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Fire-Smoke Zone Evaluation Worksheet For Health Care Facilites CMS-2786T - Official Federal Forms
| Fire-Smoke Zone Evaluation Worksheet For Health Care Facilites 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 ZONE __________ OF __________ ZONES FIRE/SMOKE ZONE* EVALUATION WORKSHEET FOR HEALTH CARE FACILITIES 2000 LIFE SAFETYCODEFACILITY BUILDING ZONE(S) EVALUATED PROVIDER/VENDOR NO. DATE OF SURVEY COMPLETE THIS WORKSHEETFOR EACH ZONE. WHERE CONDITIONS ARE THE SAME IN SEVERALZONES, ONE WORKSHEETCAN BE USED FOR THOSE ZONES. Step 1: Determine Occupancy Risk Parameter Factors - Use Table 1. A. For each Risk Parameter in Table 1, select and circle the appropriate risk factor value. Choose only one for each of the five Risk Parameters. TABLE 1.OCCUPANCY RISK PARAMETER FACTORS Risk Parameters Risk Factors Values 1. Patient Mobility Status Mobile Limited Mobility Not Mobile Not Movable Mobility (M) Risk Factor 1.0 1.6 3.2 4.5 2. Patient No. of Patients 15 610 1130 >30 Density (D) Risk Factor 1.0 1.2 1.5 2.0 st nd rd th th th 3. Zone Floor 1 2 or 3 4 to 6 7 and Above Basements Location (L) Risk Factor 1.1 1.2 1.4 1.6 1.6 Patients 12 35 610 >10 One or More 4. Ratio of Attendant 1 1 1 1 None Patients to Attendants (T) Risk Factor 1.0 1.1 1.2 1.5 4.0 5. Patient Age Under 65 Years and Over 1 year 65 Years and Over 1 Year and Younger Average Age (A) Risk Factor 1.0 1.2 Step 2: Compute Occupancy Risk Factor (F) - Use Table 2. A. Transfer the circled risk factor values from Table 1 to the corresponding blocks in Table 2. B. Compute F by multiplying the risk factor values as indicated in Table 2. TABLE 2.OCCUPANCY RISK FACTOR CALCULATION M D L T A F OCCUPANCYRISK x x x x = Step 3: Compute Adjusted Building Status (R) - Use Table 2. A. If building is classified as NEW use Table 3A. If building is classified as Existing use Table 3B. B. Transfer the value of F from Table 2 to Table 3Aor Table 3B as appropriate. Calculate R. C. Transfer R to the block labeled R in Table 7 on page 4 of the work sheet. TABLE 3A.(NEW BUILDINGS) TABLE 3B.(EXISTING BUILDINGS) F R F R 1.0 x = 0.6 x = * FIRE/SMOKE ZONE is a space separated from all other spaces by floors, horizontal exIts,or smoke barrIers. SURVEYOR SIGNATURE TITLE DATE FIRE AUTHORITYSIGNATURE TITLE DATE Form CMS-2786T(03/04) Previous Versions Obsolete Page 1 of 4 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 2Step 4: Determine Safety Parameter Values - Use Table 4. A. Select and circle the safety value for each safety parameter in Table 4 that best describes the conditions in thezone. Choose only one value for each of the 13 parameters. If two or mor e appear to apply, choose the one with the lowest point value. TABLE 4. Safety Parameters Safety Parameters Values 1. Construction Combustible NonCombustible Types III, IV, and V Types I and II Floor or Zone 000 111 200 211 + 2HH 000 111 222, 322, 433 First -2 0 -2 0 0 2 2 Second -7 -2 -4 -2 -2 2 4 Third -9 -7 -9 -7 -7 2 4 4th and Above -13 -7 -13 -7 -9 -7 4 2. Interior Finish Class C Class B Class A f f (Corridors and Exits) -5(0) 0(3) 3 3. Interior Finish Class C Class B Class A f f (Rooms) -3(1) 1(3) 3 1 1 4. Corridor None or Incomplete < /2hour > /2to <1 hour >1 hour a a a Partitions/Walls -10(0) 0 1(0) 2(0) 5. Doors to Corridor >20 min FPR and No Door <20 min FPR > 20 min FPR Auto Clos. d d -10 0 1(0) 2(0) 6. Zone Dimensions Dead End No Dead Ends >30 ft and Zone Length Is >100 ft >50 ft to 100 ft 30 ft to 50 ft >150 ft 100 ft to 150 ft <100 ft b b b c -6(0) -4(0) -2(0) -2(0) 01 7. Vertical Openings Open 4 or More Open 2 or 3 Enclosed with Indicated Fire Resist. Floors Floors <1 hr > 1 hr to <2 hr >2 hr e e -14 -10 0 2(0) 3(0) 8. Hazardous Areas Double Deficiency Single Deficiency No Deficiencies In Zone Outside Zone In Zone In Adjacent Zone -11 -5 -6 -2 0 9. Smoke Control No Control Smoke Barrier Mech.Assisted Systems Serves Zone by Zone c -5(0) 03 10. Emergency <2 Routes Multiple Routes Movement W/O Horizontal Horizontal Routes Deficient Exit(s) Exit(s) Direct Exit(s) -8 -2 0 1 5 11. Manual Fire Alarm No Manual Fire Alarm Manual Fire Alarm W/O F.D. Conn. W/F.D. Conn -4 1 2 12. Smoke Detection Corridor and Total Spaces and Alarm None Corridor Only Rooms Only Habit. Spaces In Zone g g g 0(3) 2(3) 3(3) 45 13. Automatic Corridor and Entire Sprinklers None Habit. Space Building 08 10 a e NOTE: Use (0) where parameter 5 is -10. Use (0) where Parameter 1 is based on first floor zone or on an b unprotected type of construction (columns marked 000 or 200 ) Use (0) where parameter 10 is -8. f c Use ( )if the area of Class B or C interior finish in the corridor Use (0) on floor with fewer than 31 patients and exit or room is protected by automatic sprinklers and (existing buildings only) Parameter 13 is 0; use ( ) if the room with existing Class C d Use (0) where parameter 4 is -10. interior finish is protected by automatic sprinklers, Parameter 4 is greater than or equal to 1, and Parameter 13 is 0. g Use this value in addition to Parameter 13 if the entire zone is For SIunits: 1 ft = 0.3048 m protected with quick-response automatic sprinklers. Form CMS-2786T(03/04) Previous Versions Obsolete Page 2 of 4 American LegalNet, Inc. www.USCourtForms.com<<<<<<<<<********>>>>>>>>>>>>> 3Step 5: Compute Individual Safety Evaluations Use Table 5. A. Transfer each of the 13 circled Safety Parameter Values from Table 4 to every unshaded block in the line with the corresponding Safety Parameter in Table 5. For Safety Parameter 13 (Sprinklers) the value 1 entered in the People Movement Safety column is recorded in Table 5 as /2the corresponding value circled in Table 4. B. Add the four columns, keeping in mind that any negative numbers deduct. C. Transfer the resulting total values for S1, S2, S3, SG to blocks labeled S1, S2, S3, SG in Table 7 on page 4 of this sheet. TABLE 5.INDIVIDUAL SAFETY EVALUATIONS Containment Extinguishment People Movement General Safety Parameters Safety (S 1) Safety (S2) Safety (S3) Safety (S4) 1. Construction 2. Interior Finish (Corr. and Exit) 3. Interior Finish (Rooms) 4. Corridor Partitions/Walls 5. Doors to Corridor 6. Zone Dimensions 7. Vertical Openings 8. Hazardous Areas 9. Smoke Control 10. Emergency Movement Routes 11. Manual Fire Alarm 12. Smoke Detection and Alarm . 13. Automatic Sprinklers 2 =. Total Value S1=S 2=S 3=S 4= TABLE 6. MANDATORY SAFETY REQUIREMENTS (FOR USE IN HOSPITALS OR NURSING HOMES) Containment Extinguishment People Movement (Sa)( Sb)( Sc) Zone Location New Exist. New Exist. New Exist. st a a 1 story 11 5 15(12) 4 8(5) 1 nd b a a 2 or
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