Form Cms-2786t - Fire Safety Evaluation System - Health Care 2012 Life Safety Code Page 6
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7DEPARTMENT OF HEALTH AND HUMAN SERVICES
2012 LIFE SAFETY CODE
CENTERS FOR MEDICARE & MEDICAID SERVICES
Form Approved OMB Exempt
Step 8 — Identify Zone Fire Safety Equivalency using Worksheet 4.7.9.
(1) Transfer the three circled values from Worksheet 4.7.8A, 4.7.8B, or 4.7.8C to the blocks marked Sa, Sb,
and Sc in Worksheet 4.7.9.
(2) For each row check “Yes” if the value in the answer block is zero or greater. Check “No” if the value in the
answer block is a negative number.
WORKSHET 4.7.9 - ZONE FIRE SAFETY EQUIVALENCY EVALUATION
YES
NO
C
S
S
1
a
Containment
Mandatory
≥ 0
minus
__
=
Safety (S
)
Containment (Sa)
1
S
S
E
2
b
Extinguishment
Mandatory
≥ 0
__
minus
=
Safety (S
)
Extinguishment (Sb)
2
S
S
P
3
c
People Movement
Mandatory People
≥0
__
minus
=
Safety (S
)
Movement (Sc)
3
S
R
G
4
General
≥ 0
__
minus
Occupancy Risk (R)
=
Safety (S
)
4
Step 9 — Evaluate other considerations not previously addressed using Worksheet 4.7.10.
Complete one copy of this separate worksheet for each facility.
For each consideration, select and mark the appropriate column.
WORKSHEET 4.7.10 FACILITY FIRE SAFETY REQUIREMENTS WORKSHEET
Met
Not
Not
Met
Applic.
Building utilities conform to the requirements of Section 9.1.
A.
In new facilities only, life-support systems, alarms, emergency communication
systems, and illumination of generator set locations are powered as prescribed by
B.
18.5.1.2 and 18.5.1.3.
Heating and air conditioning systems conform with the air conditioning, heating, and
ventilating systems requirements within Section 9.2, except for enclosure of vertical
C.
openings, which have been considered in Safety Parameter 7 of Worksheet 4.7.6.
Fuel-burning space heaters and portable electrical space heaters are not used.
D.
There are no flue-fed incinerators.
E.
An evacuation plan is provided and fire drills conducted in accordance with
F.
18.7.1/18.7.2 and 19.7.1/19.7.2.
Smoking regulations have been adopted and implemented in accordance with 18.7.4
G.
and 19.7.4.
Draperies, upholstered furniture, mattresses, furnishings, and decoration
H.
combustibility is limited in accordance with 18.7.5 and 19.7.5.
Fire extinguishers are provided in accordance with the requirements of 18.3.5.12 and
I.
19.3.5.12.
Exit signs are provided in accordance with the requirements of 18.2.10.1 and 19.2.10.
J.
Emergency lighting is provided in accordance with 18.2.9.1 or 19.2.9.1.
K.
Standpipes are provided in all new high rise buildings as required by 18.4.2.
L.
Form
CMS-2786T (10/2016)
Page
6
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