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Fire Safety Survey-2000 Life Safety Code Worksheet For Rating Residents CMS-2786M - Official Federal Forms

Fire Safety Survey-2000 Life Safety Code Worksheet For Rating Residents Form. This is a national form and can be used in Centers For Medicare And Medicaid Services .
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DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB ([HPSW FIRE SAFETY SURVEY -- 2000 LIFE SAFETY CODE F-1 Facility SIDE 1 Worksheet for Rating Residents Complete one Worksheet for each resident. Read Instruction Manual before filling out this form. Base ratings on commonly observed examples of poor performance. Rater Resident's Name Date Write any explanatory remarks you may wish to make here: Surveyor (Signature) Surveyor ID Fire Authority Official (Signature) Title Date Title Date Form CMS-2786M (02/2013) Previous Versions Obsolete Page 1 American LegalNet, Inc. www.FormsWorkFlow.com FIRE SAFETY SURVEY REPORT CRUCIAL DATA EXTRACT (TO BE USED WITH CMS-2786 FORMS) PROVIDER NUMBER K1 FACILITY NAME SURVEY DATE * K4 K6 DATE OF PLAN APPROVAL K3 MULTIPLE CONSTRUCTION TOTAL NUMBER OF BUILDINGS ____________ NUMBER OF THIS BUILDING ____________ A B C D BUILDING WING FLOOR APARTMENT UNIT LSC FORM INDICATOR Health Care Form 2786R 2000 EXISTING 2786R 2000 NEW ASC Form 2000 EXISTING 2000 NEW COMPLETE IF ICF/MR IS SURVEYED UNDER CHAPTER 21 SMALL (16 BEDS OR LESS) 1 PROMPT 2 SLOW 3 IMPRACTICAL 12 13 K8: LARGE 4 PROMPT K8: 14 15 2786U 2786U 16 17 * K7 ICF/MR Form 2786V, W, X 2000 EXISTING 2786V, W, X 2000 NEW SELECT NUMBER OF FORM USED FROM ABOVE 5 SLOW 6 IMPRACTICAL APARTMENT HOUSE 7 PROMPT 8 SLOW 9 IMPRACTICAL K8: (Check if K29 or K56 are marked as not applicable in the 2786 M, R, T, U, V, W, X and Y.) K29: K56: ENTER E ­ SCORE HERE K5: e.g. 2.5 *K9: FACILITY MEETS LSC BASED ON (Check all that apply) A1. (COMP. WITH ALL PROVISIONS) A2. (ACCEPTABLE POC) K0180 A3. (WAIVERS) A4. (FSES) A5. (PERFORMANCE BASED DESIGN) FACILITY DOES NOT MEET LSC B. * MANDATORY A. B. PARTIALLY SPRINKLERED C. NONE (No sprinkler system) FULLY SPRINKLERED (All required areas are sprinklered) (Not all required areas are sprinklered) Form CMS-2786M (02/2013) Previous Versions Obsolete Page 2 American LegalNet, Inc. www.FormsWorkFlow.com DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB Exempt F-1 SIDE 2 COMPLETE OTHER SIDE FIRST Worksheet for Rating Residents Read Instruction Manual before filling out this form. Base ratings on commonly observed examples of poor performance. F-1A Rating the Resident on the Risk Factors Rating the resident on each of the factors below by checking the one circle in each risk factor that best describes the resident. For the first six factors, write the scores for the circles you checked in the appropriate score boxes in the far right column. For "response to fire drills," write the three checked scores in the large circles. Write the sum of the 3 scores in the large box on the right. SCORE BOXES I. Risk of Resistance Minimal Risk Risk of Mild Resistance Risk of Strong Resistance (Check only one) II. Impaired Mobility score = 0 SelfStarting Slow score = 6 score = 20 Needs Limited Assistance Needs Full Assistance or Very Slow score = 20 (Check only one) score = 0 score = 3 Partially Impaired score = 6 Totally Impaired III. Impaired No Significant Consciousness Risk (Check only one) IV. Need for Extra Help score = 0 Needs at Most One Staff score = 6 Needs Limited Assistance from 2 Staff score = 30 Requires Supervision score = 20 Needs Full Assistance from 2 Staff score = 40 Requires Consider able Attention/May Not Respond score = 10 (Check only one) V. Response to Instructions score = 0 Follows Instructions (Check only one) VI. Waking Response to Alarm (Check only one) VII. Response to Fire Drills score = 1 Response Probable score = 3 Response Not Probable score = 0 Initiates and Completes Evacuation Promptly Chooses and Completes Back-up Strategy Stays at Designated Location Yes score = 6 No (Without Guidance or Advice from Staff) score = 0 Yes No score = 8 + score = 4 score = 0 Yes No + score = 6 score = 0 SUM OF THESE THREE ITEMS EVACUATION ASSISTANCE SCORE Page 3 American LegalNet, Inc. www.FormsWorkFlow.com F-1B Finding the ResIdent's Overall Need For AssIstance Compare the numbers in the 7 score boxes you have filled in. Take the one highest score from the score boxes and write it in this box: Form CMS-2786M (02/2013) Previous Versions Obsolete
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