DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 2000 CODE ICFs/MR FIRE SAFETY SURVEY REPORT - 2000 LIFE SAFETY CODE Intermediate Care Facilities for the Mentally Retarded 1. (A) PROVIDER NO. LARGE Form Approved OMB No. 0938-0242 1. (B) MEDICAID I.D. NO. K1 K2 PART I — Figure 6.8 — A Procedure for Determining Evacuation Capability PART II — Chapters 32 & 33 — Residential Board & Care Occupancies — Requirements PART III — Figure 7.5 — Fire Safety Evaluation System for Board & Care (Optional) — CMS-2786T Identifying information as shown in applicable records. Enter changes, if any, alongside each item, giving date of change. 2. (A) MULTIPLE CONSTRUCTION 2. NAME OF FACILITY 2. (B) ADDRESS OF FACILITY (STREET, CITY, STATE, ZIP CODE A. s Fully Sprinklered (All required areas are sprinklered) A. BUILDING B. s Partially Sprinklered (Not all required areas are sprinklered) B. WING C. C. FLOOR 4. DATE OF SURVEY DATE OF PLAN APPROVAL SURVEY UNDER: K4 K6 K7 9. E–Score E–Score Level of Evacuation Difficulty < 1.5 > 1.5 < 5.0 > 5.0 s 2000 s Chapter 32 New s Chapter 33 Existing 5. SURVEY FOR CERTIFICATION OF: SMALL FACILITY LEVEL OF EVACUATION DIFFICULTY (check one) Prompt Slow Impractical 4. Prompt 6. Impractical 5. Slow K8 K5 6. BED COMPOSITION A. TOTAL NO. OF BEDS IN THE FACILITY 7. s None (No sprinkler system) K0180 K3 E. NUMBER OF BEDS CERTIFIED FOR MEDICAID A. THE FACILITY MEETS, BASED UPON (CHECK ALL APPROPRIATE BOXES) 1. s COMPLIANCE WITH ALL PROVISIONS 2. s ACCEPTANCE OF A PLAN OF CORRECTION 4. s FSES 5. s PERFORMANCE BASED DESIGN B. THE FACILITY DOES NOT MEET THE STANDARDS K9 SURVEYOR (SIGNATURE) TITLE OFFICE DATE TITLE OFFICE DATE SURVEYOR ID K10 FIRE 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-2786W (06/07) EF 06/2007 Page 1 American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS FOR COMPLETING THE FORM (CMS-2786K) LARGE FACILITIES — 17 BEDS OR MORE 1. DetermIne the Level of Evacuation Capability of the facility. 2. Transfer the E-Score obtained in Fig. 6.8 of page 1 of this form. 3. Complete either LSC Chapter 32 for (new) or LSC Chapter 33 for (existing) requirements of this form, or Fig. 7.5 — Rating the Building. A. If completing Chapter 32 or 33 Requirements: 1. PROMPT OR SLOW - Complete sections for PROMPT and SLOW 2. Impractical - Complete a CMS-2786R (Health Care) or FSES/Health Care (Optional) — see page 13. B. If completIng the FSES/BC — Chapter 32 or 33 — Rating the Building 1. You MUST also complete the Chapter 32 or 33 requirements. An FSES building evacuation cannot be done without completing the usual survey form pages for Chapter 32 or 33 2. You may use the FSES/Health Care to evaluate the building (Form CMS-2786T Chapter 4 & Fig. 4.7), but if you choose to do so, you must use the LSC Survey Report for Health Care (CMS-2786R) *Figures for FSES/HC are taken from NFPA 101 A 2001 Edition Form CMS-2786W (06/07) EF 06/2007 Page 2 American LegalNet, Inc. www.FormsWorkflow.com Worksheet for Calculating Evacuation Difficulty Score (E-Score) F-2 BEFORE FILLING OUT THIS WORKSHEET: • • • Please read the Instruction Manual. Make sure you have the completed “Worksheets for Rating Residents” (figure 6.8) for each resident. Determine whether the requirements for using the Evacuation Difficulty Index have been satisfied by checking the one box to the left of each question below that shows whether the answer to the question is “YES” or “NO.” t YES t NO 1. Has a protection plan been developed and written and have all staff members counted in the calculation of E-Scores been trained in its implementation? t YES t NO 2. Is the total available staff at any given time able to handle the individual evacuation needs of each resident who may be in the residence? t YES t NO 3. Can every staff member counted in the calculation of E-Scores meaningfully participate in the evacuation of every resident? t YES t NO 4. Are all staff members counted in the calculation of E-Scores required to remain in the residence with only the exceptions listed in the Instruction Manual? t YES t NO 5. Were at least twelve fire drills conducted during the year? This worksheet is filled out for the staff “Shift” From To (You must fill out this worksheet for the time of day, week, etc. when the ratings for the combination of staff and residents yields the highest E-Score. This period of time will usually be late at night. When it is not obvious which time period has the highest E-Score, complete a separate worksheet for all candidate time periods and use the one having the highest E-Score.) EVALUATOR’S NAME (if other than Fire Authority Surveyor) Form CMS-2786W (06/07) EF 06/2007 DATE Page 3 American LegalNet, Inc. www.FormsWorkflow.com Worksheet 6.8.1 Cover Sheet Resident’s name___________________________________________________________________________________ Evaluator___________________________________________________________________________________ Facility __________________________________________________________________________________________ Date ______________________________________________________________________________________ Zone ______________________________________________________________________________________ Write any explanatory remarks here: Worksheet 6.8.2 Rating the Resident on the Risk Factors Rate the resident on each of the factors below by checking the one circle for each risk factor that best describes the resident. For the first six factors, write the scores for the circles checked in the appropriate score boxes in the far right column. For “Response to Fire Drills,” write the three checked scores in the large circles. Write the sum of the three scores in the large box on the right. I. Risk of Resistance Minimal Risk (Check only one) II. Impaired Mobility IV. Need for Extra Help No Significant Risk score = 0 Follows Instructions score = 30 Requires Supervision Response Probable score = 40 score = 10 Response Not Probable score = 0 (Check only one) score = 20 Needs Full Assistance from 2 Staff Requires Considerable Attention/Might Not Respond score = 3 score = 1 (Check only one) VI. Waking Response to Alarm Needs Limited Assistance from 2 Staff score = 20 Totally Impaired score = 6 score = 0 Needs at Most One Staff Needs Full Assistance or Very Slow score = 6 score = 3 Partially Impaired score = 6 VII. Response to Fire Drills Initiates and Completes Evacuation Promptly Yes (Without guidance or advice from staff) Chooses and Completes Back-up Strategy Yes No score = 0 score = 8 No score = 0 Remains at Designated Location Yes score = 4 No score = 0 Form CMS-2786W (06/07) EF 06/2007 Score Boxes score = 20 Needs Limited Assistance score = 0 (Check only one) V. Response to Instructions Slow Self-Starting (Check only one) Risk of Strong Resistance score = 6 score = 0 (Check only one) III. Impaired Consciousness Risk of Mild Resistance score = 6 Sum of These Three Scores Page 4 American LegalNet, Inc. www.FormsWorkflow.com Worksheet 6.8.3 Determining the Resident’s Overall Need for Assistance Compare the numbers in the seven score boxes filled in. Take the highest score from the score boxes (Worksheet 6.8.2.) and write it in the box at the right. Evacuation Assistance Score Notes: Worksheet 6.8.4 Resident Scores Evac. Assist. Score Resident’s Name Evacuation Assistance Score Form CMS-2786W (06/07) EF 06/2007 Total Evac. Assist. Score Resident’s Name Evacuation Assistance Score Total Page 5 American LegalNet, Inc. www.FormsWorkflow.com Worksheet 6.8.5 Cover Sheet Staff Shift Score Facility ________________________________________ Zone __________________________________________ Evaluator ______________________________________ Date ___________________________________________ Staff Shift: From_________________________________ To_____________________________________________ Worksheet 6.8.6 Staff Response and Training YES NO A protection plan has been promulgated and all staff members considered in this rating have been trained in its implementation. (See 6.5.2.1) The total available staff at any given time is able to handle the individual evacuation needs of each resident who is in the facility. (See 6.5.2.2. and Exception) Every staff member considered in this rating can meaningfully participate in the evacuation of each resident. (See 6.5.2.3) All staff members considered in this rating are required to be in the facility when on duty, except as permitted. (See 6.5.2.4 and Exceptions) At least 12 fire drills were conducted during the previous year. (See 6.5.2.5 and Exception) All items must score “Yes” before proceeding. Worksheet 6.8.7 Promptness of Response Scores Alarm Effectiveness Staff Availability Standby or asleep Immediately available Immediately available and close by Assured 16 20 20 Not Assured 2 2 10 Worksheet 6.8.8 Staff Scores Promptness of Response Score Resident’s Name Staff Shift Score Form CMS-2786W (06/07) EF 06/2007 Total Promptness of Response Score Resident’s Name Staff Shift Score Total Page 6 American LegalNet, Inc. www.FormsWorkflow.com Worksheet 6.8.9 Rating the Facility Vertical Distance from Sleeping Rooms to Exits All SR on Floors with Direct Exit Small Facility Any SR One Floor from Exit Score 0.8 Any SR Two or More Floors from Exit Score 1.0 Large Facility or Apartment Score 1.2 Score 1.0 NOTE: Small facilities have 16 or fewer residents. See 6.6.6 for apartments. Worksheet 6.8.10 Calculation of Evacuation Capability Score Total Resident Evacuation Assistance Score (Worksheet 6.8.4) Vertical Distance from Sleeping Room to Exit (Worksheet 6.8.9) X = Evacuation Capability Score (Go to Worksheet 6.8.11) Staff Shift Score (Worksheet 6.8.8) Worksheet 6.8.11 Evacuation Capability Score Evacuation Capability Score Level of Evacuation Capability 1. to 5.0 Impractical Form CMS-2786W (06/07) EF 06/2007 Evacuation Capability for this Facility or Zone Page 7 American LegalNet, Inc. www.FormsWorkflow.com ID PREFIX LARGE FACILITY PROMPT AND SLOW EVACUATION CAPABILITIES MET NOT N/A MET REMARKS LARGE PROMPT & SLOW BUILDING CONSTRUCTION (NEW & EXISTING) K12 Minimum Construction Requirements: Based on highest story normally used by residents One and Two Story s Any construction type of one-hour or greater fire rating, or s Type IV (2HH), or s Fully sheathed, or s With automatic sprinkler system throughout, in accordance with 32.3.3.5, 33.3.3.5. s Exception: One story any construction type and no more than 30 residents capable of prompt evacuation. Three to Six Stories s Type I, II or Ill construction of one-hour or greater fire resistance rating, or s Type IV construction with automatic sprinkler system throughout in accordance with 32.3.3.5 or 33.3.3.5. s Exception: Three or four story facilities of Type V (000), sheathed and with automatic sprinkler system throughout, in accordance with 32.3.3.5, 33.3.3.5. More than Six Stories s Type I or II (222) construction, or s Type II (111) construction, or s Type III (211) construction, or s Type IV (2HH) with automatic sprinkler system throughout in accordance with 32.3.3.5, 33.3.3.5. 32.3.1.3, 33.1.3.1 OCCUPANT LOAD s Not less than two exits shall be accessible from every floor and in at least two different directions. The occupant load, in number of persons for who means of egress and other provisions are required, shall be determined on the basis of the occupant load factors or Table 7.3.1.2 that are characteristic of the use of the space or shall be determined as the maximum probable population of the space under consideration, whichever is greater. 33.3.1.4, 32.3.1.4 Form CMS-2786W (06/07) EF 06/2007 Page 8 American LegalNet, Inc. www.FormsWorkflow.com ID PREFIX LARGE FACILITY PROMPT AND SLOW EVACUATION CAPABILITIES MET NOT N/A MET REMARKS LARGE PROMPT & SLOW HAZARDOUS AREAS K124 Any room containing high-pressure boilers, refrigerating machinery, transformers, or other service equipment subject to possible explosion shall not be located under or adjacent to exits. All such rooms shall be effectively separated from other parts of the building as specified in section 8.4. K29 32.3.3.2.1, 33.3.2.1 All hazardous areas shall be separated with construction of a minimum of one-hour fire resistance or automatic extinguishment system with openings protected with self-closing fire doors. s Exception: Existing buildings may have hazardous areas separated from other parts of the building by a smoke partition in accordance with section 8.2.4. Hazardous areas shall include but not be limited to the following: boiler or heating rooms, laundries, repair shop, spaces storing combustibles in quantities deemed hazardous by the authority having jurisdiction. 32.3.3.2.2, 33.3.3.2.2 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 483.470 Form CMS-2786W (06/07) EF 06/2007 Page 9 American LegalNet, Inc. www.FormsWorkflow.com ID PREFIX K211 LARGE FACILITY PROMPT AND SLOW EVACUATION CAPABILITIES MET NOT N/A MET REMARKS LARGE PROMPT & SLOW 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 483.470 DETECTION ALARM & COMMUNICATIONS SYSTEMS K51 A manual fire alarm system with approved component devices or equipment, shall be installed in accordance with section 9.6. s Exception: Where each bedroom has an exterior exit access in accordance with 7.5.3 and the building is not greater than three stories. INITIATION The required fire alarm system shall be initiated by the following means: (1) Manual means in accordance with 9.6.2 s Exception: A manual means, as specified in 9.6.2, in excess of the manual fire alarm box at a constantly attended location per 33.3.3.4.2(2) below shall not be required where there are other effective means (such as a complete automatic sprinkler or automatic detection system) for notification of fire as required. (2) A manual fire alarm box located at a convenient central control point under continuous supervision of responsible employees. (3) The automatic sprinkler system. Form CMS-2786W (06/07) EF 06/2007 Page 10 American LegalNet, Inc. www.FormsWorkflow.com ID PREFIX LARGE FACILITY PROMPT AND SLOW EVACUATION CAPABILITIES MET NOT N/A MET REMARKS LARGE PROMPT & SLOW s Exception: Automatic sprinkler systems that are not required by another section of this Code shall not be required to initiate the fire alarm system. (4) Any required detection system. s Exception: Sleeping room smoke alarms shall not be required to initiate the building fire alarm system. 32.3.3.4, 33.3.3.4 ANNUNCIATOR PANEL s An annunciator panel connected with the fire alarm system shall be provided. The location of the annunciator shall be approved by the authority having jurisdiction. s Exception: Buildings not more than two stories in height and with not more than 50 sleeping rooms. 32.3.3.4.3 OCCUPANT NOTIFICATION 2000 EXISTING s Occupant notification shall be provided automatically, without delay, by internal audible alarm in accordance with 9.6.3. 33.3.3.4.4 2000 NEW s Occupant notification shall be provided automatically, without delay, in accordance with 9.6.3. 32.3.3.4.4 FIRE DEPARTMENT NOTIFICATION s In case of a fire, provisions shall be made for the immediate notification of the public fire department by either telephone or other means. Where there is no public fire department, this notification shall be made to the private fire brigade. 32.3.3.4.6, 33.3.3.4.6 K155 Where a required fire 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 Form CMS-2786W (06/07) EF 06/2007 Page 11 American LegalNet, Inc. www.FormsWorkflow.com ID PREFIX LARGE FACILITY PROMPT AND SLOW EVACUATION CAPABILITIES MET NOT N/A MET REMARKS LARGE PROMPT & SLOW SMOKE DETECTION AND ALARM K109 SMOKE DETECTION 2000 EXISTING Each sleeping room shall be provided with an approved smoke alarm in accordance with 9.6.2.10 that is powered from the building electrical system. s Exception No.1: Existing battery-powered smoke alarms, rather than building electrical service-powered smoke alarms, shall be accepted where, in the opinion of the authority having jurisdiction, the facility has demonstrated that testing, maintenance, and battery replacement programs ensure the reliability of power to the smoke alarms. s Exception No. 2: Facilities having an existing corridor smoke detection system in accordance with Section 9.6 that is connected to the building fire alarm system. 33.3.3.4.7 2000 NEW Each sleeping room shall be provided with an approved smoke alarm in accordance with 9.6.2.10 that is powered from the building electrical system. 32.3.3.4.7 s All living areas as defined in 3.3.119 and corridors shall be provided with smoke detectors in accordance NFPA 72, National Fire Alarm Code, that are arranged to initiate an alarm that is audible in all sleeping areas. s Exception No. 1: Detectors shall not be required in living areas and kitchens in facilities protected throughout by an approved automatic sprinkler system installed in accordance with 33.3.3.5. s Exception No. 2: Unenclosed corridors, passageways, balconies, colonnades, or other arrangements with one or more sides along the long dimension fully or extensively open to the exterior at all times. 32.3.3.4.8, 33.3.3.4.8 Form CMS-2786W (06/07) EF 06/2007 Page 12 American LegalNet, Inc. www.FormsWorkflow.com ID PREFIX LARGE FACILITY PROMPT AND SLOW EVACUATION CAPABILITIES MET NOT N/A MET REMARKS LARGE PROMPT & SLOW AUTOMATIC SPRINKLERS K56 2000 EXISTING Where an automatic sprinkler system is installed for total or partial building coverage, the system shall be in accordance with Section 9.7. s Exception No. 1: In buildings not more than four stories in height, a sprinkler system complying with NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height, shall be permitted. s Exception No. 2: Automatic sprinklers shall not be required in small clothes closets where the smallest dimension does not exceed 3 ft (0.9m), the area does not exceed 24f 2 (2.2m 2), and the walls and ceilings are finished with noncombustible or limited-combustible material. s Exception No. 3: Initiation of the fire alarm system shall not be required for existing installations in accordance with 33.3.3.5.4. Automatic sprinkler systems shall be supervised in accordance with Section 9.7. Waterflow alarms shall not be required to be transmitted off-site. Sprinkler piping serving not more than six sprinklers for any isolated hazardous area in accordance with 9.7.1.2 shall be permitted. In new installations where more than two sprinklers are installed in a single area, waterflow detection shall be provided to initiate the fire alarm system required by 33.3.3.4.1. 33.3.3.5.1, 33.3.3.5.2, 33.3.3.5.3, 33.3.3.5.4 2000 NEW All buildings shall be protected throughout by an approved automatic sprinkler system in accordance with Section 9.7. Quick-response or residential sprinklers shall be provided throughout. s Exception No. 1: In buildings not more than four stories in height, a sprinkler system complying with NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height, shall be permitted Form CMS-2786W (06/07) EF 06/2007 Page 13 American LegalNet, Inc. www.FormsWorkflow.com ID PREFIX LARGE FACILITY PROMPT AND SLOW EVACUATION CAPABILITIES MET NOT N/A MET REMARKS LARGE PROMPT & SLOW s Exception No. 2: Automatic sprinklers shall not be required in small clothes closets where the smallest dimension does not exceed 24 ft2 (2.2m2), and the walls and ceilings are finished with noncombustible or limited-combustible materials. s Exception No. 3: Standard response sprinklers shall be permitted for use in hazardous areas in accordance with 32.3.3.2. Automatic sprinkler systems shall be supervised in accordance with Section 9.7. 32.3.3.5.1, 32.3.3.5.3 K154 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 A. Date sprinkler system last checked and necessary maintenance provided. ______________________________ B. Show who provided the service._______________________ C. Note the source of the water supply for the automatic sprinkler system. ___________________________________ (Provide, in REMARKS, information on coverage for any non-required or partial automatic sprinkler system.) PORTABLE FIRE EXTINGUISHERS K64 Portable fire extinguishers shall be provided near hazardous areas in accordance with 9.7.4.1. 33.3.3.5.5, 32.3.3.5.5 SEPARATION OF SLEEPING ROOMS FROM EXIT ACCESS K17 2000 EXISTING Access shall be provided from every resident use area to not less than one means of egress that is separated from all other rooms or spaces by walls complying with 33.3.3.6.3 through 33.3.3.6.6. Form CMS-2786W (06/07) EF 06/2007 Page 14 American LegalNet, Inc. www.FormsWorkflow.com ID PREFIX LARGE FACILITY PROMPT AND SLOW EVACUATION CAPABILITIES MET NOT N/A MET REMARKS LARGE PROMPT & SLOW s Exception No. 1: Rooms or spaces, other than sleeping rooms, protected throughout by an approved automatic sprinkler system in accordance with 33.3.3.5. s Exception No. 2: Prompt evacuation capability facilities in buildings not over two stories in height where not less than one required means of egress from each sleeping room provides a path of travel to the outside without traversing any corridor or other spaces exposed to unprotected vertical openings, living areas, and kitchens. s Exception No. 3: Rooms or spaces, other than sleeping rooms, provided with a smoke detection and alarm system connected to activate the building evacuation alarm. Furnishings, finishes, and furniture, in combination with all other combustibles within the spaces, shall be of minimum quantity and arranged so that a fully developed fire is unlikely to occur. Sleeping rooms shall be separated from corridors, living areas, and kitchens by walls complying with 33.3.3.6.3 through 33.3.3.6.6. Walls required by 33.3.3.6.1 or 33.3.3.6.2 shall have a fire resistance rating of not less than 1/2 hour. s Exception No. 1: In buildings protected throughout by an approved automatic sprinkler system in accordance with 33.3.35, walls shall be smoke partitions in accordance with 8.2.4. The provisions of 8.2.4.3.5 shall not apply. s Exception No. 2: In buildings not more than two stories in height that are classified as prompt evacuation capability and that house not more than 30 residents, walls shall be smoke partitions in accordance with 8.2.4. The provisions of 8.2.4.3.5 shall not apply. Doors in walls required by 33.3.3.6.1 or 33.3.3.6.2 shall have a fire protection rating of not less than 20 minutes. s Exception No. 1: Solid-bonded wood core doors of not less than 13/4 in. (4.4cm) thickness shall be permitted to continue to be used. s Exception No. 2: In buildings protected throughout by an approved automatic sprinkler system in accordance with 33.3.3.5, doors that are nonrated shall be permitted to continue to be used. Form CMS-2786W (06/07) EF 06/2007 Page 15 American LegalNet, Inc. www.FormsWorkflow.com ID PREFIX LARGE FACILITY PROMPT AND SLOW EVACUATION CAPABILITIES MET NOT N/A MET REMARKS LARGE PROMPT & SLOW s Exception No. 3: Where automatic sprinkler protection is provided in the corridor with 31.3.5.2 through 31.3.5.4, doors shall not be required to have a fire protection rating but shall be in accordance with 8.2.4.3. The provisions of 8.2.4.3.5 shall not apply. Doors shall be equipped with latches for keeping the doors tightly closed. Walls and doors required by 33.3.3.6.1 and 33.3.3.6.2 shall be constructed as smoke partitions in accordance with 8.2.4. The provisions of 8.2.4.3.5 shall not apply. No louvers, transfer grilles, operable transoms, or other air passages shall penetrate such walls or doors, except properly installed heating and utility installations. Doors in walls required by 33.3.3.6.1 and 33.3.3.6.2 shall be self-closing or automatic-closing in accordance with 7.2.1.8. Doors in walls separating sleeping rooms from corridors shall be automatic-closing in accordance with 7.2.1.8. s Exception No. 1: Doors to sleeping rooms that have occupantcontrol locks such that access is normally restricted to the occupants or staff personnel shall be permitted to be self-closing. s Exception No. 2: In buildings protected throughout by an approved automatic sprinkler system installed in accordance with 33.3.3.5, doors, other than doors to hazardous areas, vertical openings, and exit enclosures, shall not be required to be self-closing or automatic-closing. 33.3.3.6.6 2000 NEW Access shall be provided from every resident use area to not less than one means of egress that is separated from all sleeping rooms by walls complying with 32.3.3.6.3 through 32.3.3.6.6. Sleeping rooms shall be separated from corridors, living areas, and kitchens by walls complying with 32.3.3.6.3 through 32.3.3.6.6. Walls required by 32.3.3.6.1 or 32.3.3.6.2 shall have a fire resistance rating of not less than 1/2 hour. s Exception: In conversions (see 32.1.1.3), no fire resistance rating shall be required, but the wall shall be a smoke partition in accordance with 8.2.4. The provisions of 8.2.4.3.5 shall not apply. Form CMS-2786W (06/07) EF 06/2007 Page 16 American LegalNet, Inc. www.FormsWorkflow.com ID PREFIX LARGE FACILITY PROMPT AND SLOW EVACUATION CAPABILITIES MET NOT N/A MET REMARKS LARGE PROMPT & SLOW Doors in walls required by 32.3.3.6.1 or 32.3.3.6.2 shall have a fire protection rating of not less than 20 minutes. s Exception: Doors in renovations and conversions (see 32.1.1.3) that are nonrated doors that resist the passage of smoke shall be permitted to continue to be used. Doors to hazardous areas, vertical openings, exits, and exit passageways shall be self-closing or automatic-closing. 32.3.3.6.6 K18 Doors in walls separating sleeping rooms from corridors shall have a fire protection rating of not less than 20 minutes. Doors shall be equipped with latches for keeping the doors tightly closed. s Exception No. 1: Existing 13/4 inch solid bonded wood core doors shall be permitted. s Exception No. 2: Where walls are only required to resist the passage of smoke, doors without fire rating and which resist the passage of smoke are permitted. s Exception No. 3: Where automatic sprinkler protection is provided in the corridor in accordance with 31.3.5.3 through 31.3.5.4, doors shall not be required to have a fire protection rating but shall be in accordance with 8.2.4.3. The provisions of 8.2.4.3.5 shall not apply. Doors shall be equipped with latches for keeping the doors tightly closed. 32.3.3.6.4, 33.3.3.6.4 Walls and doors required by 32.3.3.6.1 and 32.3.3.6.2. shall be constructed as smoke partitions in accordance with 8.2.4. The provisions of 8.2.4.3.5 shall not apply. No louvers, transfer grilles, operable transoms, or other air passages shall penetrate such walls or doors, except properly installed heating and utility installations. 32.3.3.6.5, 33.3.3.6.5 Form CMS-2786W (06/07) EF 06/2007 Page 17 American LegalNet, Inc. www.FormsWorkflow.com ID PREFIX LARGE FACILITY PROMPT AND SLOW EVACUATION CAPABILITIES MET NOT N/A MET REMARKS LARGE PROMPT & SLOW EXIT SYSTEM K34 Exits or exit components, arranged in accordance with Chapter 7, shall be of types in accordance with 32.3.2 or 33.3.2. K35 Capacity of means of egress shall be in accordance with 7.3. K38 Access to all required exits shall be in accordance with 7.3. 32.3.2.5.1, 33.3.2.5.1 K43 DOORS 2000 Existing Doors in means of egress shall be as follows: (1) Doors complying with 7.2.1 shall be permitted. (2) Doors within individual rooms and suites of rooms shall be permitted to be swinging or sliding. (3) No door in any means of egress shall be locked against egress when the building is occupied. s Exception No. 1: The requirement of 33.3.2.2.2(3) shall not apply to delayed-egress locks in accordance with 7.2.1.6.1, provided that not more than one device exists in a means of egress. s Exception No. 2: The requirement of 33.3.2.2.2(3) shall not apply to access-controlled egress doors in accordance with 7.2.1.6.2. (4) Revolving doors complying with 7.2.1.10 shall be permitted. 33.3.2.2.2, 32.3.2.2.2 2000 NEW (5) Every bathroom door shall be designed to allow opening from the outside during an emergency when locked. 32.3.2.2.2 K32 Not less than two exits shall be accessible from every story, including floors below the level of exit discharge and floors occupied from public purposes. 33.3.2.4, 32.3.2.4 Form CMS-2786W (06/07) EF 06/2007 Page 18 American LegalNet, Inc. www.FormsWorkflow.com ID PREFIX LARGE FACILITY PROMPT AND SLOW EVACUATION CAPABILITIES MET NOT N/A MET REMARKS LARGE PROMPT & SLOW The width of corridors shall be sufficient for the occupant load served but shall be not less than 44 in. (112cm). s Exception: Corridors serving an occupant load fewer than 50 shall be not less than 36 in. (91cm) wide. 33.3.2.3.3, 32.3.2.3.3 Stairs complying with 7.2.2 shall be permitted. 33.3.2.2.3, 32.3.2.2.3 ARRANGEMENT OF MEANS OF EGRESS K40 2000 EXISTING Common paths of travel shall not exceed 110 ft (33.5m) s Exception: In buildings protected throughout by automatic sprinkler systems in accordance with 33.3.3.5, common path of travel shall not exceed 160ft (48.8m). Dead-end corridors shall not exceed 50 ft (15m). 33.3.2.5 2000 NEW Common paths of travel shall not exceed 125ft (38.1m). Dead end corridor shall not exceed 50ft (15m). 32.3.2.5.2 SUBDIVISION OF BUILDING SPACES K120 Every sleeping room floor shall be divided into not less than two smoke compartments of approximately the same size, with smoke barriers in accordance with 8.3. Smoke dampers shall not be required. Additional smoke barriers shall be provided such that the travel distance from a sleeping room corridor door to a smoke barrier shall not exceed 150 ft (45m). s Exception No. 1: Buildings protected throughout by an approved automatic sprinkler system installed in accordance with 33.3.3.5. s Exception No. 2: Where each sleeping room is provided with exterior ways of exit access arranged in accordance with 7.5.3. Form CMS-2786W (06/07) EF 06/2007 Page 19 American LegalNet, Inc. www.FormsWorkflow.com ID PREFIX LARGE FACILITY IMPRACTICAL EVACUATION MET NOT N/A MET REMARKS LARGE IMPRACTICAL s Exception No. 3: Smoke barriers shall to be required where the aggregate corridor length on each floor is not more than 150 ft (45m). 33.3.3.7 K36 2000 EXISTING Travel distance from the corridor door of any room to nearest exit shall be a maximum of 100 feet. 33.3.2.6.2 2000 NEW Travel distance from the corridor door of any room to the nearest exit, measured in accordance with 7.6, shall not exceed 200 feet (60m). 32.3.2.6.2 2000 EXISTING Travel distance from the door or most remote room in a suite or apartment to the corridor shall not exceed 75 feet (23m). s Exception: Travel distance may be 125ft (48m) in building protected throughout by an approved automatic sprinkler system in accordance with 33.3.3.5. 33.3.2.6.1 2000 NEW Travel distance within a room, suite, or living unit to a corridor door shall not exceed 125 ft (38.1m) 32.3.2.6.1. INTERIOR FINISH K14 2000 EXISTING Interior wall and ceiling finish shall be Class A or Class B in accordance with Section 10.2. Interior floor finish in accordance with 10.2.7 shall be Class I or Class II in corridors and exits. s Exception: Previously installed floor coverings, subject to the approval of the authority having jurisdiction. 33.3.3.3 Form CMS-2786W (06/07) EF 06/2007 Page 20 American LegalNet, Inc. www.FormsWorkflow.com ID PREFIX LARGE FACILITY IMPRACTICAL EVACUATION MET NOT N/A MET REMARKS LARGE IMPRACTICAL 2000 NEW Interior finish shall be in accordance with 10.2. 10.2, 32.3.3.3.1. K15 Interior wall and ceiling finish materials complying with 10.2.3 shall be permitted as follows: (1) Exit enclosures - Class A (2) Lobbies and corridors - Class A or Class B (3) Other spaces - Class A or Class B 32.3.3.3.2 K16 Interior floor finish in corridors and exits shall be class I or II in accordance with 10.2.7, 32.3.3.3.3. K20 2000 EXISTING Any vertical opening shall be enclosed or protected in accordance with 8.2.5. s Exception No. 1: Unprotected vertical openings not part of required egress shall be permitted to be waived by the authority having jurisdiction where such openings do not endanger required means of egress. This exception shall apply only in buildings protected throughout by an approved automatic sprinkler system in accordance with 33.3.3.5.1 and in which exits and required ways of travel thereto are adequately safeguarded against fire and smoke within the building, or in which every individual room has direct access to an exterior exit without passing through a public corridor. s Exception No. 2: In buildings not more than two stories in height, unprotected vertical openings shall be permitted by the authority having jurisdiction if the building is protected throughout by an approved automatic sprinkler system in accordance with 33.3.3.5.1 No floor below the level of exit discharge used only for storage, heating equipment, or purposes other than residential occupancy shall have unprotected openings to floors used for residential occupancy. 32.3.3.1.1, 32.3.3.1.2, 33.3.3.1.1, 33.3.3.1.2 Form CMS-2786W (06/07) EF 06/2007 Page 21 American LegalNet, Inc. www.FormsWorkflow.com ID PREFIX K21 LARGE FACILITY IMPRACTICAL EVACUATION MET NOT N/A MET REMARKS LARGE IMPRACTICAL Building Services 2000 EXISTING Utilities shall comply with the provisions of 9.1. Heating, ventilating, and air conditioning equipment shall comply with the provisions of 9.2. No stove or combustion heater shall be located to block escape in case of fire caused by the malfunction of the stove or heater. Unvented fuel-fired heaters shall not be used in any board and care occupancy. Elevators, dumbwaiters, and vertical conveyors shall comply with the provisions of 9.4. Rubbish chutes, incinerators, and laundry chutes shall comply with the provisions of 9.5. 33.3.6.1, 33.3.6.2, 33.3.6.2.1, 33.3.6.2.2, 33.3.6.2.3. 33.3.6.3, 33.3.6.4 2000 NEW In high-rise buildings, one elevator shall be provided with a protected power supply and shall be available for use by the fire department in case of emergency. 32.3.6.1, 32.3.6.2, 32.3.6.2.1, 32.3.6.2.2, 32.3.6.2.3, 32.3.6.3.1, 32.3.6.3.2, 32.3.6.4 Facilities housing groups of persons classed as IMPRACTICAL TO EVACUATE shall meet the requirements for custodial care facilities, Chapter 18 or 19 as appropriate. s Exception: Facilities found to have equivalent safety. Example 7.5 Using the applicable mandatory safety requirement. 32.3.1.2.2 See CMS-2786R Form CMS-2786W (06/07) EF 06/2007 Page 22 American LegalNet, Inc. www.FormsWorkflow.com Fire Safety Evaluation Worksheet for a Large Facility Fig. 7.5 Facility Identification ______________________________________________________________________________________________________________ Evaluator______________________________________________________________________Date _____________________________________________ (Complete one worksheet for each large facility. This normally means a capacity for more than 16 residents.) First complete Fig. 7.5.1. Continue with Fig. 7.5.2, 7.5.3, 7.5.4A, 7.5.4B, 7.5.5. Then return to this page to obtain the Equivalency Conclusions. TURN TO NEXT PAGE Part 2E. Equivalency Conclusions Complete Fig. 7.5.1 through 7.5.5 before doing this part. 1. All of the checks in Fig. 7.5.5 are in the “YES” column. The level of fire safety is at least equivalent to that prescribed for large residentail facilities.* 2. One or more of the checks in Fig. 7.5.5 is in the “NO” column. The level of fire safety is not shown by this system to be equivalent to that prescribed by the Life Safety Code for large residential facilities. *The equivalency covered by this worksheet includes the majority of consideratons covered by the Life Safety Code. There are a few consideratons 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. Facility Fire Safety Requirements Worksheet Considerations Met Not Met Not Applicable A. Utilities comply with provisions of 9.1. B. Heating, ventilating, and air conditioning equipment comply with provisions of 9.2. C. Elevators, dumbwaiters, and vertical conveyors comply with the provisions of 9.4. D. Rubbish chutes, incineratiors, and laundry chutes comply with the provisions of 9.5. E. Complies with the applicable requirements of Sections 32.7 and/or 33.7. Form CMS-2786W (06/07) EF 06/2007 Page 23 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 K1 K6 * K4 K3 DATE OF PLAN APPROVAL MULTIPLE CONSTRUCTION TOTAL NUMBER OF BUILDINGS ____________ NUMBER OF THIS BUILDING LSC FORM INDICATOR ____________ 12 13 14 15 SMALL (16 BEDS OR LESS) K8: ASC Form 2000 EXISTING 2000 NEW 1 PROMPT 2 SLOW 3 IMPRACTICAL LARGE K8: ICF/MR Form 2786V, W, X 2000 EXISTING 2786V, W, X 2000 NEW 16 17 SELECT NUMBER OF FORM USED FROM ABOVE *K9: 7 PROMPT 8 SLOW 9 IMPRACTICAL ENTER E – SCORE HERE (Check if K29 or K56 are marked as not applicable in the 2786 M, R, T, U, V, W, X and Y.) K29: 4 PROMPT 5 SLOW 6 IMPRACTICAL APARTMENT HOUSE K8: * K7 BUILDING WING FLOOR APARTMENT UNIT COMPLETE IF ICF/MR IS SURVEYED UNDER CHAPTER 21 Health Care Form 2786R 2000 EXISTING 2786R 2000 NEW 2786U 2786U A B C D K5: K56: e.g. 2.5 FACILITY MEETS LSC BASED ON (Check all that apply) A1. (COMP. WITH ALL PROVISIONS) A2. A3. (ACCEPTABLE POC) FACILITY DOES NOT MEET LSC (WAIVERS) A5. (FSES) (PERFORMANCE BASED DESIGN) K0180 A. B. A4. FULLY SPRINKLERED B. PARTIALLY SPRINKLERED (All required areas are sprinklered) (Not all required areas are sprinklered) C. NONE (No sprinkler system) * MANDATORY Form CMS-2786W (06/07) EF 06/2007 Page 24 American LegalNet, Inc. www.FormsWorkflow.com