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Fire Safety Survey Report-Abulatory Surgical Centers-Medicare CMS-2786U - Official Federal Forms
| Fire Safety Survey Report-Abulatory Surgical Centers-Medicare Form. This is a national form and can be used in Centers For Medicare And Medicaid Services . |
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DEPARTMENT OF HEALTH & HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 2000 CODE 1. (A) PROVIDER NUMBER K1 Form Approved OMB No. 0938-0242 FIRE SAFETY SURVEY REPORT - AMBULATORY SURGICAL CENTERS Medicare 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. 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. Fully Sprinklered (All required areas are sprinklered) Partially Sprinkleredsprinklered) (Not all required areas are None (No sprinkler system) K0180 3. DATE OF SURVEY Initial Survey Resurvey K4 New Existing DATE FIRST OCCUPIED AS AMBULATORY SURGICAL CTR. CHECK ONE Facility is: Physically located in a hospital Free-standing: only occupancy in building Located in an Office Occupancy Located in a Mercantile/Business Occupancy Indicate Occupancy _________________________ Other (specify) _____________________________ Accredited by ______________________________ Non Accredited DATE OF BLDG. PERMIT OR PLAN APPROVAL: K6 If facility is located in a hospital or hospital owned/operated, was facility surveyed as part of Hospital LSC Survey? YES A. 1. 2. 3. NO B. K9 The facility MEETS based upon: Compliance with all provisions Acceptance of a Plan of Correction Recommended waivers The facility DOES NOT MEET THE STANDARD. OFFICE 5. Performance Based Design SURVEYOR (SIGNATURE) TITLE DATE SURVEYOR ID K10 REVIEW AUTHORITY OFFICIAL (SIGNATURE) TITLE OFFICE DATE According to the Paperwork Reduction Act to 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-2786U (11/05) Previous Versions Obsolete EF 11/2005 Page 1 American LegalNet, Inc. www.USCourtForms.com ID PREFIX MET NOT MET N/A REMARKS 2000 CODE CONSTRUCTION K12 Buildings two or more stories in height and of Type II(000),III (200) V (000) construction are equipped throughout with a supervised approved automatic sprinkler system in accordance with section 9.7. 20.1.6.3, 21.1.6.3 Number of stories in the building __________________________ K13 Construction Type _____________________________________ EXITS K32 K42 At least two exits, located remote from each other are provided for each floor or fire section of the building. 20.2.4.1, 21.2.4.1 Rooms or suites of rooms of more than 2,500 sq. ft. have at least two exit access doors located remote from each other. 20.2.4.2, 21.2.4.2 Dead-end corridors do not exceed 50 ft. (Note: A common path of travel for the first 25 ft. is permitted.) 39.2.5.1, 39.2.5.2, 39.2.5.3 Travel distance between any room door required as exit access and an exit does not exceed 100 ft. The travel distance between any point in a room and an exit does not exceed 150 ft. (Note: In approved automatic sprinklered buildings, the travel distances may be increased by 50 ft.). 20.2.6.2, 21.2.6.2 At least 50 percent of the required exit capacity from upper floors discharges directly to the exterior of the building in accordance with section 7.7, 38.2.7, 39.2.7, 21.1.6.1, 20.1.6.1 Designated aisles, corridors, passageways, and exitways are provided with illumination in accordance with section 7.8. 20.2.8, 21.2.8 Emergency illumination is provided in accordance with section 7.9. 20.2.9.1, 21.2.9.1 Exits and ways of travel thereto are marked in accordance with section 7.10. 20.2.10, 21.2.10 Doors of patient treatment, diagnostic, or recovery rooms arranged to provide a clear width of not less than 32 inches and existing 34 inch door. 20.2.3.3, 21.2.3.3 Exit and exit access doors are at least 34 inches wide. 20.2.3.3, 21.2.3.3 Page 2 American LegalNet, Inc. www.USCourtForms.com K37 K36 K112 K113 K46 K47 K43 K40 Form CMS-2786U (11/05) Previous Versions Obsolete EF 11/2005 ID PREFIX MET NOT MET N/A REMARKS 2000 CODE LABORATORIES K31 Laboratories employing quantities of flammable, combustible, or hazardous materials that are considered a severe hazard shall be protected in accordance with NFPA 99. (Laboratories that are not considered to be a severe hazard shall meet the provision of K29.) Laboratories in health care occupancies and medical and dental offices shall be in accordance with NFPA 99, Standard for Health Care Facilities and NFPA101. Ventilating Systems shall comply with NFPA 101. 20.3.2.1, 21.3.2.1, 8.4.4, 9.2.4 Procedures for laboratory emergencies shall be developed. Such procedures shall include alarm actuation, evacuation, and equipment shutdown procedures, and provisions for control of emergencies that could occur in the laboratory, including specific detailed plans for control operations by an emergency control group within the organization or a public fire department in accordance with NFPA 99 and NFPA 101. 10.2.1.3.1, 20.3.2.1, 21.3.2.1 Emergency procedures established for controlling chemical spills shall be in accordance with NFPA 99. 10.2.1.3.2 Continuing safety education and supervision shall be provided, incidents shall be reviewed monthly, and procedures reviewed annually shall be in accordance with NFPA 99. 10.2.1.4.2 Fume hoods shall be in accordance with NFPA 99. 5.4.3, 5.6.2 Emergency Shower: Where the eyes or body of any person can be exposed to injurious corrosive materials, suitable fixed facilities for quick drenching or flushing of the eyes and body shall be provided within the work area for immediate emergency use. Fixed eye baths shall be designed and installed to avoid injurious water pressure shall be in accordance with NFPA 99. 10.6 Flammable and combustible liquids used from and stored in approved containers shall be in accordance with NFPA 30, Flammable and Combustible Liquids Code, and NFPA 45, Standard on Fire Protection for Laboratories Using Chemicals. Storage cabinets for flammable and combustible liquid
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