRUCTION (BLDGS)WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the HonorableA. BUILDING B. WING,located at County ofC. FLOOR, on the, at or adjourned date, to testify and give evidence as a witness in this action on the part of the, 20noon, and at any recessed in roomo'clock in the day ofK33. SURVEY FORSURVEY UNDER 5. 2000 EXISTINGDATE OF PLAN APPROVAL6. 2000 NEWMEDICARE MEDICAID 4. DATE OF SURVEY K4K6K75. SURVEY FOR CERTIFICATION OFYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.1. HOSPITAL2. SKILLED/NURSING FACILITY4. ICF/MR UNDER HEALTH CARE5. HOSPICEIF 2 OR 5 ABOVE IS MARKED, CHECK APPROPRIATE ITEM(S) BELOWIF DISTINCT PART OF HOSPITAL, IS HOSPITALACCREDITED BY JCAHO/AOA? 3.1. ENTIRE FACILITY2. DISTINCT PART OF (SPECIFY)b. NO K5a. YES, one of the Justices of the6. BED COMPOSITION a. TOTAL NO. OF BEDS IN THE FACILITY Court in Witness, Honorable, 20 County,day ofb. NUMBER OF HOSPITAL BEDS CERTIFIED FOR MEDICARE c. NUMBER OF SKILLED BEDS CERTIFIED FOR MEDICARE d. NUMBER OF SKILLED BEDS CERTIFIED FOR MEDICAID e. NUMBER OF NF or ICF/MR BEDS CERTIFIED FOR MEDICAID 7. A. THE FACILITY MEETS, BASED UPON (CHECK ALL APPROPRIATE BOXES)(Attorney must sign above and type name below)1. COMPLIANCE WITH ALL PROVISIONS5. PERFORMANCE BASED DESIGN4. FSES3. RECOMMENDED WAIVERS2. ACCEPTANCE OF A PLAN OF CORRECTIONB. THE FACILITY DOES NOT MEET THE STANDARDK9Attorney(s) forSURVEYOR (Signature)DATEOFFICETITLESURVEYOR ID K10FIRE AUTHORITY OFFICIAL (Signature)DATEOFFICETITLEOffice and P.O. AddressTelephone No.: Facsimile No.: E-Mail Address:According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0242. The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.Mobile Tel. No.:Page 1Form CMS-2786R (03/04) Previous Versions ObsoleteAmerican LegalNet, Inc. www.USCourtForms.coms): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Name of Facility2000 CODETHE PEOPLE OF THE STATE OF NEW YORK TOID PREFIXMET NOTMET N/AREMARKSPART I -LSC REQUIREMENTS -Items in italics relate to the FSESBUILDING CONSTRUCTIONK11If 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 shall be protected by approved self-closing fire doors. 18.1.1.4.1, 18.1.1.4.2, 19.1.1.4.1, 19.1.1.4.2GREETINGS:WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable,located at County of, on the, at or adjourned date, to testify and give evidence as a witness in this action on the part of the, 20noon, and at any recessed in roomo'clock in the day of2000 EXISTING Building construction type and height meets one of the following: 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1K12Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.TA91I (443), I (332), II (222)Any Height One story only (non-sprinklered). Not over three stories with complete automatic sprinkler system.II (111)2, one of the Justices of theCourt in Witness, Honorable, 20 County,day of3II (111)4III (211)(Attorney must sign above and type name below)5V (111)Not over two stories with complete automatic sprinkler system.6IV (2HH)Attorney(s) for7II (000)8III (200)Not over one story with complete automatic sprinkler system.Office and P.O. Address9V (000) Building contains fire treated wood. Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.Telephone No.: Facsimile No.: E-Mail Address:Mobile Tel. No.:Page 2Form CMS-2786R (03/04) Previous Versions ObsoleteAmerican LegalNet, Inc. www.USCourtForms.coms): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Name of Facility2000 CODETHE PEOPLE OF THE STATE OF NEW YORK TOID PREFIXMET NOTMET N/AREMARKS2000 NEW Building construction type and height meets one of the following: 18.1.6.2, 18, 18.1.6.3, 18.2.5.1K12GREETINGS:K13Any height with complete automatic sprinkler systemWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorable1I (443), I (332), II (222),located at County of, on the, at or adjourned date, to testify and give evidence as a witness in this action on the part of the, 20noon, and at any recessed in roomo'clock in the day ofNot over three stories with complete automatic sprinkler system2II (111)3III (211)Your failure to comply with thi
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