Official Federal Forms > Centers For Medicare And Medicaid Services
Fire Safety Survey Report-2000 Life Safety Code Intermediate Care Facilities For The Mentally Retarded CMS-2786X - Official Federal Forms
| Fire Safety Survey Report-2000 Life Safety Code Intermediate Care Facilities For The Mentally Retarded Form. This is a national form and can be used in Centers For Medicare And Medicaid Services . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
DEPARTMENTOF HEALTH AND HUMAN SERVICES Form ApprovedCENTERS FOR MEDICARE & MEDICAID SERVICES 2000 CODE ICFs/MR OMB No. 0938-0242 1. (A) PROVIDER NO. 1. (B) MEDICAID I.D. NO. FIRE SAFETY SURVEY REPORT - 2000 LIFE SAFETY CODE Intermediate Care Facilities for the Mentally Retarded APARTMENT HOUSE K1 K2 PART I 32 or 33 Residential Board &Care Occupancies Requirements PART II 7.7 (101A, 2001) Fire Safety Evaluation System for Board & Care (Optional) Identifying information as shown in applicable records. Enter changes, if any, alongside each item, giving date of change. 2. NAME OF FACILITY 2. (A) MULTIPLE CONSTRUCTION (BLDGS) 2. (B) ADDRESS OF FACILITY(STREET, CITY, STATE, ZIPCODE) A. BUILDING ________________ B. WING ________________ C. FLOOR ________________ K3 4. DATE OF SURVEY DATE OF PLAN APPROVAL SURVEY UNDER: 9. 2000 Chapter 32 New Chapter 33 Existing K4 K6 K7 5. SURVEY FOR CERTIFICATION OF: APARTMENTHOUSE- E-SCORE E-Score Level of Evacuation Difficulty LEVELOF EVACUATION DIFFICULTY (check one) = 1.5 Prompt > 1.5 = 5.0 Slow 7. Prompt 8. Slow 9. Impractical > 5.0 Impractical K5 K8 6. BED COMPOSITION a. TOTAL NO. OF BEDS IN e. NUMBER OF ICF/MR BEDS e. NUMBER OF ICF/MR BEDS THE FACILITY CERTIFIED FOR MEDICAID CERTIFIED FOR MEDICAID 7. A. THE FACILITYMEETS, BASED UPON (check all appropriate boxes): 1. COMPLIANCE WITH ALL PROVISIONS 2. ACCEPTANCE OF A PLAN OF CORRECTION 4. FSES 5. PERFORMANCE BASED DESIGN B. THE FACILITYDOES NOTMEETTHE STANDARD K9 SURVEYOR (Signature) TITLE OFFICE DATE SURVEYOR ID K10 FIRE AUTHORITYOFFICIAL (Signature) TITLE OFFICE 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 andreview the information collection. If you have any comments concerning the accuracyof 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. FORMCMS-2786X (03/04) Previous Versions Obsolete Page 1<<<<<<<<<********>>>>>>>>>>>>> 2 INSTRUCTIONS FOR COMPLETING THIS FORM (CMS-2786X) SUITABILITY OF AN APARTMENT BUILDING TO HOUSE A BOARD AND CARE OCCUPANCY 1. FIRST complete FORMCMS-2786Y(Small Facility Survey Report) 2. NEXT complete THIS form,to rate the suitability of the Apartment Building to House a Board and Care Occupancy. NOTE: The items on this form refer to the part of the building the Board and Care Occupancy (Apartment). 3. If using NFPA 101A Figure 7.7 FSES/BC Rating the Building,complete Part I of this form FIRST. NOTE: When using this form, you must also complete a CMS 2786Y. FORMCMS-2786X (03/04) Previous Versions Obsolete Page 2<<<<<<<<<********>>>>>>>>>>>>> 3 ID SUITABILITYOF AN APARTMENTBUILDING TO HOUSE NOT APARTMENT MET N/A REMARKS PREFIX A BOARD AND CARE OCCUPANCY MET HOUSE NOTE: You must complete a CMS-2786Y for each Apartment unit with a Board & Care Occupancy. BUILDINGCONSTRUCTION K12 Minimum Construction Requirements:(Based on highest story normally used by residents)PROMPT and SLOW One and Two Story ? Any construction type of one-hour or greater fire rating or, ? Type IV(2HH) or, ? Fully sheathed or, ? With automatic sprinkler system throughout,in accordance with Section 9.6 and 9.7. ? Exception:One story any construction type and no more than 30 residents capable of prompt evacuation. Three to Six Stories ? Type I,II or III construction of one-hour or greater fire rating or, ? Type IVconstruction with automatic sprinkler system throughout in accordance with Section 9.6 or 9.7. ? Exception:Three or four story facilities of type V (000),sheathed and with automatic sprinkler system throughout,in accordance with Sections 9.6 and 9.7. More than Six Stories ? Type I or II(222) construction or, ? Type II(111) construction or, ? Type III(211) construction or, ? Type IV (2HH)with automatic sprinkler system throughout in accordance with Sections 9.6 and 9.7. FORMCMS-2786X (03/04) Previous Versions Obsolete Page 3<<<<<<<<<********>>>>>>>>>>>>> 4 ID SUITABILITYOF AN APARTMENTBUILDING TO HOUSE NOT APARTMENT MET N/A REMARKS PREFIX A BOARD AND CARE OCCUPANCY MET HOUSE Minimum Construction Requirements:(Based on highest story normally used by residents)PROMPT and SLOW ? Type I or II(222) construction,beyond 75 feet in height with automatic sprinkler protection throughout in accordance with Section 9.6 and 9.7. ? Type II(111) construction,limited to three stories with automatic sprinkler protection throughout in accordance with Sections 9.6 and 9.7 ? Type II (000),III (211),IV (2HH),V (111) limited to one story with automatic sprinkler protection throughout in accordance with Section 9.6 and 9.7. 32.3.1.3,33.3.1.3 HAZARDOUS AREAS (Outside B &C Units) K29 Where buildings are without suppression or detection systems,or have total automatic detection or partial sprinkler protection every hazardous area shall be separated by construction of one-hour fire rating. Openings shall be protected by smoke-actuated automatic or self-closing fire doors, 3 with a /4 hour fire rating or the area is equipped with an automatic sprinkler system. Hazardous areas include,but are not limited to: ? Boiler and heater rooms ? Laundries ? Repair shop ? Rooms or spaces used for storage of combustibles or equipment deemed hazardous by the authority having jurisdiction. Where buildings have an automatic extinguishment system installed in accordance with NFPA 13,areas may be smoke-resisting construction. 30.3.2,31.3.2,8.4 MANUAL FIRE ALARM K51 Apartment buildings with more than three stories or more than eleven units shall have a fire alarm system,not a presignal type,with occupant notification accomplished automatically and without delay in accordance with Section 9.6,30.3.4,31.3.4. An annunciator panel shall be provided. 31.3.4.3.2. FORMCMS-2786X (03/04) Previous Versions Obsolete Page 4<<<<<<<<<********>>>>>>>>>>>>> 5 ID SUITABILITYOF AN APARTMENTBUILDING TO HOUSE NOT APARTMENT MET N/A REMARKS PREFIX A BOARD AND CARE OCCUPANCY MET HOUSE SMOKE DETECTION AND ALARM (Outside B &C) K109 Every living unit within the apartment building regardless of number of stories,number of apartments,sprinkl
|
|||||||
