002003002003227002003 American LegalNet, Inc. www.FormsWorkFlow.com Repair, Renovation, Modification, or Reconstruction Change of Use or Change of OccupancyAdditions American LegalNet, Inc. www.FormsWorkFlow.com 002 American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com 002 American LegalNet, Inc. www.FormsWorkFlow.com 002 American LegalNet, Inc. www.FormsWorkFlow.com 002 American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com Name of Facility 2012 LIFE SAFETY CODE ID PREFIX MET NOT MET N/A REMARKS K374 2012 NEW Doors in smoke barriers have at least a 20-minute fire protection rating or are at least 1276-inch thick solid bonded core wood. Required clear widths are provided per 18.3.7.6(4) and (5). Nonrated protective plates of unlimited height are permitted. Horizontal-sliding doors comply with 7.2.1.14. Swinging doors shall be arranged so that each door swings in an opposite direction. Doors shall be self-closing and rabbets, bevels, or astragals are required at the meeting edges. Positive latching is not required. 18.3.7.6, 18.3.7.7, 18.3.7.8 K379 Smoke Barrier Door Glazing 2012 EXISTING Openings in smoke barrier doors shall be fire-rated glazing or wired glass panels in steel frames. 19.3.7.6, 19.3.7.6.2, 8.5 2012 NEW Windows in smoke barrier doors shall be installed in each cross corridor swinging or horizontal-sliding door protected by fire-rated glazing or by wired glass panels in approved frames. 18.3.7.9 K381 Sleeping Room Outside Windows and Doors Every patient sleeping room has an outside window or outside door. In new occupancies, sill height does not exceed 36 inches above the floor. Windows in atrium walls are considered outside windows. Newborn nurseries and rooms intended for occupancy less than 24 hours have no outside window or door requirements. Window sills in special nursing care areas (e.g., ICU, CCU, hemodialysis, neonatal) do not exceed 60 inches above the floor. 42 CFR 403, 418, 460, 482, 483, and 485 SECTION 4 SPECIAL PROVISIONS K400 Special Provisions Other List in the REMARKS section any LSC Section 18.4 and 19.4 Special Provisions requirements that are not addressed by the provided K-tags, 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-2786RPage 29 American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com oooo American LegalNet, Inc. www.FormsWorkFlow.com 002003 American LegalNet, Inc. www.FormsWorkFlow.com PART IV - FIRE SAFETY SURVEY REPORT002 CRUCIAL DATA EXTRACT002 (TO BE USED WITH CMS 2786 FORMS)002 Provider Number Facility Name Survey Date K1 *K4K6 DATE OF PLAN APPROVAL K3 MULTIPLE CONSTRUCTION A. BUILDINGTOTAL NUMBER OF BUILDINGS B. WING C.FLOORNUMBER OF THIS BUILDING D.APARTMENT UNITLSC FORM INDICATOR HEALTH CARE FORM 12 2786R 2012 EXISTING 13 2786R 2012 NEW AHCO FORM 14 2786U 2012 EXISTING 15 2786U 2012 NEW ICF/IID FORM 16 2786V, W, X 2012 EXISTING 17 2786V, W, X 2012 NEW *K7SELECT NUMBER OF FORM USED FROM ABOVECOMPLETE IF ICF/IID IS SURVEYED UNDER CHAPTER 33, EXISTING SMALL (16 BEDS OR LESS) K8 1.PROMPT2.SLOW3.IMPRACTICALLARGE K8 4.PROMPT5.SLOW6.IMPRACTICALAPARTMENT HOUSE K8 7.PROMPT8.SLOW9.IMPRACTICALK321: K351: COMPLETE IF ICF/IID IS SURVEYED UNDER CHAPTER 33, EXISTING ENTER E SCORE K5: e.g. 2.5*K9FACILITY MEETS LSC BASED ON A1. A2. A3. A4. A5. (COMP. WITH ALL (ACCEPTABLE POC) (WAIVERS) (FSES) (PERFORMANCE PROVISIONS) BASED DESIGN) K0180 FACILITY DOES NOT MEET LSC A.B.C.B. FULLY SPRINKLERED PARTIALLY SPRINKLERED NONE (All required areas are (Not all required areas are (No sprinkler system) sprinklered) sprinklered) *MANDATORYForm CMS-2786R (Page 50 American LegalNet, Inc. www.FormsWorkFlow.com