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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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DEPARTMENTOF HEALTH AND HUMAN SERVICES Form ApprovedCENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0242 FIRE SAFETY SURVEY 2000 LIFE SAFETY CODE SIDE 1 Worksheet for Rating Residents F-1 Complete one Worksheet for each resident. Read Instruction Manual before filling out this form. Base ratings on commonly observed examples of poor performance. Residents Name Rater Facility Date Write any explanatory remarks you may wish to make here: Surveyor (Signature) Title Date Surveyor ID Fire Authority Official (Signature) Title Date 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:PRAReports Clearance Officer, 7500 Security Boulevard,Baltimore,Maryland 21244-1850. Form CMS-2786M (03/04) Previous Versions Obsolete Page 1 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2DEPARTMENTOF HEALTH AND HUMAN SERVICES Form ApprovedCENTERS FOR MEDICARE & MEDICAID SERVICES OMB No. 0938-0242 COMPLETE OTHER SIDE FIRST SIDE 2 Worksheet for Rating Residents F-1 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 cir cle 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 thethree 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 Minimal Risk of Mild Risk of Strong Resistance Risk Resistance Resistance (Check only one) score = 0 score = 6 score = 20 II. Impaired Self- Slow Needs Limited Needs Full Mobility Starting Assistance Assistance or Very Slow (Check only one) score = 0 score = 3 score = 6 score = 20 III. Impaired No Significant Partially Totally Consciousness Risk Impaired Impaired (Check only one) score = 0 score = 6 score = 20 IV. Need for Needs at Most Needs Limited Needs Full Extra Help One Staff Assistance Assistance from 2 Staff from 2 Staff (Check only one) score = 0 score = 30 score = 40 V. Response to Follows Requires Requires Consider- Instructions Instructions Supervision able Attention/May Not Respond (Check only one) score = 1 score = 3 score = 10 VI. Waking Response Response Response to Probable Not Probable Alarm (Check only one) score = 0 score = 6 VII.Response Initiates and Yes No to Fire Drills Completes Evacuation Promptly score = 0 score = 8 (Without Guidance or Chooses and Yes No Advice from Completes + Staff) Back-up Strategy score = 0 score = 4 Stays at Yes No SUM OF Designated + THESE Location THREE ITEMS score = 0 score = 6 F-1B Finding the ResIdents Overall Need EVACUATION For AssIstance ASSISTANCE Compare the numbers in the 7 score boxes you have filled in. SCORE Take the one highest score from the score boxes and write it in this box: Form CMS-2786M (03/04) Previous Versions Obsolete Page 2 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 3 FIRE SAFETYSURVEY REPORT CRUCIALDATA EXTRACT (TO BE USED WITH CMS-2786 FORMS) PROVIDER NUMBER FACILITYNAME SURVEY DATE K1 * K4 K3MULTIPLE CONSTRUCTION A BUILDING K6 DATE OF PLAN B WING APPROVAL TOTAL NUMBER OF BUILDINGS ____________ C FLOOR D APARTMENTUNIT NUMBER OF THIS BUILDING ____________ LSC FORM INDICATOR COMPLETE IF ICF/MR IS SURVEYED UNDER CHAPTER 21 SMALL (16 BEDS OR LESS) Health Care Form 12 2786R 2000 EXISTING 1 PROMPT K8: 2 SLOW 13 2786R 2000 NEW 3 IMPRACTICAL ASC Form LARGE 14 2786U 2000 EXISTING 4 PROMPT 15 2786U 2000 NEW K8: 5 SLOW 6 IMPRACTICAL ICF/MR Form APARTMENTHOUSE 16 2786V, W, X 2000 EXISTING 17 2786V, W, X 2000 NEW 7 PROMPT K8: 8 SLOW * K7 SELECTNUMBER OF FORM USED FROM ABOVE 9 IMPRACTICAL (Check if K29 or K56 are marked as not applicable ENTER E SCORE HERE in the 2786 M, R, T, U, V, W, X and Y.) K5: e.g. 2.5 K29: K56: *K9:FACILITYMEETS LSC BASED ON (Check all that apply) A1. A2. A3. A4. A5. (COMP. WITH (ACCEPTABLE POC) (WAIVERS) (FSES) (PERFORMANCE ALL PROVISIONS) BASED DESIGN)FACILITYDOES NOTMEET LSC B. * MANDATORY Form CMS-2786M (03/04) Previous Versions Obsolete Page 3 American LegalNet, Inc. www.USCourtForms.com
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