Form Cms-2786x - Fire Safety Survey Report - Icf-Iid (Apartment House) 2012 Life Safety Code
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332012 LIFE SAFETY CODE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Form Approved OMB Exempt
FIRE SAFETY SURVEY REPORT - 2012 LIFE SAFETY CODE
1. (A) PROVIDER NO.
1. (B) MEDICAID I.D. NO.
Intermediate Care Facilities with Intellectual Disabilities
APARTMENT HOUSE
K1
K2
PART I — Instructions for Completing the Form (CMS-2786X)
PART II — Existing Residential Board & Care Occupancies Requirements (NFPA 101, Chapter 33)
PART III — New Residential Board & Care Occupancies Requirements (NFPA 101, Chapter 32)
PART IV — Building Services (New and Existing Apartment Buildings)
PART V — Operating Features (New and Existing Apartment Buildings)
PART VI — Crucial Data Extract
OPTIONAL — Fire Safety Evaluation System for Board and Care Occupancies (2013 NFPA 101A, Chapter 7)
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
2. (B) ADDRESS OF THE FACILITY (CITY, STREET,
A.
Fully Sprinklered
STATE, ZIP CODE)
(All required areas are sprinklered)
A. BUILDING
B.
Partially Sprinklered
B. WING
(Not all required areas are sprinklered)
C. FLOOR
C.
None
(No sprinkler system)
K3
K0180
3. SURVEY FOR
4. DATE OF SURVEY
DATE OF PLAN APPROVAL
SURVEY UNDER:
9.
2012 EXISTING
2012 NEW
MEDICARE
MEDICAID
K4
K6
K7
5. SURVEY OF CERTIFICATION OF APARTMENT HOUSE FACILITY LEVEL OF
E-SCORE
USE FOR EXISTING FACILITIES ONLY
EVACUATION DIFFICULTY (check one)
E-Score
Level of Evacuation Difficulty
USE FOR EXISTING FACILITIES ONLY
≤1.5
Prompt
> 1.5 ≤ 5.0
Slow
4. Prompt
5. Slow
6. Impractical
Impractical
> 5.0
K8
K5
E. NUMBER OF ICF/IID BEDS CERTIFIED FOR MEDICAID
6. BED COMPOSITION
A. TOTAL NO. OF BEDS IN THE FACILITY
7.
A. THE FACLITIY MEETS, BASED UPON (CHECK ALL APPROPRIATE BOXES)
1.
COMPLIANCE WITH ALL PROVISIONS
2.
ACCEPTANCE OF A PLAN OF CORRECTION
4.
FSES
5.
PERFORMANCE BASED DESIGN
B. THE FACILITY DOES NOT MEET THE STANDARDS
K9
SURVEYOR (SIGNATURE)
TITLE
OFFICE
DATE
SURVEYOR ID
K10
FIRE AUTHORITY OFFICIAL (SIGNATURE)
TITLE
OFFICE
DATE
CMS FORMS SHALL BE COMPLETED AND RETAINED AS PART OF THE SURVEY RECORD.
Form CMS-2786X (10/2016)
Page 1
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