Form Cms 2786Y – Fill Out and Use This PDF

FIRE SAFETY SURVEY REPORT - 2000 LIFE SAFETY CODE	1. (A) PROVIDER NO.	1. (B) MEDICAID I.D. NO.
Intermediate Care Facilities for the Mentally Retarded
SMALL FSES	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)			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
				K4			K6	K7
	E-SCORE						5. SURVEY FOR CERTIFICATION OF: SMALL FACILITY - LEVEL OF EVACUATION DIFFICULTY
			E-Score	Level of Evacuation Difficulty			(Check one)
			≤ 1.5	Prompt
			> 1.5 ≤ 5.0	Slow			1. ■ Prompt	2. ■ Slow	3. ■ Impractical
			> 5.0	Impractical
K5							K8

7. A. ■ THE FACILITY MEETS, BASED UPON (Check all appropriate boxes):

1. ■ COMPLIANCE WITH ALL PROVISIONS		2. ■ ACCEPTANCE OF A PLAN OF CORRECTION		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-2786Y (06/07) EF 06/2007

Page 1

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.■ 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.■ 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

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

____________________________________________________________________

WORKSHEET 7.3.2 SAFETY PARAMETER VALUES — SMALL FACILITY

Safety Parameters

Parameter Values

1. Construction/

Exposed Structural

Protected

Protected

Fire Resistance

Members

15 min

1 hr

0

1

3

2. Hazardous Areas

Double Deficiency

Single Deficiency

None or No Deficiency

-7

-4

0

3. Manual Fire Alarm

None or Incomplete

w/o F.D. Notification

w/ F.D. Notification

0

1

2

4. Smoke Detection

Warning to All Bedrooms

and Alarm

None or

Single Lev. Det./

Every Lev. Plus

Total Coverage

Incomplete

Limited Warning

Every Lev. Det.e

Det. in Each Bdrm.

System

-4

0

2

3(4)f

4

5. Automatic Sprinklers

Quick-Response or

Nonsprinklered

Standard Sprinklers

Residential Sprinklers

0

8

10

6. Interior Finish

Flame-Spread Ratings

>75 to <200

>25 to <75

<25

-3

-1

0

7. Separation of

Unprotected

Sleeping Rooms

Vertical Openings

Protected Vertical Openings

d

(from other levels

and from corridors)

None or

Smoke

Smoke

None or

Smoke

1/2 hr

Smoke Res.

1/2 hr

Resisting

Resisting

Auto

w/ Door

w/ Door

Incomp.

w/o Closers

w/ Closers

Incomp.

Resisting

1/2 hr.

Closing

Closer

Closer

-6

-4

0(0)c

-2

0

1(0)a

2(0)a

1

2(1)a

8. Means

Means of

<2 Remote Routes

of Escape

Escape on

w/o Alt.

w/ Alt.

2 Remote Routes

2 Remote Routes

Direct Exit from

All Sleeping

Means

Means

Unseparated

Separated

Each Bdrm.

Levels

-1

0

1(0)b

2(0)b

3(0)b

Means of

Primary Route Not Protected

Primary Route Protected

Escape Not

<2 Remote Routes

< 2 Remote Routes

on All

Sleeping

w/o Alt.

w/ Alt.

2 Remote

w/o Alt

w/ Alt.

2 Remote

Means

Means

Routes

Means

Means

Routes

Levels

-4

-3

0

-1

0

2(0)b

NOTES:

a	Use ( ) if Parameter 1 is 0 and Parameter 5 is 0.

buse (0) if Parameter 7 is based on a “none or incomplete” situation.

cUse (0) if door is 20 minute and has automatic closer.

dConsider a single level building as having protected vertical openings.

eEvery level detection is permitted to be omitted with a quick-response automatic sprinklers throughout; however, detection in each bedroom is required.

fUse (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 06/2007

Page 3

	Building
	Identification
_________________________________________
_________________________________

DateEvaluator

Figure 7.3 Continued

WORKSHEET 7.3.3 INDIVIDUAL SAFETY EVALUATIONS — SMALL FACILITY

						General
		Fire Control		Egress	Refuge	Fire Safety
	Safety Parameters	(S1)		(S2)	(S3)	(S4)
1.	Construction
2.	Hazardous Areas			–: 2 =
3.	Manual Fire Alarm	–:	2 =	(See note)
4.	Smoke Detection and Alarm	–:	2 =		–: 2 =
5.	Automatic Sprinklers			–: 2 =
6.	Interior Finish	–:	2 =
7.	Separation of Sleeping Rooms
8.	Means of Escape
	Total	S1=		S2=	S3=	S4=

NOTE: Maximum value of manual fire alarm for means of escape is 1.

WORKSHEET 7.3.4 MANDATORY SAFETY REQUIREMENTS

	Control				Egress		Refuge			General Fire Safety
Level of Evacuation	Requirements (Sa)			Requirements (Sb)			Requirements (Sc)			Requirements (Sd)
Difficulty	New		Exist.	New		Exist.	New		Exist.	New	Exist.
Prompt	10(1/2)a		0	5(5)a		4	11(21/2)a		2	7(2)a	1
Slow	10		2	9		7	11		4	11	7
Slowb			1			6			2		5
Impractical	10		8	10		9	11		9	12	10

a	Use ( ) for small board and care facility conversion serving eight or fewer residents with an evacuation capability rating
	of “prompt.”

bIn existing buildings only, use these mandatory safety requirements if evacuation time is 8 minutes or less or if the evacuation capability score is 3 or less as determined by Chapter 6.

(For use with NFPA 101A-2001/NFPA 101-2000, B & C Small)

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

Page 4

Figure 7.3 Continued

WORKSHEET 7.3.5 EQUIVALENCY EVALUATION

YES

NO

Control

Required

S1

Sa

Provided (S1)

minus

Control (Sa)

>

0

–

=

Egress

Required

S2

Sb

minus

>

0

–

=

Provided (S2)

Egress (Sb)

Refuge

minus

Required

>

0

S3

Sc

–

=

Provided (S3)

Refuge (Sc)

General

minus

Required General

>

0

S4

Sd

Fire Safety (S4)

Fire Safety (Sd)

–

=

1.❑ All of the checks in Worksheet 7.3.5 are in the “YES” column. The level of fire safety is at least equivalent to that prescribed by NFPA 101, Life Safety Code.*

2.❑ One or more of the checks in Worksheet 7.3.5 are in the “NO” column. The level of fire safety is not shown by this system to be equivalent to that prescribed by NFPA 101 for small dwelling units.

*The equivalency covered by this worksheet includes the majority of considerations covered by NFPA 101, Life Safety Code. There are some considerations that are not evaluated by this method. These must be considered separately. These additional considerations are covered in Worksheet 7.3.6, “Facility Fire Safety Requirements Worksheet.” One copy of this worksheet is to be completed for each facility.

(For use with NFPA 101A-2001/NFPA 101-2000, B & C Small)

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

Page 5

FIRE SAFETY SURVEY REPORT

CRUCIAL DATA EXTRACT

(TO BE USED WITH CMS-2786 FORMS)

*K9: FACILITY MEETS LSC BASED ON (Check all that apply)

(COMP. WITH	(ACCEPTABLE POC)	(WAIVERS)	(FSES)	(PERFORMANCE
ALL PROVISIONS)				BASED DESIGN)

FACILITY DOES NOT MEET LSC			K0180
			A.			B.			C.
B.
			FULLY SPRINKLERED			PARTIALLY SPRINKLERED			NONE
			(All required areas are sprinklered)			(Not all required areas are sprinklered)			(No sprinkler system)

* MANDATORY

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

Page 6

APPROVAL

	TOTAL
NUMBER	NUMBER
OF
THIS
	OF
BUILDING
	BUILDINGS

D B
	WING
APARTMENT
UNIT