Form Cms-2786r - Fire Safety Survey Report - Health Care 2012 Life Safety Code Page 49
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50Name of Facility
2012 LIFE SAFETY CODE
PART III – RECOMMENDATION FOR WAIVER OF SPECIFI C LIFE SAF ETY CODE PROVISIONS
For each item of the Life Safety Code recommended for waiver, list the survey report form item number and state the reason for the conclusion that:
(a) the specific provisions of the code, if rigidly applied, would result in unreasonable hardship on the facility, and (b) the waiver of such unmet
provisions will not adversely affect the health and safety of the patients. If additional space is required, attach additional sheet(s).
PROVISION NUMBER(S)
JUSTIFICATION
K400
Surveyor (Signature)
Title
Office
Date
Fire Authority Official (Signature)
Title
Office
Date
Form CMS-2786R (10/2016)
Page 49
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