Form Cms-2786r - Fire Safety Survey Report - Health Care 2012 Life Safety Code
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50DEPARTMENT 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 2012 CODE – HEALTH CARE
Medicare – Medicaid
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
OPTIONAL
Chapter 4 – NFPA 101A - Fire Safety Evaluation System for Health Care Occupancies – CMS-2786T
—
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.
Fully Sprinklered
(All required areas are sprinklered)
A. BUILDING _______________
Partially Sprinklered
B.
B. WING
_______________
(Not all required areas are
C. FLOOR
________________
sprinklered)
None
C.
(No sprinkler system)
K3
K0180
3. SURVEY FOR
4. DATE OF SURVEY
DATE OF PLAN APPROVAL
SURVEY UNDER
6.
2012 NEW
MEDICARE
MEDICAID
5.
2012 EXISTING
K4
K6
K7
5. SURVEY FOR CERTIFICATION OF
1.
HOSPITAL
2.
SKILLED/NURSING FACILITY
4.
ICF/IID UNDER HEALTH CARE
5.
HOSPICE
IF “2” OR “5” ABOVE IS MARKED, CHECK APPROPRIATE ITEM(S) BELOW
3.
IF DISTINCT PART OF H
OSPITAL, IS HOSPITAL ACCREDITED?
1.
ENTIRE FACILITY 2.
DISTINCT PART OF (SPECIFY) _____________________________________
a.
YES
b.
NO
6. BED COMPOSITION
a. TOTAL NO. OF BEDS IN
b. NUMBER OF HOSPITAL BEDS
c. NUMBER OF SKILLED BEDS
d. NUMBER OF SKILLED BEDS
e. NUMBER OF NF or ICF/IID BEDS
THE FACILITY _____
CERTIFIED FOR MEDICARE ____
CERTIFIED FOR MEDICARE ______
CERTIFIED FOR MEDICAID ____
CERTIFIED FOR MEDICAID ____
7. A.
THE FACILITY MEETS THE STANDARD, BASED UPON (CHECK ALL APPROPRIATE BOXES)
1.
COMPLIANCE WITH ALL PROVISIONS 2.
ACCEPTANCE OF A PLAN OF CORRECTION 3.
RECOMMENDED WAIVERS
.
FSES 5.
PERFORMANCE BASED DESIGN
4
B.
THE FACILITY DOES NOT MEET THE STANDARD
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.
Page 1
Form CMS-2786R (10/2016)
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