DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES2012 LIFE SAFETY CODEForm Approved OMB ExemptFIRE SAFETY EVALUATION SYSTEMHEALTH CARE FACILITIES 002 (NFPA 101A, 223Guide on Alternative Approaches to Life Safety224 2013 Edition)Complete the following worksheets for each fire/smoke zone*.Where conditions are the same in several zones, one set of worksheets can be used for those zones.* Fire/smoke zone is a space separated from all other spaces by floors, horizontal exits, or smoke barriersStep 1 227 Complete Cover Sheet using Worksheet 4.7.1. WORKSHEET 4.7.1 226 COVER SHEETZONEOFZONESNAME OF FACILITYADDRESS OF FACILITYZONE(S) EVALUATEDPROVIDER/VENDOR NO.DATE OF SURVEYSURVEYOR SIGNATURESURVEYOR IDTITLEOFFICEDATEFIRE AUTHORITY SIGNATURETITLEOFFICEDATEADDITIONAL COMMENTS:CMS FORMS SHALL BE COMPLETED AND RETAINED AS PART OF THE SURVEY RECORD.Page 1 American LegalNet, Inc. www.FormsWorkFlow.com DEPARTMENT OF HEALTH ANDHUMAN SERVICES 2012 LIFE SAFETY CODE CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB Exempt Step 2 227 Determine Occupancy Risk Parameter Factors using Worksheet 4.7.2. For each Risk Parameter in Worksheet 7.2, select and circle the appropriate risk factor value. Choose only one for each of the five Risk Parameters. WORKSHEET 4.7.2 226 OCCUPANCY RISK PARAMETER FACTORS Risk Parameters Risk Factor Values 1. Patient Mobility (M) Mobility Status Mobile Limited Mobility Not Mobile Not Movable Risk Factor 1.0 1.6 3.2 4.5 2. Patient Density (D) No. of Patients 12265 622610 1122630 >30 Risk Factor 1.0 1.2 1.5 2.0 3.Zone Location (L) Floor 1st 2nd or 3rd 4th to 6th 7th and Above Basements Risk Factor 1.1 1.2 1.4 1.6 1.6 4.Ratio of Patients to Attendants (T) Patients Attendant 12262 1 32265 1 622610 1 >10 1 One or More None Risk Factor 1.0 1.1 1.2 1.5 4.0* 5. Patient Average Age (A) Age Under 65 Years and Over 1 Year 65 Years and Over or 1 Year and Younger Risk Factor 1.0 1.2 *A risk factor of 4.0 is charged to any zone that houses patients without any staff in immediate attendance. Step 3 227 Compute Occupancy Risk Factor (F) using Worksheet 4.7.3. (1) Transfer the circled risk factor values from Worksheet 4.7.2 to the corresponding blocks in Worksheet 4.7.3. (2) Compute F by multiplying the risk factor values as indicated in Worksheet 4.7.3. WORKSHEET 4.7.3 - OCCUPANCY RISK FACTOR CALCULATION OCCUPANCY RISKMxDx Lx Tx A =F Step 4 227 Compute Adjusted Building Status (R) - Use Worksheets 4.7.4 or 4.7.5. WORKSHEET 4.7.4 ADJUSTED OCCUPANCY RISK FACTOR (NEW(1) If building is classified as 223NEW224 use Worksheet 4.7.4. If building is classified as 223Existing224 use Worksheet 4.7.5. (2) Transfer the value of F from Worksheet 4.7.3 to Worksheets 4.7.4 or 4.7.5, as appropriate. Calculate R. (3) Transfer R to the block labeled R in Worksheet 4.7.9. (4) In Worksheets 4.7.4 and 4.7.5, results are always rounded up (i.e., 3.2 is rounded to 4.0). ) F R F R WORKSHEET 4.7.5 ADJUSTED OCCUPANCY RISK FACTOR (EXISTING)0.6 x = Page 2 x = American LegalNet, Inc. www.FormsWorkFlow.com Step 5 227 Determine Safety Parameter Values using Worksheet 4.7.6. (1) Select and circle the safety value for each safety parameter that best describes the conditions in the zone. (2) Choose only one value for each of the 13 parameters. (3) If two or more appear to apply, choose the one with the lowest point value. WORKSHEET 4.7.6 226 SAFETY PARAMETER VALUES Safety Parameters Parameters Values 1. ConstructionCombustible Non-Combustible Types III, IV, and V Types I and II Floor or Zone 000 111 200 211, 2HH 000 111 222, 322, 442 First -2 0 -2 0 0 2 2 Second -7 -2 -4 -2 -2 2 4 Third -9 -7 -9 -7 -7 2 4 4th and Above -13 -7 -13 -7 -9 -7 4 2.Interior Finish Class C Class B Class A (Corridors and Exits) -5(0)f 0(3)f 3 3.Interior Finish Class C Class B Class A (Rooms) -3(1)f 1(3)f 3 4.Corridor None or Incomplete 1/2 to 100 ft. >50 ft. to 100 ft. 30 ft. to 50 ft. >150 ft. 100 ft. to 150 ft.