CMS-2786T FSES Worksheet

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB No. 0938-0242

ZONE __________ OF __________ ZONES

FIRE/SMOKE ZONE* EVALUATION WORKSHEET FOR HEALTH CARE FACILITIES
2000 LIFE SAFETY CODE
FACILITY

BUILDING

ZONE(S) EVALUATED
PROVIDER/VENDOR NO.

DATE OF SURVEY

COMPLETE THIS WORKSHEET FOR EACH ZONE. WHERE CONDITIONS ARE THE SAME IN SEVERAL ZONES,
ONE WORKSHEET CAN BE USED FOR THOSE ZONES.
Step 1: Determine Occupancy Risk Parameter Factors - Use Table 1.
A. For each Risk Parameter in Table 1, select and circle the appropriate risk factor value.
Choose only one for each of the five Risk Parameters.
TABLE 1. OCCUPANCY RISK PARAMETER FACTORS
Risk Parameters

Risk Factors Values

1. Patient
Mobility (M)

Mobility Status

Mobile

Limited Mobility

Not Mobile

Not Movable

Risk Factor

1.0

1.6

3.2

4.5

2. Patient
Density (D)

No. of Patients

1–5

6–10

11–30

>30

Risk Factor

1.0

1.2

1.5

2.0

3. Zone
Location (L)

4. Ratio of
Patients to
Attendants (T)
5. Patient
Average
Age (A)

Floor

1st

2nd or 3rd

4th to 6th

7th and Above

Basements

Risk Factor

1.1

1.2

1.4

1.6

1.6

Patients
Attendant

1–2
1

3–5
1

6–10
1

>10
1

One or More
None

Risk Factor

1.0

1.1

1.2

1.5

4.0

Age

Under 65 Years and Over 1 year

65 Years and Over 1 Year and Younger

Risk Factor

1.0

1.2

Step 2: Compute Occupancy Risk Factor (F) - Use Table 2.
A. Transfer the circled risk factor values from Table 1 to the corresponding blocks in Table 2.
B. Compute F by multiplying the risk factor values as indicated in Table 2.
TABLE 2. OCCUPANCY RISK FACTOR CALCULATION

nxnxnxnx n=n
M

OCCUPANCY RISK
Step 3:
A.
B.
C.

D

L

T

A

F

Compute Adjusted Building Status (R) - Use Table 2.
If building is classified as “NEW” use Table 3A. If building is classified as “Existing” use Table 3B.
Transfer the value of F from Table 2 to Table 3A or Table 3B as appropriate. Calculate R.
Transfer R to the block labeled R in Table 7 on page 4 of the work sheet.
TABLE 3A. (NEW BUILDINGS)

n=n
F

1.0

x

TABLE 3B. (EXISTING BUILDINGS)

R

n=n
F

0.6

x

R

* FIRE/SMOKE ZONE is a space separated from all other spaces by floors, horizontal exIts, or smoke barrIers.

SURVEYOR SIGNATURE

TITLE

DATE

FIRE AUTHORITY SIGNATURE

TITLE

DATE

Form CMS-2786T (XX/XXXX) Previous Versions Obsolete

Page 1

Step 4: Determine Safety Parameter Values - Use Table 4.
A. Select and circle the safety value for each safety parameter in Table 4 that best describes the conditions
in the zone. Choose only one value for each of the 13 parameters. If two or more appear to apply, choose
the one with the lowest point value.
TABLE 4.
Safety Parameters

Safety Parameters Values

1. Construction
Floor or Zone
First
Second
Third
4th and Above

Combustible
Types III, IV, and V
000
-2
-7
-9
-13

111
0
-2
-7
-7

NonCombustible
Types I and II
200
-2
-4
-9
-13

211 + 2HH
0
-2
-7
-7

000
0
-2
-7
-9

111
2
2
2
-7

2. Interior Finish
(Corridors and Exits)

Class C
-5(0)f

Class B
0(3)f

Class A
3

3. Interior Finish
(Rooms)

Class C
-3(1)f

Class B
1(3)f

Class A
3

None or Incomplete
-10(0)a

<1/2 hour
0

>1/2 to <1 hour
1(0)a

>1 hour
2(0)a

No Door

<20 min FPR

>20 min FPR

>20 min FPR and
Auto Clos.

-10

0

1(0)d

2(0)d

4. Corridor
Partitions/Walls
5. Doors to Corridor

6. Zone Dimensions

7. Vertical Openings

Dead End
>50 ft to 100 ft

30 ft to 50 ft

-6(0)b

-4(0)b

-2(0)b

Open 4 or More
Floors

Open 2 or 3
Floors

-14

-10

8. Hazardous Areas

Double Deficiency
In Zone
Outside Zone
-11
-5

9. Smoke Control

10. Emergency
Movement
Routes

>100 ft

No Control

Smoke Barrier
Serves Zone

-5(0)c

0

13. Automatic
Sprinklers

NOTE:

0

1

<1 hr

Enclosed with Indicated Fire Resist.
>1 hr to <2 hr

>2 hr

0

2(0)e

3(0)e
No Deficiencies
0

3
Multiple Routes
W/O Horizontal
Horizontal
Exit(s)
Exit(s)

-2

0

No Manual Fire Alarm

1

Direct Exit(s)
5

Manual Fire Alarm
W/O F.D. Conn.
W/F.D. Conn
1
2

-4
12. Smoke Detection
and Alarm

-2(0)c

Mech. Assisted Systems
by Zone

Deficient

11. Manual Fire Alarm

No Dead Ends >30 ft and Zone Length Is
>150 ft
100 ft to 150 ft
<100 ft

Single Deficiency
In Zone
In Adjacent Zone
-6
-2

<2 Routes

-8

222, 332, 433
2
4
4
4

None

Corridor Only

Rooms Only

Corridor and
Habit. Spaces

Total Spaces
In Zone

0(3)g

2(3)g

3(3)g

4

5

None

Corridor and
Habit. Space

Entire
Building

0

8

10

a

Use (0) where parameter 5 is -10.

b

Use (0) where parameter 10 is -8.

c

Use (0) on floor with fewer than 31 patients
(existing buildings only)

d

Use (0) where parameter 4 is -10.

For SI units: 1 ft = 0.3048 m
Form CMS-2786T (XX/XXXX) Previous Versions Obsolete

e

Use (0) where Parameter 1 is based on first floor zone or on an
unprotected type of construction (columns marked “000” or “200”)

f

Use ( ) if the area of Class B or C interior finish in the corridor
and exit or room is protected by automatic sprinklers and
Parameter 13 is 0; use ( ) if the room with existing Class C
interior finish is protected by automatic sprinklers, Parameter 4
is greater than or equal to 1, and Parameter 13 is 0.

g

Use this value in addition to Parameter 13 if the entire zone is
protected with quick-response automatic sprinklers.
Page 2

Step 5: Compute Individual Safety Evaluations – Use Table 5.
A. Transfer each of the 13 circled Safety Parameter Values from Table 4 to every unshaded block in the line
with the corresponding Safety Parameter in Table 5. For Safety Parameter 13 (Sprinklers) the value
entered in the People Movement Safety column is recorded in Table 5 as 1/2 the corresponding value
circled in Table 4.
B. Add the four columns, keeping in mind that any negative numbers deduct.
C. Transfer the resulting total values for S1, S2, S3, SG to blocks labeled S1, S2, S3, SG in Table 7 on page 4
of this sheet.
TABLE 5. INDIVIDUAL SAFETY EVALUATIONS
Containment
Safety (S1)

Safety Parameters

Extinguishment
Safety (S2)

People Movement
Safety (S3)

General
Safety (S4)

1. Construction
2. Interior Finish
(Corr. and Exit)
3. Interior Finish (Rooms)
4. Corridor Partitions/Walls
5. Doors to Corridor
6. Zone Dimensions
7. Vertical Openings
8. Hazardous Areas
9. Smoke Control
10. Emergency Movement Routes
11. Manual Fire Alarm
12. Smoke Detection and Alarm
–.. 2 =

13. Automatic Sprinklers
Total Value

S1=

S2=

S3=

S4=

TABLE 6.
MANDATORY SAFETY REQUIREMENTS (FOR USE IN HOSPITALS OR NURSING HOMES)
Containment
(Sa)
Zone Location
1st story
2nd or 3rd storyb
4th story or higher

New

Exist.

11
15
18

5
9
9

Extinguishment
(Sb)
New
15(12)a
17(14)a
19(16)a

People Movement
(Sc)

Exist.

New

Exist.

4
6
6

8(5)a
10(7)a
11(8)a

1
3
3

a. Use ( ) in zones that do not contain patient sleeping rooms.
b. For a 2nd story zone location in a sprinklered EXISTING facility, as an alternative to the mandatory safety
requirement values set specified in the table, the following mandatory values set shall be permitted to be
used: Sa=7, Sb=10, and Sc=7
Form CMS-2786T (XX/XXXX) Previous Versions Obsolete

Page 3

Step 6: Determine Mandatory Safety Requirement Values - Use Table 6.
A. Using the classification of the building (i.e., New or Existing) and the floor where the zone is located circle the
appropriate value in each of the three columns in Table 6.
B. Transfer the three circled values from Table 6 to the blocks marked Sa, Sb, and Sc in Table 7.
C. 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.

n-n=n
n-n=n
n-n=n
n-n=n

TABLE 7. ZONE FIRE SAFETY EQUIVALENCY EVALUATION
Containment
Safety (S1)

minus

Mandatory
Containment (S )

≥0

Extinguishment
Safety (S2)

minus

Mandatory
Extinguishment (S )

≥0

People Movement minus
Safety (S3)

Mandatory People
Movement (S )

≥0

General
Safety (S4)

Occupancy
Risk (R)

≥0

a

b

minus

c

S1

Sa

C

S2

Sb

E

S3

Sc

P

S4

R

G

No

Yes

TABLE 8. FACILITY FIRE SAFETY REQUIREMENTS WORKSHEET
Complete one copy of this worksheet for each facility.
For each consideration, select and mark the appropriate column.
A.

Building utilities conform to the requirements of Section 9.1.

B.

In new facilities only, life-support systems, alarms, emergency communication systems, and
illumination of generator set locations are powered as prescribed by 18.5.1.2 and 18.5.1.3.

C.

Heating and air conditioning systems conform with the air conditioning, heating, and ventilating
systems requirements within Section 9.2, except for enclosure of vertical openings, which have
been considered in Safety Parameter 7 of Worksheet 4.7.6.

D.

Fuel-burning space heaters and portable electrical space heaters are not used.

E.

There are no flue-fed incinerators.

F.

An evacuation plan is provided and fire drills conducted in accordance with 18.7.1/18.7.2 and
19.7.1/19.7.2.

G.

Smoking regulations have been adopted and implemented in accordance with 18.7.4 and 19.7.4.

H.

Draperies, upholstered furniture, mattresses, furnishings, and decoration combustibility is limited
in accordance with 18.7.5 and 19.7.5.

I.
J.
K.

Fire extinguishers are provided in accordance with the requirements of 18.3.5.4 and 19.3.5.6.
Exit signs are provided in accordance with the requirements of 18.2.10.1 and 19.2.10.
Emergency lighting is provided in accordance with 18.2.9.1 or 19.2.9.

L.

Standpipes are provided in all new high rise buildings as required by 18.4.2.

Met

Not
Met

Not
Applic.

CONCLUSIONS

1.

n All of the checks in Table 7 are in the “Yes” column. The level of fire safety is at least equivalent to that
prescribed by the Life Safety Code.*

2.

n One of more of the checks in Table 7

are in the “No” column. The level of fire safety is not shown by this
system to be equivalent to that prescribed by the Life Safety Code.*

*The equivalency covered by this worksheet includes the majority of considerations covered by the Life Safety Code. There are a few
considerations that are not evaluated by this method. These must be considered separately. These additional considerations are covered in
Table 8, the “Facility Fire Safety Requirements Worksheet.” One copy of this separate worksheet is to be completed for each facility.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid
OMB control number for this information collection is 0938-0242. The time required to complete this information collection is estimated to average 5 minutes per response,
including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard,
Baltimore, Maryland 21244-1850.
Form CMS-2786T (XX/XXXX) Previous Versions Obsolete

Page 4

FIRE SAFETY SURVEY REPORT
CRUCIAL DATA EXTRACT
(TO BE USED WITH CMS-2786 FORMS)
PROVIDER NUMBER

FACILITY NAME

SURVEY DATE

K1

K6

* K4

K3

DATE OF PLAN
APPROVAL

MULTIPLE CONSTRUCTION

TOTAL NUMBER OF BUILDINGS ____________
NUMBER OF THIS BUILDING

LSC FORM INDICATOR

____________

12
13

14
15

ASC Form
2000 EXISTING
2000 NEW

SMALL

(16 BEDS OR LESS)

K8:

1 PROMPT
2 SLOW
3 IMPRACTICAL

LARGE

K8:

ICF/MR Form
2786V, W, X
2000 EXISTING
2786V, W, X
2000 NEW

16
17

SELECT NUMBER OF FORM USED FROM ABOVE

*K9:

7 PROMPT
8 SLOW
9 IMPRACTICAL

ENTER E – SCORE HERE

(Check if K29 or K56 are marked as not applicable
in the 2786 M, R, T, U, V, W, X and Y.)
K29:

4 PROMPT
5 SLOW
6 IMPRACTICAL

APARTMENT HOUSE

K8:
* K7

BUILDING
WING
FLOOR
APARTMENT UNIT

COMPLETE IF ICF/MR IS SURVEYED UNDER CHAPTER 21

Health Care Form
2786R
2000 EXISTING
2786R
2000 NEW

2786U
2786U

A
B
C
D

K5:

K56:

e.g. 2.5

FACILITY MEETS LSC BASED ON (Check all that apply)
A1.

A2.

(COMP. WITH
ALL PROVISIONS)

A3.

(ACCEPTABLE POC)

FACILITY DOES NOT MEET LSC
B.

A4.

(WAIVERS)

A5.
(FSES)

(PERFORMANCE
BASED DESIGN)

K0180

A.
FULLY SPRINKLERED

B.
PARTIALLY SPRINKLERED

(All required areas are sprinklered) (Not all required areas are sprinklered)

C.
NONE
(No sprinkler system)

* MANDATORY

Form CMS-2786T (XX/XX)

Previous Versions Obsolete

Page 5