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Fire Safety Survey Report-2000 Life Safety Code Intermediate Care Facilities For The Mentally Retarded Small CMS-2786V - Official Federal Forms
| Fire Safety Survey Report-2000 Life Safety Code Intermediate Care Facilities For The Mentally Retarded Small 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 ICFs/MR 1. (A) PROVIDER NO. K1 Form Approved OMB No. 0938-0242 FIRE SAFETY SURVEY REPORT - 2000 LIFE SAFETY CODE Intermediate Care Facilities for the Mentally Retarded SMALL 1. (B) MEDICAID I.D. NO. K2 PART I Chapter 6 NFPA 101A A Procedure for Determining Evacuation Capability PART II Chapter 32 & 33 Residential Board & Care Occupancies Requirements PART III Chapter 7-101A Fire Safety Evaluation System for Board & Care (Optional) CMS-2786Y 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) A. BUILDING ________________ B. WING C. FLOOR K3 2. (B) ADDRESS OF FACILITY (STREET, CITY, STATE, ZIP CODE) A. B. C. DATE OF PLAN APPROVAL SURVEY UNDER: 5. Fully Sprinklered (All required areas are sprinklered) ________________ ________________ Partially Sprinkleredsprinklered) (Not all required areas are None (No sprinkler system) K0180 3. SURVEY FOR 4. DATE OF SURVEY MEDICARE E-SCORE MEDICAID K4 K6 2000 EXISTING 6. 2000 NEW K7 E-Score 1.5 > 1.5 5.0 > 5.0 Level of Evacuation Difficulty Prompt Slow Impractical 5. SURVEY FOR CERTIFICATION OF: SMALL FACILITY - LEVEL OF EVACUATION DIFFICULTY (Check one) 1. K8 Prompt 2. Slow 3. Impractical K5 6. BED COMPOSITION a. TOTAL NO. OF BEDS IN THE FACILITY e. NUMBER OF ICF/MR BEDS CERTIFIED FOR MEDICAID THE FACILITY MEETS, BASED UPON (check all appropriate boxes): 1. COMPLIANCE WITH ALL PROVISIONS 2. ACCEPTANCE OF A PLAN OF CORRECTION B. THE FACILITY DOES NOT MEET THE STANDARD K9 7. A. SURVEYOR (Signature) SURVEYOR ID K10 4. FSES 5. PERFORMANCE BASED DESIGN TITLE OFFICE DATE FIRE 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-2786V (11/05) Previous Versions Obsolete EF 11/2005 American LegalNet, Inc. www.USCourtForms.com Page 1 INSTRUCTIONS FOR COMPLETING THE FORM (CMS-2786V) SMALL FACILITIES --16 BEDS OR LESS 1. Complete a Worksheet for Rating Residents (CMS-2786M) for each resident in the facility. 2. Complete the first few pages of this form, a Worksheet for Calculating Evacuation Difficulty Score (Chapter 6 NFPA 101A, 2001 Edition). Note: This is the ONLY method permitted to determine Level of Evacuation Difficulty in SMALL facilities. 3. Transfer the E-Score obtained in Scoresheet F2 C (Page 5) to the E-SCORE block on Page 1 of this form. 4. Complete either Chapter 31 or 32 Requirements or the FSES/BC Appendix G - Rating the Building. A. If completing Chapter 31 or 32 Requirements: 1. PROMPT - Complete ONLY the PROMPT section of this form. 2. SLOW - Complete both PROMPT and SLOW sections of this form. 3. IMPRACTICAL - Complete all three sections of this form PROMPT, SLOW and IMPRACTICAL. B. If completing the FSES/BC - Appendix G - Rating The Building 1. You must also complete the Chapter 31 or 32 requirements. An FSES building evaluation cannot be done without completing the usual survey form pages for these Chapters. 2. You may use the FSES Health Care to evaluate the building (Form CMS-2786T), but if you choose to do so, you must also use the LSC Survey Report for Health Care Form CMS-2786R. Form CMS-2786V (11/05) Previous Versions Obsolete EF 11/2005 American LegalNet, Inc. www.USCourtForms.com Page 2 Worksheet for Calculating Evacuation Difficulty Score (E-Score) F-2 BEFORE FILLING OUT THIS WORKSHEET: · Please read the Instruction Manual. · Make sure you have the completed "Worksheets for Rating Residents" (CMS-2786M) for each resident. · Determine whether the requirements for using the Evacuation Difficulty Index have been satisfied by checking the one box to the left of each question below that shows whether the answer to the question is "YES" or "NO." Yes Yes Yes Yes Yes No No No No No 1. Has a protection plan been developed and written and have all staff members counted in the calculation of E-Scores been trained in its implementation? 2. Is the total available staff at any given time able to handle the individual evacuation needs of each resident who may be in the residence? 3. Can every staff member counted in the calculation of E-Scores meaningfully participate in the evacuation of every resident? 4. Are all staff members counted in the calculation of E-Scores required to remain in the residence with only the exceptions listed in the Instruction Manual? 5. Were at least twelve fire drills conducted during the year? This worksheet is filled out for the staff "Shift" From ______________________________________ To ______________________________________ (You must fill out this worksheet for the time of day, week, etc., when the ratings for the combination of staff and residents yields the highest E-Score. This period of time will usually be late at night. When it is not obvious which time period has the highest E-Score, complete a separate worksheet for all candidate time periods and use the one having the highest E-Score.) Form CMS-2786V (11/05) Previous Versions Obsolete EF 11/2005 American LegalNet, Inc. www.USCourtForms.com Page 3 F-2A Finding the Total Resident Score 1. List each resident's name in the scoresheet below. (Scoresheet F-2A) 2. For each resident, transfer the Evacuation Assistance Score (Part F-1B) from his/her Worksheet for Rating Residents (Step 1). 3. Add the Evacuation Assistance Score for all the residents and write the answer in the appropriate space at the bottom of Scoresheet F-2A. Scoresheet F-2A RESIDENT SCORES Evacuation Resident's Name Assistance Score Resident's Name Evacuation Assistance Score Resident's Name Evacuation Assistance Score Evacuation Assistance TOTAL F-2B Finding the Staff Shift Score 1. In Scoresheet F-2B (below), list the names of staff memb
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