Form Cms-2786u - Fire Safety Survey Report - Asc & Esrd 2012 Life Safety Code
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39DEPARTMENT OF HEALTH AND HUMAN SERVICES
2012 LIFE SAFETY CODE
CENTERS FOR MEDICARE & MEDICAID SERVICE
Form Approved OMB Exempt
1. (A) PROVIDER NUMBER
1. (B) MEDICAID I.D. NO.
FIRE SAFETY SURVEY REPORT – AMBULATORY SURGICAL
CENTERS (ASC) & END STAGE RENAL DISEASE (ESRD)
MEDICARE
K1
K2
PART I — Life Safety Code, New and Existing
PART II — Health Care Facilities Code, New and Existing
PART III — Recommendation for Waiver
PART IV – Crucial Data Extract
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 (STATE, CITY, ZIP
A.
Fully Sprinklered
CODE)
(All required areas are sprinklered)
A.
BUILDING _________________
B.
Partially Sprinklered
B.
WING
_________________
(Not all required areas are
C.
FLOOR
_________________
sprinklered)
C.
None (No sprinkler system)
K3
K0180
Date of Survey
Initial Survey
Resurvey
New
Existing
Number of Stations in ESRD
K4
CHECK ONE
DATE OF BLDG. PERMIT OR PLAN APPROVAL
DATE FIRST OCCUPIED AS AMBULATORY SURGICAL
Facility is:
CTR.
Physically located in a hospital
K6
Free-standing: only occupancy in building
If facility is located in a hospital or hospital owned/operated, was facility surveyed as part of Hospital LSC Survey?
Located in an Office Occupancy
Located in a Mercantile/Business Occupancy
Yes
No
Indicate Occupancy ____________________
Other (specify) ________________________
A
The facility MEETS based upon:
B
The facility DOES NOT MEET THE STANDARD
Accredited by __________________________
1.
Compliance with all provisions
2.
Acceptance of a Plan of Correction
Non Accredited
3.
Recommended waivers
4.
Performance Based Design
K9
SURVEYOR (Signature)
TITLE
OFFICE
DATE
SURVEYOR ID
K10
REVIEW AUTHORITY OFFICIAL (Signature)
TITLE
OFFICE
DATE
CMS FORMS SHALL BE COMPLETED AND RETAINED AS PART OF THE SURVEY RECORD.
Page 1
Form CMS-2786U (10/2016)
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