DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES 2000 CODE ICFs/MR Form Approved OMB No. 0938-0242 1. (A) PROVIDER NO. 1. (B) MEDICAID I.D. NO. K1 FIRE SAFETY SURVEY REPORT - 2000 LIFE SAFETY CODE Intermediate Care Facilities for the Mentally Retarded SMALL FSES 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. (All required areas are sprinklered) A. BUILDING ________________ B. WING B. ________________ 4. DATE OF SURVEY s E-SCORE DATE OF PLAN APPROVAL K4 s MEDICARE SURVEY UNDER: K6 5. MEDICAID E-Score ≤ 1.5 s None (No sprinkler system) K0180 K3 3. SURVEY FOR s Partially Sprinkleredsprinklered) (Not all required areas are C. ________________ C. FLOOR s Fully Sprinklered Level of Evacuation Difficulty Prompt > 1.5 ≤ 5.0 6. s 2000 NEW 5. SURVEY FOR CERTIFICATION OF: SMALL FACILITY - LEVEL OF EVACUATION DIFFICULTY (Check one) Slow > 5.0 s 2000 EXISTING K7 1. s Prompt 2. s Slow 3. s Impractical Impractical K5 K8 6. BED COMPOSITION a. TOTAL NO. OF BEDS IN THE FACILITY e. NUMBER OF ICF/MR BEDS CERTIFIED FOR MEDICAID s THE FACILITY MEETS, BASED UPON (Check all appropriate boxes): 1. s COMPLIANCE WITH ALL PROVISIONS 2. s ACCEPTANCE OF A PLAN OF CORRECTION B. s THE FACILITY DOES NOT MEET THE STANDARD 7. A. 4. s FSES 5. s PERFORMANCE BASED DESIGN 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-2786Y (06/07) EF 06/2007 Page 1 American LegalNet, Inc. www.FormsWorkflow.com 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. s 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. s 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 American LegalNet, Inc. www.FormsWorkflow.com 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 Building Identification ____________________________________________________________________ Evaluator _________________________________________Date _________________________________ WORKSHEET 7.3.2 SAFETY PARAMETER VALUES — SMALL FACILITY Safety Parameters Parameter Values 1. Construction/ Fire Resistance Exposed Structural Members Protected 15 min Protected 1 hr 2. Hazardous Areas 0 Double Deficiency 1 Single Deficiency 3 None or No Deficiency -7 -4 0 3. Manual Fire Alarm None or Incomplete w/o F.D. Notification w/ F.D. Notification 0 4. Smoke Detection and Alarm None or Incomplete -4 1 Warning to All Bedrooms Every Lev. Plus e Every Lev. Det. Det. in Each Bdrm. 2 3(4)f Single Lev. Det./ Limited Warning 0 5. Automatic Sprinklers 2 Total Coverage System 4 Quick-Response or Residential Sprinklers Nonsprinklered Standard Sprinklers 0 8 Flame-Spread Ratings 10 >75 to 25 to 0 NO Sa S1 – = Sb S2 – = Sc S3 – = Sd S4 – = WORKSHEET 7.3.6 FACILITY FIRE SAFETY REQUIREMENTS WORKSHEET CONSIDERATIONS A. MET NOT MET Complies with the applicable requirements of Sections 32.7 and 33.7. (NFPA 101). WORKSHEET 7.3.7 CONCLUSIONS 1. u 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. u 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 American LegalNet, Inc. www.FormsWorkflow.com FIRE SAFETY SURVEY REPORT CRUCIAL DATA EXTRACT (TO BE USED WITH CMS-2786 FORMS) FACILITY NAME PROVIDER NUMBER SURVEY DATE * K4 K1 K6 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-2786Y (06/07) EF 06/2007 Page 6 American LegalNet, Inc. www.FormsWorkflow.com