Form Cms 2786R PDF Details

The CMS 2786R form, sanctioned by the Department of Health and Human Services and specifically the Centers for Medicare & Medicaid Services, is a critical component in ensuring fire safety within healthcare facilities, adhering to the 2000 Code. This document serves as a comprehensive fire safety survey report, guiding the evaluation of both new and existing buildings within the healthcare sector, from hospitals to skilled nursing facilities. Among its detailed items, the form addresses vital aspects such as the provider's information, building construction types, interior finishes, and the presence of sprinkler systems, specifying whether they are fully, partially, or not sprinklered. Moreover, it tackles the certification process for various healthcare services under Medicare and Medicaid, highlighting the importance of conforming to patient safety regulations through structural and fire safety standards. This form not only catalogues data regarding the facility's compliance with multiple safety provisions but also provides space for waiver recommendations and the implementation of plans of correction, ensuring that every healthcare facility meets or exceeds federal fire safety requirements. A unique feature of the form is its consideration of both the life safety code (Part I) and specific construction and design details, including but not limited to, the materials used in interior walls, fire resistance ratings, and the specifications of corridor walls and doors, ensuring a comprehensive approach to fire safety.

QuestionAnswer
Form NameForm Cms 2786R
Form Length27 pages
Fillable?No
Fillable fields0
Avg. time to fill out6 min 45 sec
Other names2007, occupancies, fillable cms2786r form, ICF

Form Preview Example

DEPARTMENT OF HEALTH AND HUMAN SERVICES

 

2000 CODE

Form Approved

CENTERS FOR MEDICARE & MEDICAID SERVICES

 

 

OMB No. 0938-0242

FIRE SAFETY SURVEY REPORT 2000 CODE - HEALTH CARE

1. (A) PROVIDER NUMBER

1. (B) MEDICAID I.D. NO.

 

 

 

 

Medicare – Medicaid

K1

K2

 

 

 

 

 

 

 

PART I — Life & Safety Code, New and Existing

PART IV — Waiver Recommendation Form

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, ZIP CODE)

A. ■ Fully Sprinklered

 

 

 

A. BUILDING ________________

 

 

 

 

(All required areas are sprinklered)

 

 

 

 

 

 

B. ■ Partially Sprinklered

 

 

B. WING

________________

 

 

 

 

 

 

 

 

 

 

(Not all required areas are sprinklered)

 

 

 

 

 

 

 

 

 

 

C. FLOOR

________________

 

 

 

 

C. ■ None (No sprinkler system)

 

 

K3

 

 

 

 

 

 

 

 

 

 

 

 

K0180

 

 

 

 

 

 

 

 

3. SURVEY FOR

 

4. DATE OF SURVEY

 

DATE OF PLAN APPROVAL

 

SURVEY UNDER

 

 

 

■ MEDICARE

■ MEDICAID

 

 

 

 

5. ■ 2000 EXISTING

6. ■ 2000 NEW

 

 

K6

 

 

 

 

 

 

 

K4

 

 

K7

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. SURVEY FOR CERTIFICATION OF

 

 

 

 

 

 

 

1. ■ HOSPITAL

2. ■ SKILLED/NURSING FACILITY

4. ■ ICF/MR UNDER HEALTH CARE

5. ■ HOSPICE

 

 

 

IF “2” OR “5” ABOVE IS MARKED, CHECK APPROPRIATE ITEM(S) BELOW

1. ■ ENTIRE FACILITY 2. ■ DISTINCT PART OF (SPECIFY)_________________________________

3. ■ IF DISTINCT PART OF HOSPITAL, IS HOSPITALACCREDITED BY

JCAHO/AOA?

 

a. ■ YES

b. ■ NO

6. BED COMPOSITION a. TOTAL NO. OF BEDS

IN THE FACILITY _______

b. NUMBER OF HOSPITAL BEDS CERTIFIED FOR MEDICARE ____

c. NUMBER OF SKILLED BEDS CERTIFIED FOR MEDICARE ______

d. NUMBER OF SKILLED BEDS CERTIFIED FOR MEDICAID ______

e. NUMBER OF NF or ICF/MR BEDS CERTIFIED FOR MEDICAID _______

7. A. ■ THE FACILITY MEETS, BASED UPON (CHECK ALL APPROPRIATE BOXES)

 

 

 

 

1. ■ COMPLIANCE WITH ALL PROVISIONS

2. ■ ACCEPTANCE OF A PLAN OF CORRECTION 3. ■ RECOMMENDED WAIVERS

4. ■ FSES 5. ■ PERFORMANCE BASED DESIGN

B. ■ THE FACILITY DOES NOT MEET THE STANDARD

 

 

 

 

K9

 

 

 

 

 

SURVEYOR (Signature)

TITLE

OFFICE

 

DATE

 

 

 

 

 

 

SURVEYOR ID

 

 

 

 

 

K10

 

 

 

 

 

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-2786R (06/07) EF 06/2007

Page 1

 

Name of Facility

 

 

 

 

2000 CODE

 

 

 

 

 

 

 

 

 

 

 

ID

 

 

 

MET

NOT

N/A

REMARKS

 

PREFIX

 

 

 

MET

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART I - LSC REQUIREMENTS - Items in italics relate to the FSES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BUILDING CONSTRUCTION

 

 

 

 

 

 

 

 

 

 

 

 

 

K11 If the building has a common wall with a nonconforming building,

 

 

 

 

 

the common wall is a fire barrier having at least a two hour fire

 

 

 

 

 

resistance rating constructed of materials as required for the

 

 

 

 

 

addition. Communicating openings occur only in corridors and

 

 

 

 

 

shall be protected by approved self-closing fire doors.

 

 

 

 

18.1.1.4.1, 18.1.1.4.2, 19.1.1.4.1, 19.1.1.4.2

 

 

 

 

 

 

 

 

 

 

 

 

K12 2000 EXISTING

 

 

 

 

 

 

 

Building construction type and height meets one of the following:

 

 

 

 

19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

I (443), I (332), II (222)

Any Height

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

II (111)

One story only

 

 

 

 

 

 

(non-sprinklered).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Not over three stories with

 

 

 

 

 

3

 

II (111)

complete automatic

 

 

 

 

 

 

 

 

 

sprinkler system.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

 

III (211)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5

 

V (111)

Not over two stories with

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

complete automatic

 

 

 

 

 

6

 

IV (2HH)

 

 

 

 

 

 

sprinkler system.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7

 

II (000)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8

 

III (200)

Not over one story with

 

 

 

 

 

 

 

 

 

complete automatic

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9

 

V (000)

sprinkler system.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

■Building contains fire treated wood.

Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.

Form CMS-2786R (06/07) EF 06/2007

Page 2

Name of Facility

 

 

 

 

2000 CODE

 

 

 

 

 

 

 

 

 

ID

 

 

 

MET

NOT

N/A

REMARKS

PREFIX

 

 

 

MET

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

K12 2000 NEW

 

 

 

 

 

 

Building construction type and height meets one of the following:

 

 

 

18.1.6.2, 18.1.6.3, 18.2.5.1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

I (443), I (332), II (222)

Any height with complete

 

 

 

 

 

automatic sprinkler system

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Not over three stories

 

 

 

 

2

 

II (111)

with complete automatic

 

 

 

 

 

 

 

 

sprinkler system

 

 

 

 

 

3

 

III (211)

 

 

 

 

 

 

 

 

 

Not over one story with

 

 

 

 

 

 

 

 

 

 

 

 

4

 

V (111)

complete automatic

 

 

 

 

 

 

 

 

sprinkler system.

 

 

 

 

5

 

IV (2HH)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6

 

II (000)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7

 

III (200)

 

 

 

 

 

 

 

 

 

Not Permitted

 

 

 

 

8

 

V (000)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

■Building contains fire treated wood.

Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.

K103 Interior walls and partitions in buildings of Type I or Type II construction shall be noncombustible or limited-combustible materials. 18.1.6.3, 19.1.6.3

(Indicate N/A for existing buildings using listed fire retardant treated wood studs within non-load bearing one-hour rated partitions.)

Form CMS-2786R (06/07) EF 06/2007

Page 3

Name of Facility

 

 

 

 

2000 CODE

 

 

 

 

 

 

ID

 

MET

NOT

N/A

REMARKS

PREFIX

 

MET

 

 

 

 

 

 

 

 

 

 

 

INTERIOR FINISH

 

 

 

 

 

 

 

 

 

K14 2000 EXISTING

 

 

 

 

 

 

Interior finish for corridors and exitways, including exposed

 

interior surfaces of buildings such as fixed or movable walls,

 

partitions, columns, and ceilings has a flame spread rating of

 

Class A or Class B. 19.3.3.1, 19.3.3.2

 

Indicate flame spread rating/s _________

 

2000 NEW

 

Interior finish for corridors and exitways, including exposed

 

interior surfaces of buildings such as fixed or movable walls,

 

partitions, columns, and ceilings has a flame spread rating of

 

Class A or Class B. Lower portion of corridor walls can be

 

Class C. 18.3.3.1, 18.3.3.2

 

Indicate flame spread rating/s_________

 

 

K15

2000 EXISTING

 

Interior finish for rooms and spaces not used for corridors or

 

exitways, including exposed interior surfaces of buildings such

 

as fixed or movable walls, partitions, columns, and ceilings has

 

a flame spread rating of Class A or Class B. (In fully-sprinklered

 

buildings, flame spread rating of Class A, Class B, or Class C

 

may be continued in use within rooms separated in accordance

 

with 19.3.6 from the access corridors.) 19.3.3.1, 19.3.3.2

 

Indicate flame spread rating/s_________

 

2000 NEW

 

Interior finish for rooms and spaces not used for corridors or

 

exitways, including exposed interior surfaces of buildings such

 

as fixed or movable walls, partitions, columns, and ceilings has

 

a flame spread rating of Class A or Class B. (Rooms not over

 

4 persons in capacity may have a flame spread rating of Class A,

 

Class B, or Class C). 18.3.3.1, 18.3.3.2.

 

Indicate flame spread rating/s_________

Form CMS-2786R (06/07) EF 06/2007

Page 4

Name of Facility

 

 

2000 CODE

 

 

 

 

 

 

ID

 

MET

NOT

N/A

REMARKS

PREFIX

 

MET

 

 

 

 

 

 

 

 

 

 

K16

Newly installed interior floor finish complying with 10.2.7 shall be

 

 

 

 

 

permitted in corridors and exits if Class I. 18.3.3.3, 19.3.3.3

 

 

 

 

 

(Indicate N/A for existing interior floor finish.)

 

 

 

 

 

In smoke compartments protected throughout by an approved,

 

 

 

 

 

supervised automatic sprinkler system in accordance with

 

 

 

 

 

19.3.5.2, no interior floor finish requirements shall apply.

 

 

 

 

 

 

 

 

 

 

 

CORRIDOR WALLS AND DOORS

 

 

 

 

 

 

 

 

 

K17

2000 EXISTING

 

 

 

 

 

Corridors are separated from use areas by walls constructed with

 

 

 

 

 

at least 1/2 hour fire resistance rating. In fully sprinklered smoke

 

 

 

 

 

compartments, partitions are only required to resist the passage

 

 

 

 

 

of smoke. In non-sprinklered buildings, walls properly extend

 

 

 

 

 

above the ceiling. (Corridor walls may terminate at the underside

 

 

 

 

 

of ceilings where specifically permitted by Code. Charting and

 

 

 

 

 

clerical stations, waiting areas, dining rooms, and activity spaces

 

 

 

 

 

may be open to corridor under certain conditions specified in the

 

 

 

 

 

Code. Gift shops may be separated from corridors by non-fire

 

 

 

 

 

rated walls if the gift shop is fully sprinklered.)

 

 

 

 

 

19.3.6.1, 19.3.6.2.1, 19.3.6.5

 

 

 

 

 

If the walls have a fire resistance rating, give rating_________

 

 

 

 

 

if the walls terminate at the underside of a ceiling, give a brief

 

 

 

 

 

description in REMARKS, of the ceiling, describing the ceiling

 

 

 

 

 

throughout the floor area.

 

 

 

 

 

2000 NEW

 

 

 

 

 

Corridor walls shall form a barrier to limit the transfer of smoke.

 

 

 

 

 

Such walls shall be permitted to terminate at the ceiling where

 

 

 

 

 

the ceiling is constructed to limit the transfer of smoke. No fire

 

 

 

 

 

resistance rating is required for the corridor walls.

 

 

 

 

 

18.3.6.1, 18.3.6.2, 18.3.6.5

 

 

 

 

 

 

 

 

 

 

Form CMS-2786R (06/07) EF 06/2007

Page 5

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