2000 CODE DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 0938-0242 1. (A) PROVIDER NUMBER 1. (B) MEDICAID I.D. NO. K1 FIRE SAFETY SURVEY REPORT SHORT FORM Medicare – Medicaid 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) 2. (B) ADDRESS OF FACILITY (STREET, CITY, STATE, ZIP CODE) A. A. BUILDING ________________ B. WING C. FLOOR B. ________________ ________________ s MEDICARE C. s None (No sprinkler system) K0180 SURVEY UNDER SHORT FORM 4. DATE OF SURVEY s s Partially Sprinklered (Not all required areas are sprinklered) K3 3. SURVEY FOR s Fully Sprinklered sprinklered) (All required areas are CHECK HERE MEDICAID K4 s 5. s 2000 EXISTING s 2000 NEW K5 5. SURVEY FOR CERTIFICATION OF 1. s HOSPITAL 2. s SKILLED/NURSING FACILITY K8 IF “2” OR “3” ABOVE IS MARKED, CHECK APPROPRIATE ITEM(S) BELOW 1. s ENTIRE FACILITY 2. 3. s DISTINCT PART OF (SPECIFY)_____________________________ s IF DISTINCT PART OF HOSPITAL, IS HOSPITAL ACCREDITED BY JCAHO/AOA? a. s YES b. s 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 K9: FOR STATE AGENCY USE ONLY A. The facility MEETS based upon: I HAVE CONDUCTED A FIRE SAFETY SCREENING USING THE SHORT FORM: s s The facility meets all of the items on the form. B. s The facility does not meet all of the items on the form. C. s A complete fire safety survey is recommended. A. s Compliance with all provisions s Acceptance of a Plan of Correction 3. s Recommended waivers. 1. 2. B. K9 SURVEYOR (Signature) e. NUMBER OF ICF BEDS CERTIFIED FOR MEDICAID s The facility DOES NOT MEET THE STANDARD. TITLE OFFICE DATE TITLE OFFICE DATE 8. SURVEYOR I.D. NO K10 REVIEW AUTHORITY OFFICIAL (Signature) 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-2786S (06/07) EF 06/2007 Page 1 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility 2000 CODE ID PREFIX MET NOT MET N/A REMARKS CORRIDOR WALLS AND DOORS K18 2000 EXISTING Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Doors shall be provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted. 19.3.6.3 Roller latches are prohibited by CMS regulations in all health care facilities. Show in REMARKS, details of doors, such as fire protection ratings, automatic closing devices, etc. 2000 New Doors protecting corridor openings shall be constructed to resist the passage of smoke. Doors shall be provided with positive latching hardware. Dutch doors meeting 18.3.6.3.6 are permitted. Roller latches shall be prohibited. 18.3.6.3 Show in REMARKS, details of doors, such as fire protection ratings, automatic closing devices, etc. K22 Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants. 7.10.1.4 VERTICAL OPENINGS K20 2000 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least one hour. An atrium may be used in accordance with 8.2.5.6, 19.3.1.1. If all vertical openings are properly enclosed with construction providing at least a two hour fire resistance rating, also check this box. s Form CMS-2786S (06/07) EF 06/2007 Page 2 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility ID PREFIX 2000 CODE MET NOT MET N/A REMARKS If enclosures are less than required, give a brief description and specific location in REMARKS. 2000 NEW Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least two hours connecting four stories or more. (One hour for single story building and sprinklered buildings up to three stories in height.) 18.3.1.1. An atrium may be used in accordance with 8.2.2.3.5. If enclosures are less than required, give a brief description and specific location in REMARKS. SMOKE COMPARTMENTATION AND CONTROL K23 2000 EXISTING Smoke barriers shall be provided to form at least two smoke compartments on every sleeping room floor for more than 30 patients. 19.3.7.1, 19.3.7.2 2000 NEW Smoke barriers shall be provided to form at least two smoke compartments on every floor used by inpatients for sleeping or treatment, and on every floor with an occupant load of 50 or more persons, regardless of use. Smoke barriers shall also be provided on floors that are usable, but unoccupied. 18.3.7.1, 18.3.7.2 K28 2000 EXISTING Door openings in smoke barriers shall provide a minimum clear width of 32 inches (81 cm) for swinging or horizontal doors. Vision panels are of fire-rated glazing or wired glass panels and steel frames. 19.3.7.5, 19.3.7.7 Form CMS-2786S (06/07) EF 06/2007 Page 3 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility 2000 CODE ID PREFIX MET NO MET N/A REMARKS 2000 NEW Door openings in smoke barriers are installed as swinging or horizontal doors shall provide a minimum clear width as follows: Provider Type Swinging Doors Horizontal Sliding Doors Hospitals and Nursing Facilities 41.5 inches (105 cm) 83 inches (211 cm) Psychiatric Hospitals and Limited Care Facilities 32 inches (81 cm) 64 inches (163 cm) Vision panels of fire-rated glazing or wired panels in approved frames are provided for each door. 18.3.7.5, 18.3.7.7 HAZARDOUS AREA K29 2000 EXISTING One hour fire rated construction (with 3/4 hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protects hazardous areas. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors. Doors shall be self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. 19.3.2.1 Area Automatic Sprinkler a. Boiler and Fuel-Fired Heater Rooms c. Laundries (greater than 100 sq feet) d. Repair Shops and Paint Shops e. Laboratories (if classified a Severe Hazard - see K31) f. Combustible Storage Rooms/Spaces (over 50 sq feet) g. Trash Collection Rooms i. Soiled Linen Rooms Separation N/A Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. Form CMS-2786S (06/07) EF 06/2007 Page 4 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility 2000 CODE ID PREFIX MET NO MET N/A REMARKS 2000 NEW Hazardous areas are protected in accordance with 8.4. The areas shall be enclosed with a one hour fire-rated barrier, with a 3 /4 hour fire-rated door, without windows (in accordance with 8.4). Doors shall be self-closing or automatic closing in accordance with 7.2.1.8. 18.3.2.1 Area Automatic Sprinkler a. Boiler and Fuel-Fired Heater Rooms c. Laundries (greater than 100 sq feet) d. Repair, Maintenance and Paint Shops e. Laboratories (if classified a Severe Hazard - see K31) f. Combustible Storage Rooms/Spaces (over 50 and less than 100 sq feet) g. Trash Collection Rooms i. Soiled Linen Rooms m.Combustible Storage Rooms/Spaces (over 100 sq feet) Separation N/A Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. K30 Gift shops shall be protected as hazardous areas when used for storage or display of combustibles in quantities considered hazardous. Non-rated walls may separate gift shops that are not considered hazardous, have separate protected storage and that are completely sprinkled. Gift shops may be open to the corridor if they are not considered hazardous, have separate protected storage, are completely sprinklered and do not exceed 500 square ºfeet. 18.3.2.5, 19.3.2.5 Area L. Gift Shop storing hazardous quantities of combustibles Automatic Sprinkler Separation N/A 18.2.6, 19.2.6 K211 2000 EXISTING Where Alcohol Based Hand Rub (ABHR) dispensers are installed: t The corridor is at least 6 feet wide t The maximum individual fluid dispenser capacity shall be 1.2 liters (2 liters in suites of rooms) t The dispensers shall have a minimum spacing of 4 ft from each other t Not more than 10 gallons are used in a single smoke compartment outside a storage cabinet. t Dispensers are not installed over or adjacent to an ignition source. t If the floor is carpeted, the building is fully sprinklered. 19.3.2.7, CFR 482.41, 483.70, 483.623 Form CMS-2786S (06/07) EF 06/2007 Page 5 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility 2000 CODE ID PREFIX K211 MET NO MET N/A REMARKS 2000 NEW Where Alcohol Based Hand Rub (ABHR) dispensers are installed: t The corridor is at least 6 feet wide t The maximum individual fluid dispenser capacity shall be 1.2 liters (2 liters in suites of rooms) t The dispensers shall have a minimum spacing of 4 ft from each other t Not more than 10 gallons are used in a single smoke compartment outside a storage cabinet. t Dispensers are not installed over or adjacent to an ignition source. t If the floor is carpeted, the building is fully sprinklered. 18.3.2.7, CFR 482.41, 483.70, 483.623 EXISTS AND EGRESS K38 Exit access is so arranged that exits are readily accessible at all times in accordance with 7.1. 18.2.1, 19.2.1 K39 2000 EXISTING Width of aisles or corridors (clear and unobstructed) serving as exit access shall be at least 4 feet. 19.2.3.3 2000 NEW Width of aisles or corridors (clear and unobstructed) serving as exit access in hospitals and nursing homes shall be at least 8 feet. In limited care facility and psychiatric hospitals, width of aisles or corridors shall be at least 6 feet. 18.2.3.3, 18.2.3.4 K40 2000 EXISTING Exit access doors and exit doors used by health care occupants are of the swinging type and are at least 32 inches in clear width. 19.2.3.5 2000 NEW Exit access doors and exit doors used by health care occupants are of the swinging type, with openings of at least 41.5 inches wide. Doors in exit stairway enclosures shall be no less than 32 inches in clear width. In ICFs/MR, doors are at least 32 inches wide. 18.2.3.5 Form CMS-2786S (06/07) EF 06/2007 Page 6 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility 2000 CODE ID PREFIX K43 MET NO MET N/A REMARKS Patient room doors are arranged such that the patients can open the door from inside without using a key. Special door locking arrangements are permitted in health facilities. 18.2.2.2.4, 18.2.2.2.5 If door locking arrangement without delay egress is used indicate in REMARKS 18.2.2.2.2, 19.2.2.2.2 ILLUMINATION AND EMERGENCY POWER K45 Illumination of means of egress, including exit discharge, is arranged so that failure of any single lighting fixture (bulb) will not leave the area in darkness. 18.2.8, 19.2.8, 7.8 K47 2000 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one story buildings with less than 30 occupants where the line of exit travel is obvious.) 2000 NEW Exit and directional signs are displayed with continuous illumination also served by the emergency lighting, system in accordance with 7.10. 18.2.10.1 K105 2000 NEW (INDICATE N/A FOR EXISTING) Buildings equipped with or requiring the use of life support systems (electro-mechanical or inhalation anesthetics) have illumination of means of egress, emergency lighting equipment, exit, and directional signs supplied by the Life Safety Branch of the electrical system described in NFPA 99. 18.2.9.2., 18.2.10.2, 18.5.1.1, 18.5.1.2 (Indicate N/A if life support equipment is for emergency purposes only). Form CMS-2786S (06/07) EF 06/2007 Page 7 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility 2000 CODE ID PREFIX MET NO MET N/A REMARKS EMERGENCY PLAN AND FIRE DRILLS K48 There is a written plan for the protection of all patients and for their evacuation in the event of an emergency. 18.7.1.1, 19.7.1.1 K50 Fire drills are held at unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Responsibility for planning and conducting drills is assigned only to competent persons who are qualified to exercise leadership. Where drills are conducted between 9:00 PM and 6:00 AM a coded announcement may be used instead of audible alarms. 18.7.1.2, 19.7.1.2 FIRE ALARM SYSTEMS K51 2000 EXISTING A fire alarm system with approved component, devices or equipment installed according to NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. Activation of the complete fire alarm system shall be by manual fire alarm initiation, automatic detection or extinguishing system operation. Pull stations in patient sleeping areas, may be omitted provided that manual pull stations are within 200 ft of nurse’s stations. Pull stations are located in the path of egress. Electronic or written records of tests shall be available. A reliable second source of power must be provided. Fire alarm systems shall be in accordance with NFPA 72, and records of maintenance kept readily available. There shall be annunciation of the fire alarm system to an approved central station. 19.3.4, 9.6 2000 NEW A fire alarm system with approved component, devices or equipment installed according to NFPA 72, to provide effective warning of fire in any part of the building. Activation of the complete fire alarm system shall be by manual fire alarm initiation, automatic detection or extinguishing system operation. Pull stations are located in the path of egress. Electronic or written records of tests shall be available. A reliable second source of power must be provided. Fire alarm systems shall be maintained in accordance with NFPA72, and records of maintenance kept readily available. There shall be remote annunciation of the fire alarm system to an approved central station. 18.3.4, 9.6 Form CMS-2786S (06/07) EF 06/2007 Page 8 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility ID PREFIX 2000 CODE MET K52 REMARKS Where a required fires alarm system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. 9.6.1.8 K53 N/A A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with NFPA 70 National Electrical Code and NFPA 72. The system shall have an approved maintenance and testing program complying with applicable requirement of NFPA 70 and 72. 9.6.1.4 K155 NO MET 2000 EXISTING (INDICATE N/A FOR HOSPITALS AND FULLY SPRINKLERED NURSING HOMES) In an existing nursing home, not fully sprinklered, the resident sleeping rooms and public areas (dining rooms, activity rooms, resident meeting rooms, etc) are to be equipped with single station battery-operated smoke detectors. There will be a testing, maintenance and battery replacement program to ensure proper operation. CFR 483.70 2000 NEW (NURSING HOME AND EXISTING LIMITED CARE FACILITIES) An automatic smoke detection system is installed in all corridors. (As an alternative to the corridor smoke detection system on patient sleeping room floors, smoke detectors may be installed in each patient sleeping room and at smoke barrier or horizontal exit doors in the corridor.) Such detectors are electrically interconnected to the fire alarm system. 18.3.4.5.3 Form CMS-2786S (06/07) EF 06/2007 Page 9 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility 2000 CODE ID PREFIX K109 MET NO MET N/A REMARKS 2000 EXISTING LIMITED CARE FACILITIES (INDICATE N/A FOR HOSPITALS OR NURSING HOMES) An automatic smoke detection system is installed in all corridors, with detector spacing no further apart than 30 ft on center in accordance with NFPA 72. (As an alternative to the corridor smoke detection system on patient sleeping room floors, smoke detectors may be installed in each patient sleeping room and at smoke barrier or horizontal exit doors in the corridors.) Such detectors are electrically interconnected to the fire alarm system. 19.3.4.5.1 Smoke Detection System t Corridors t Rooms t Bath AUTOMATIC SPRINKLER SYSTEMS K56 2000 EXISTING Where required by section 19.1.6, Health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with section 9.7. Required sprinkler systems are equipped with water flow and tamper switches which are electrically interconnected to the building fire alarm. 19.3.5, NPFA 13 2000 NEW When required by construction type, there is an automatic sprinkler system installed in accordance with NFPA13, Standard for the Installation of Sprinkler Systems, with approved components, device and equipment, to provide complete coverage of all portions of the facility. Systems are equipped with waterflow and tamper switches, which are connected to the fire alarm system. 18.3.5. A. Date sprinkler system last checked and necessary maintenance provided. _______________________________ B. Show who provided the service. _______________________ Form CMS-2786S (06/07) EF 06/2007 Page 10 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility 2000 CODE ID PREFIX MET K154 REMARKS Automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 18.7.6, 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5 K64 N/A Where a required automatic sprinkler system is out of service for more than 4 hours in a 24-hour period, the authority having jurisdiction shall be notified, and the building shall be evacuated or an approved fire watch system be provided for all parties left unprotected by the shutdown until the sprinkler system has been returned to service. 9.7.6.1 K62 NO MET Portable fire extinguishers shall be provided in all health care occupancies in accordance with 9.7.4.1, NFPA 10. 18.3.5.6, 19.3.5.6 SMOKING REGULATIONS K66 Smoking regulations shall be adopted and shall include not less than the following provisions: 18.7.4, 19.7.4 s (1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. s (2) Smoking by patients classified as not responsible shall be prohibited, except when under direct supervision. s (3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. s (4) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. Form CMS-2786S (06/07) EF 06/2007 Page 11 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility 2000 CODE ID PREFIX MET NO MET N/A REMARKS BUILDING SERVICE EQUIPMENT K70 Portable space heating devices shall be prohibited in all health care occupancies. Except it shall be permitted to be used in non-sleeping staff and employee areas where the heating elements of such devices do not exceed 212oF (100oC). 18.7.8, 19.7.8 FURNISHINGS AND DECORATIONS K72 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress there from, or visibility thereof shall be in accordance with 7.1.10 K74 Draperies, curtains, including cubicle curtains, and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with provisions of 10.3.1 and NFPA 13 Standard for the Installation of Sprinkler Systems. Except shower curtains shall be in accordance with NFPA 701. s Newly introduced upholstered furniture shall meet the criteria specified when tested in accordance with the methods cited in 10.3.2 (2) and 10.3.1. 18.3.5.3 and NFPA 13 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 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 10.5.1. Form CMS-2786S (06/07) EF 06/2007 Page 12 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility ID PREFIX 2000 CODE MET K134 N/A REMARKS 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 designed and installed to avoid injurious water pressure shall be in accordance with NFPA 99, 10.6. K135 NO MET Flammable and combustible liquids shall be used from and stored in approved containers 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 liquids shall be constructed in accordance with NFPA 30, Flammable and Combustible liquids Code NFPA 99, 4.3, 10.7.2.1. MEDICAL GASES AND ANESTHETIZING AREAS K76 Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities. (a) Oxygen storage locations of greater than 3,000 cu.ft. are enclosed by a one-hour separation. (b) Locations for supply systems of greater than 3,000 cu.ft. are vented to the outside. NFPA 99, 4.3.1.1.2, 18.3.2.4, 19.3.2.4 K141 Non-smoking and no smoking signs in areas where oxygen is used or stored shall be in accordance with 18.3.2.4, 19.3.2.4, NFPA 99, 8.6.4.2 K143 Transferring of oxygen shall be: (a) separated from any portion of a facility wherein patients are housed, examined, or treated by a separation of a fire barrier of 1-hour fire-resistive construction; and (b) the area that is mechanically ventilated, sprinklered, and has ceramic or concrete flooring; and (c) in an area that is posted with signs indicating that transferring is occurring, and that smoking in the immediate area is not permitted in accordance with NFPA 99 and Compressed Gas Association. 8.6.2.5.2 Form CMS-2786S (06/07) EF 06/2007 Page 13 American LegalNet, Inc. www.FormsWorkflow.com Name of Facility 2000 CODE ID PREFIX MET NO MET N/A REMARKS ELECTRICAL K144 Generators inspected weekly and exercised under load for 30 minutes per month and shall be in accordance with NFPA 99, 3.4.4.1, NFPA 110, 8.4.2. K146 The nursing home/hospice with no life support equipment shall have an alternate source of power separate and independent from the normal source that will be effective for minimum of 11/2 hour after loss of the normal source NFPA 99, 3.6 K130 Miscellaneous List in the REMARKS sections, any items that are not listed previously, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Form CMS-2786S (06/07) EF 06/2007 Page 14 American LegalNet, Inc. www.FormsWorkflow.com FIRE SAFETY SURVEY REPORT CRUCIAL DATA EXTRACT (TO BE USED WITH CMS-2786 FORMS) PROVIDER NUMBER FACILITY NAME SURVEY DATE * K4 * K4 MULTIPLE CONSTRUCTION TOTAL NUMBER OF BUILDINGS ____________ NUMBER OF THIS BUILDING ____________ LSC FORM INDICATOR 1 2 3 4 5 6 7 8 9 *K7 BUILDING WING FLOOR APARTMENT UNIT COMPLETE IF ICF/MR IS SURVEYED UNDER CHAPTER 21 SMALL (16 BEDS OR LESS) K8: 2786 A-67 EXISTING A-67 NEW B-73 EXISTING B-73 NEW F-81 EXISTING F-81 NEW C-SHORT H-ASC J, K, L 85-CHAPTER 21 (ICFs/MR ONLY) P-85 EXISTING P-85 NEW 10 11 A B C D 1 PROMPT 2 SLOW 3 IMPRACTICAL LARGE K8: 4 PROMPT 5 SLOW 6 IMPRACTICAL APARTMENT HOUSE 7 PROMPT SELECT NUMBER OF FORM USED FROM ABOVE K8: 8 SLOW 9 IMPRACTICAL (Check if not applicable) ENTER E – SCORE HERE K29: K56: K5: e.g. 2.5 *K9: FACILITY MEETS LSC BASED ON: (Check all that apply) A1. (COMP. WITH ALL PROVISIONS) FACILITY DOES NOT MEET LSC: B. A2. A3. (ACCEPTABLE POC) A4. (WAIVERS) (FSES) K0180 A. FULLY SPRINKLERED B. PARTIALLY SPRINKLERED (All required areas are sprinklered) (Not all required areas are sprinklered) C. NONE (No sprinkler system) * MANDATORY Form CMS-2786S (06/07) EF 06/2007 Page 14 American LegalNet, Inc. www.FormsWorkflow.com