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Fire Safety Report Short Form Medicare-Medicaid CMS-2786S - Official Federal Forms
| Fire Safety Report Short Form Medicare-Medicaid 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 2000 CODE 1. (A) PROVIDER NUMBER K1 Form Approved OMB No. 0938-0242 FIRE SAFETY SURVEY REPORT SHORT FORM Medicare Medicaid 2. NAME OF FACILITY 2. (A) MULTIPLE CONSTRUCTION (BLDGS) A. BUILDING ________________ B. WING C. FLOOR K3 1. (B) MEDICAID I.D. NO. K2 Identifying information as shown in applicable records. Enter changes, if any, alongside each item, giving date of change. 2. (B) ADDRESS OF FACILITY (STREET, CITY, STATE, ZIP CODE) A. B. C. SHORT FORM CHECK HERE K4 K5 Fully Sprinklered sprinklered) (All required areas are Partially Sprinklered (Not all required areas are sprinklered) ________________ ________________ SURVEY UNDER None (No sprinkler system) K0180 3. SURVEY FOR 4. DATE OF SURVEY MEDICARE MEDICAID 5. 2000 EXISTING 2000 NEW 5. SURVEY FOR CERTIFICATION OF 1. K8 HOSPITAL 2. SKILLED/NURSING FACILITY 3. IF "2" OR "3" ABOVE IS MARKED, CHECK APPROPRIATE ITEM(S) BELOW 1. ENTIRE FACILITY 2. DISTINCT PART OF (SPECIFY)_____________________________ c. NUMBER OF SKILLED BEDS CERTIFIED FOR MEDICARE IF DISTINCT PART OF HOSPITAL, IS HOSPITAL ACCREDITED BY JCAHO/AOA? b. NO a. YES e. NUMBER OF ICF BEDS CERTIFIED FOR MEDICAID 6. BED COMPOSITION a. TOTAL NO. OF BEDS IN THE FACILITY b. NUMBER OF HOSPITAL BEDS CERTIFIED FOR MEDICARE d. NUMBER OF SKILLED BEDS CERTIFIED FOR MEDICAID K9: FOR STATE AGENCY USE ONLY The facility MEETS based upon: A. I HAVE CONDUCTED A FIRE SAFETY SCREENING USING THE SHORT FORM: The facility meets all of the items on the form. B. The facility does not meet all of the items on the form. C. A complete fire safety survey is recommended. A. K9 2. B. OFFICE The facility DOES NOT MEET THE STANDARD. DATE Compliance with all provisions Acceptance of a Plan of Correction 3. Recommended waivers. 1. SURVEYOR (Signature) TITLE 8. SURVEYOR I.D. NO K10 REVIEW AUTHORITY OFFICIAL (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 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. Form CMS-2786S (11/05) EF 11/2005 American LegalNet, Inc. www.USCourtForms.com Page 1 Name of Facility ID PREFIX MET NOT MET N/A REMARKS 2000 CODE CORRIDOR WALLS AND DOORS K18 2000 EXISTING Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Doors shall be provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted. 19.3.6.3 Roller latches are prohibited by CMS regulations in all health care facilities. Show in REMARKS, details of doors, such as fire protection ratings, automatic closing devices, etc. 2000 New Doors protecting corridor openings shall be constructed to resist the passage of smoke. Doors shall be provided with positive latching hardware. Dutch doors meeting 18.3.6.3.6 are permitted. Roller latches shall be prohibited. 18.3.6.3 Show in REMARKS, details of doors, such as fire protection ratings, automatic closing devices, etc. K22 Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants. 7.10.1.4 VERTICAL OPENINGS K20 2000 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least one hour. An atrium may be used in accordance with 8.2.5.6, 19.3.1.1. If all vertical openings are properly enclosed with construction providing at least a two hour fire resistance rating, also check this box. Form CMS-2786S (11/05) EF 11/2005 American LegalNet, Inc. www.USCourtForms.com Page 2 Name of Facility ID PREFIX MET NOT MET N/A REMARKS 2000 CODE If enclosures are less than required, give a brief description and specific location in REMARKS. 2000 NEW Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least two hours connecting four stories or more. (One hour for single story building and sprinklered buildings up to three stories in height.) 18.3.1.1. An atrium may be used in accordance with 8.2.2.3.5. If enclosures are less than required, give a brief description and specific location in REMARKS. SMOKE COMPARTMENTATION AND CONTROL K23 2000 EXISTING Smoke barriers shall be provided to form at least two smoke compartments on every sleeping room floor for more than 30 patients. 19.3.7.1, 19.3.7.2 2000 NEW Smoke barriers shall be provided to form at least two smoke compartments on every floor used by inpatients for sleeping or treatment, and on every floor with an occupant load of 50 or more persons, regardless of use. Smoke barriers shall also be provided on floors that are usable, but unoccupied. 18.3.7.1, 18.3.7.2 K28 2000 EXISTING Door openings in smoke barriers shall provide a minimum clear width of 32 inches (81 cm) for swinging or horizontal doors. Vision panels are of fire-rated glazing or wired glass panels and steel frames. 19.3.7.5, 19.3.7.7 Form CMS-2786S (11/05) EF 11/2005 American LegalNet, Inc. www.USCourtForms.com Page 3 Name of Facility ID PREFIX MET NO MET N/A REMARKS 2000 CODE 2000 NEW Door openings in smoke barriers are installed as swinging or horizontal doors shall provide a minimum clear width as follows: Provider Type Hospitals and Nursing Facilities Psychiatric Hospitals and Limited Care Facilities Swinging Doors 41.5 inches (105 cm) 32 inches (81 cm) Horizontal Sliding Doors 83 inches (211 cm) 64 inches (163 cm) Vision p
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