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Fire Safety Survey Report-2000 Life Safety Code Intermediate Care Facilities CMS-2786Y - Official Federal Forms
| Fire Safety Survey Report-2000 Life Safety Code Intermediate Care Facilities 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. Form Approved OMB No. 0938-0242 FIRE SAFETY SURVEY REPORT - 2000 LIFE SAFETY CODE Intermediate Care Facilities for the Mentally Retarded SMALL FSES 1. (B) MEDICAID I.D. NO. K1 K2 PART III -- Chapter 7-101A 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) 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. s Fully Sprinklered (All required areas are sprinklered) ________________ ________________ s Partially Sprinkleredsprinklered) (Not all required areas are s None (No sprinkler system) K0180 3. SURVEY FOR 4. DATE OF SURVEY s MEDICARE E-SCORE s MEDICAID K4 K6 s 2000 EXISTING 6. s 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 s Prompt 2. s Slow 3. s Impractical K5 6. BED COMPOSITION a. TOTAL NO. OF BEDS IN THE FACILITY e. NUMBER OF ICF/MR BEDS CERTIFIED FOR MEDICAID 7. A. s THE FACILITY MEETS, BASED UPON (Check all appropriate boxes): 1. s COMPLIANCE WITH ALL PROVISIONS 2. s ACCEPTANCE OF A PLAN OF CORRECTION B. s THE FACILITY DOES NOT MEET THE STANDARD TITLE OFFICE 4. s FSES 5. s PERFORMANCE BASED DESIGN K9 SURVEYOR (Signature) SURVEYOR ID K10 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-2786Y (06/07) EF 06/2007 Page 1 American LegalNet, Inc. www.FormsWorkflow.com Fire Safety Evaluation Worksheet for a Small Facility Facility Identification ___________________________________________________________________________________ Evaluator _________________________________________ Date __________________________________________ (Complete one worksheet for each individual residence or apartment used as a board and care home. A small facility normally means a capacity for 16 or fewer residents.) First complete Worksheet 7.3.1. Continue with Worksheets 7.3.3, 7.3.4, 7.3.5 and 7.3.6. Then return to this page to obtain the Equivalency Conclusions. TURN TO NEXT PAGE Part 1E. Equivalency Conclusions. Complete Worksheets 7.3.1 through 7.3.6 before doing this part. 1. s All of the checks in Worksheet 7.3.7 are in the "YES" column. The level of fire safety is at least equivalent to that prescribed by the Life Safety Code.* 2. s One or more of the checks in Worksheet 7.3.7 is in the "NO" column. The level of fire safety is not shown by this system to be equivalent to that prescribed for small dwelling units. * The equivalency covered by this worksheet includes the majority of considerations covered by the Life Safety Code. There are a few considerations that are not evaluated by this method. These must be considered separately. These additional considerations are covered in the "Facility Fire Safety Requirements Worksheet." One copy of this separate worksheet is to be completed for each facility. Form CMS-2786Y (06/07) EF 06/2007 Page 2 American LegalNet, Inc. www.FormsWorkflow.com Figure 7.3 Worksheets for evaluating fire safety in a small facility. WORKSHEET 7.3.1 COVER SHEET Fire Safety Evaluation Worksheet for Small Facility Building Identification ____________________________________________________________________ Evaluator _________________________________________Date _________________________________ WORKSHEET 7.3.2 SAFETY PARAMETER VALUES -- SMALL FACILITY Safety Parameters 1. Construction/ Fire Resistance Exposed Structural Members 0 Double Deficiency -7 3. Manual Fire Alarm 4. Smoke Detection and Alarm None or Incomplete 0 None or Incomplete -4 Single Lev. Det./ Limited Warning 0 Parameter Values Protected 15 min 1 Single Deficiency -4 w/o F.D. Notification 1 Warning to All Bedrooms Every Lev. Plus e Every Lev. Det. Det. in Each Bdrm. 2 3(4)f Standard Sprinklers 8 Flame-Spread Ratings >25 to <75 -1 Protected Vertical Openingsd None or Incomp. Smoke Resisting 1/2 hr. 1/2 hr Auto Closing Smoke Res. w/ Door Closer 1/2 hr w/ Door Closer Protected 1 hr 3 None or No Deficiency 0 w/ F.D. Notification 2 Total Coverage System 4 2. Hazardous Areas 5. Automatic Sprinklers Nonsprinklered 0 6. Interior Finish >75 to <200 7. Separation of Sleeping Rooms (from other levels and from corridors) -3 Unprotected Vertical Openings None or Incomp. Smoke Resisting w/o Closers Smoke Resisting w/ Closers c Quick-Response or Residential Sprinklers 10 <25 0 -6 8. Means Means of of Escape Escape on All Sleeping Levels Means of Escape Not on All Sleeping Levels -4 0(0) <2 Remote Routes -2 0 2 Remote Routes Unseparated 1(0)b 1(0)a 2(0)a 1 2(1)a w/o Alt. Means -1 <2 Remote Routes w/o Alt. Means w/ Alt. Means w/ Alt. Means 0 2 Remote Routes Separated 2(0)b Direct Exit from Each Bdrm. 3(0)b Primary Route Not Protected 2 Remote Routes w/o Alt Means Primary Route Protected < 2 Remote Routes w/ Alt. Means 2 Remote Routes -4 -3 0 -1 0 2(0)b NOTES: a Use ( ) if Parameter 1 is 0 and Parameter 5 is 0. b use (0) if Parameter 7 is based on a "none or incomplete" situation. c Use (0) if door is 20 minute and has automatic closer. d Consider a single level building as having protected vertical openings. e Every level detection is permitted to be omitted with a quick-response automatic sprinklers throughout; however, detection in each bedroom is required. f Use (4) in existing buildings if detection in each bedroom and quick-response automatic sprinklers throughout. (For use with NFPA 101A-2001/NFPA 101-2000, B & C Small) Form CMS-2786Y (06/07) EF
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