Form Cms-2786v - Fire Safety Survey Report - Icf-Iid (Small Facilities) 2012 Life Safety Code

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2012 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. (A) MEDICAID I.D. NO.
Intermediate Care Facilities for Individuals with Intellectual Disabilities
SMALL FACILITIES
K1
K2
PART I – Instructions for Completing the Form (CMS-2786V)
PART II – Existing Resident 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 Facilities)
PART V – Operating Features (New and Existing Facilities)
PART VI – Crucial Data Extract
Optional – Fire Safety Evaluation System for Board and Care Occupancies (CMS-2786Y, NFPA 101A, Chapter 7)
Identifying information as shown in applicable records. Enter changes, if any, alongside each item, giving date of change.
2. (A) MULTIPLE CONSTRUCTION (BLDGS)
2. (B) ADDRESS OF FACULTY (STREET, CITY, STATE,
2. NAME OF FACILITY
A. ☐ Fully Sprinklered
ZIP CODE)
A. BUILDING
(All required areas are sprinklered)
B. WING
B. ☐ Partially Sprinklered
C. FLOOR
(Not all required areas are sprinklered)
C. ☐ None
(No sprinkler system)
K0180
K3
4. DATE OF SURVEY
DATE OF PLAN APPROVAL
SURVEY UNDER:
3. SURVEY FOR
5. ☐ 2012 EXISITING
6. ☐ 2012 NEW
☐ MEDICARE
☐ MEDICAID
K7
K4
K6
5. SURVEY FOR CERTIFICATION OF: SMALL FACILITY - LEVEL OF EVACUATON
E-SCORE
USE FOR EXISTING FACILITIES ONLY
DIFFICULTY (Check one)
E-Score
Level of Evacuation Difficulty
USE FOR EXISTING FACILITIES ONLY
Prompt
≤ 1.5
1. ☐ Prompt
2. ☐ Slow
3. ☐ Impractical
> 1.5 ≤ 5.0
Slow
> 5.0
Impractical
K8
K5
6. BED COMPOSITION
e. NUMBER OF ICF/IID BEDS CERTIFIED FOR MEDICAID
a. TOTAL NO. OF BEDS IN THE FACILITY
6. A.
THE FACILITY 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 STANDARD
K9
SURVEYOR (Signature)
OFFICE
DATE
TITLE
SURVEYOR ID
K10
FIRE AUTHORITY OFFICIAL (Signature)
OFFICE
DATE
TITLE
CMS FORMS SHALL BE COMPLETED AND RETAINED AS PART OF THE SURVEY RECORD.
Form CMS-2786V (10/2016)
Page 1

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Parent category: Medical