DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 0938-0242 FIRE SAFETY SURVEY — 2000 LIFE SAFETY CODE F-1 Worksheet for Rating Residents SIDE 1 Complete one Worksheet for each resident. Read Instruction Manual before filling out this form. Base ratings on commonly observed examples of poor performance. Resident’s Name Rater Facility Date Write any explanatory remarks you may wish to make here: Surveyor (Signature) Title Date Title Date Surveyor ID 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-2786M (03/04) Previous Versions Obsolete American LegalNet, Inc. www.USCourtForms.com Page 1 Form Approved OMB No. 0938-0242 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES F-1 COMPLETE OTHER SIDE FIRST Worksheet for Rating Residents SIDE 2 Read Instruction Manual before filling out this form. Base ratings on commonly observed examples of poor performance. F-1A Rating the Resident on the Risk Factors Rating the resident on each of the factors below by checking the one circle in each risk factor that best describes the resident. For the first six factors, write the scores for the circles you 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 3 scores in the large box on the right. SCORE BOXES I. Risk of Resistance (Check only one) II. Impaired Mobility (Check only one) Minimal Risk score = 0 SelfStarting IV. Need for Extra Help (Check only one) V. Response to Instructions (Check only one) VI. Waking Response to Alarm (Check only one) VII. Response to Fire Drills (Without Guidance or Advice from Staff) Slow score = 3 Needs Limited Assistance from 2 Staff score = 1 Response Probable score = 20 score = 20 Needs Full Assistance from 2 Staff score = 40 Requires Considerable Attention/May Not Respond score = 3 score = 10 Response Not Probable score = 0 Initiates and Completes Evacuation Promptly score = 6 score = 30 Requires Supervision Needs Full Assistance or Very Slow Totally Impaired score = 6 score = 0 Follows Instructions score = 20 Needs Limited Assistance Partially Impaired score = 0 Needs at Most One Staff Risk of Strong Resistance score = 6 score = 0 No Significant III. Impaired Consciousness Risk (Check only one) Risk of Mild Resistance score = 6 Yes No score = 0 Chooses and Completes Back-up Strategy Yes Stays at Designated Location Yes score = 8 No score = 0 + score = 4 No score = 0 + score = 6 F-1B Finding the ResIdent’s Overall Need For AssIstance Compare the numbers in the 7 score boxes you have filled in. Take the one highest score from the score boxes and write it in this box: SUM OF THESE THREE ITEMS EVACUATION ASSISTANCE SCORE Form CMS-2786M (03/04) Previous Versions Obsolete Page 2 American LegalNet, Inc. www.USCourtForms.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. (ACCEPTABLE POC) A3. (WAIVERS) A4. A5. (FSES) (PERFORMANCE BASED DESIGN) FACILITY DOES NOT MEET LSC B. * MANDATORY Form CMS-2786M (03/04) Previous Versions Obsolete Page 3 American LegalNet, Inc. www.USCourtForms.com