CMS-2786V` FSES-ICFs/MR-Small Facilities

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

2000 CODE ICFs/MR

FIRE SAFETY SURVEY REPORT - 2000 LIFE SAFETY CODE
Intermediate Care Facilities for the Mentally Retarded
SMALL

1. (A) PROVIDER NO.

1. (B) MEDICAID I.D. NO.

K1

K2

Form Approved
OMB No. 0938-0242

PART I – Chapter 6 – NFPA 101A – A Procedure for Determining Evacuation Capability
PART II – Chapter 32 & 33 – Residential Board & Care Occupancies – Requirements
PART III – Chapter 7-101A Fire Safety Evaluation System for Board & Care (Optional) – CMS-2786Y
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.

A. BUILDING ________________
B. WING

________________

C. FLOOR

________________

B.

■ MEDICARE
E-SCORE

■

C.

■ None (No sprinkler system)

K0180

4. DATE OF SURVEY

DATE OF PLAN APPROVAL

K4

K6

SURVEY UNDER:
5.

MEDICAID
E-Score
≤ 1.5

■ Partially Sprinklered
(Not all required areas are sprinklered)

K3

3. SURVEY FOR

Sprinklered
■ Fully
(All required areas are sprinklered)

Level of Evacuation Difficulty
Prompt

> 1.5 ≤ 5.0

6.

■ 2000 NEW

5. SURVEY FOR CERTIFICATION OF: SMALL FACILITY - LEVEL OF EVACUATION DIFFICULTY
(Check one)

Slow

> 5.0

■ 2000 EXISTING

K7

1.

■ Prompt

2.

■

Slow

3.

■

Impractical

Impractical

K5

K8

6. BED COMPOSITION
a. TOTAL NO. OF BEDS IN
THE FACILITY

e. NUMBER OF ICF/MR BEDS
CERTIFIED FOR MEDICAID

■ THE FACILITY MEETS, BASED UPON (check all appropriate boxes):
1. ■ COMPLIANCE WITH ALL PROVISIONS
2. ■ ACCEPTANCE OF A PLAN OF CORRECTION
B. ■ THE FACILITY DOES NOT MEET THE STANDARD
K9
7. A.

SURVEYOR (Signature)

4.

■

FSES

5.

■

PERFORMANCE BASED DESIGN

TITLE

OFFICE

DATE

TITLE

OFFICE

DATE

SURVEYOR ID
K10

FIRE AUTHORITY OFFICIAL (Signature)

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.
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INSTRUCTIONS FOR COMPLETING THE FORM (CMS-2786V)
SMALL FACILITIES —16 BEDS OR LESS
1. Complete a Worksheet for Rating Residents (CMS-2786M) for each resident in the facility.
2. Complete the first few pages of this form, a Worksheet for Calculating Evacuation Difficulty Score
(Chapter 6 NFPA 101A, 2001 Edition).
Note: This is the ONLY method permitted to determine Level of Evacuation Difficulty in SMALL facilities.
3. Transfer the E-Score obtained in Scoresheet F2 C (Page 5) to the E-SCORE block on Page 1 of this form.
4. Complete either Chapter 31 or 32 Requirements or the FSES/BC Appendix G - Rating the Building.
A. If completing Chapter 31 or 32 Requirements:
1. PROMPT - Complete ONLY the PROMPT section of this form.
2. SLOW - Complete both PROMPT and SLOW sections of this form.
3. IMPRACTICAL - Complete all three sections of this form PROMPT, SLOW and IMPRACTICAL.
B. If completing the FSES/BC - Appendix G - Rating The Building
1. You must also complete the Chapter 31 or 32 requirements. An FSES building evaluation cannot be done without
completing the usual survey form pages for these Chapters.
2. You may use the FSES Health Care to evaluate the building (Form CMS-2786T), but if you choose to do so,
you must also use the LSC Survey Report for Health Care Form CMS-2786R.

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Worksheet for Calculating Evacuation Difficulty Score
(E-Score)

F-2
BEFORE FILLING OUT THIS WORKSHEET:
• Please read the Instruction Manual.
• Make sure you have the completed “Worksheets for Rating Residents” (CMS-2786M) for each resident.
• Determine whether the requirements for using the Evacuation Difficulty Index have been satisfied by checking the one box to
the left of each question below that shows whether the answer to the question is “YES” or “NO.”
■ Yes

■ No

1. Has a protection plan been developed and written and have all staff members counted in the
calculation of E-Scores been trained in its implementation?

■ Yes

■ No

2. Is the total available staff at any given time able to handle the individual evacuation needs of each
resident who may be in the residence?

■ Yes

■ No

3. Can every staff member counted in the calculation of E-Scores meaningfully participate in the
evacuation of every resident?

■ Yes

■ No

4. Are all staff members counted in the calculation of E-Scores required to remain in the residence with
only the exceptions listed in the Instruction Manual?

■ Yes

■ No

5. Were at least twelve fire drills conducted during the year?

This worksheet is filled out for the staff “Shift”
From ______________________________________ To ______________________________________
(You must fill out this worksheet for the time of day, week, etc., when the ratings for the combination of staff and residents
yields the highest E-Score. This period of time will usually be late at night. When it is not obvious which time period has the
highest E-Score, complete a separate worksheet for all candidate time periods and use the one having the highest E-Score.)

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F-2A

Finding the Total Resident Score

1. List each resident's name in the scoresheet below. (Scoresheet F-2A)
2. For each resident, transfer the Evacuation Assistance Score (Part F-1B) from his/her Worksheet for Rating Residents (Step 1).
3. Add the Evacuation Assistance Score for all the residents and write the answer in the appropriate space at the bottom of Scoresheet F-2A.

Scoresheet F-2A

RESIDENT SCORES
Evacuation
Resident’s Name
Assistance
Score

Resident's Name

Evacuation
Assistance
Score

Evacuation
Assistance
Score

Resident's Name

Evacuation Assistance TOTAL

F-2B

Finding the Staff Shift Score

1. In Scoresheet F-2B (below), list the names of staff members who are required to remain in the group home during the time period (shift) specified on the front page of this worksheet.
2. Determine whether the effectiveness of the alarm system is rated as "assured" or "not assured" as explained in the Instruction Manual.
3. Using the appropriate “assured” or “not assured” column in the table below, find each staff member's Promptness of Response Score for the time period specified. Write each staff member's score
in the appropriate space in Scoresheet F-2B.
4. Add the staff members’ Promptness of Response Scores and write the total in the appropriate space in Scoresheet F-2B.

Scoresheet F-2B

STAFF SCORES

Staff’s Name

Promptness of
Response
Score

Staff's Name

Promptness of
Response
Score

PROMPTNESS OF RESPONSE SCORES
Alarm Effectiveness
Staff Availability
Assured
Not Assured
Standby or asleep

16

2

Immediately available

20

2

Immediately
available & close by

20

10

Staff Shift TOTAL
NOTE: If the facility is a large residential facility, staff members may be responsible for assisting the residents in a fire/smoke zone, but may also have responsibilities for residents in other fire/smoke
zones. See the glossary for Step 2 for the special procedure for assigning Promptness of Response Scores.
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F-2C

Finding the Home's Evacuation Difficulty Score

1. Rate the home on the factor below by checking the circle that best describes the home.
Vertical Distance From Bedrooms to Exits

Small Facility

All BR on
floor with
direct exits

Any BR
one floor
from exit

Any BR
two or more
floors from exit

● score = 0.8

● score = 1.0

● score = 1.2

Large Facility
or Apartment

● score = 1.0

2. Write the score for the category you checked in the appropriate box in Scoresheet F-2C below.
3. Compute the E-Score as show in Scoresheet F-2C:
a. Multiply the Resident Score Total by the score for Vertical Distance from Bedrooms to Exits.
b. Divide the answer by the Staff Shift Score Total to find the Evacuation Difficulty Score (E-Score).

Scoresheet F-2C

CALCULATION OF E-SCORE
Vertical Distance
from Bedrooms
to Exits

Resident
Score Total

x
Staff Shift
Score
Total

ENTER THIS SCORE
on COVER of
THIS FORM
E-SCORE

=

4. Determine and record Level of Evacuation Difficulty appropriate to the Calculated E-Score; use Scoresheet F-2D.
Scoresheet F-2D
E-Score
≤ 1.5

Level of Evacuation Difficulty

Level of Evacuation
Difficulty

Prompt

> 1.5 ≤ 5.0

Slow

> 5.0

Impractical

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SMALL FACILITY PROMPT EVACUATION

NO
MET MET

N/A

REMARKS

BUILDING CONSTRUCTION
No Requirements
HAZARDOUS AREAS
K29

2000 EXISTING
Any hazardous area that is on the same floor as, and is in or abut, a
primary means of escape or a sleeping room shall be protected by one
of the following means.
(a) Protection shall be an enclosure with a fire resistance rating
of not less than 1 hour, with a self-closing or automatic
closing fire door in accordance with 7.2.1.8 that has a fire
protection rating of not less than 3/4 hour.
(b) Protection shall be automatic sprinkler protection, in
accordance with 33.2.3.5, and a smoke partition, in
accordance with 8.2.4, located between the hazardous
area and the sleeping area or primary escape route. Any
doors in such separation shall be self-closing or automatic
closing in accordance with 7.2.1.8.
33.2.3.2.2.
2000 NEW
Any hazardous area that is on the same floor as, and is in or abut, a
primary means of escape or a sleeping room shall be protected by one
of the following means:
(a) Protection shall be an enclosure with a fire resistance rating
of not less than 1 hour, with a self-closing or automatic
closing fire door in accordance with 7.2.18 that has a fire
protection rating of not less than 3/4 hour. The enclosure
shall be protected by an automatic fire detection system
connected to the fire alarm system provided in 32.2.3.4.1.
(b) Protection shall be automatic sprinkler protection, in
accordance with 32.2.3.5, and a smoke partition, in
accordance with 8.2.4, located between the hazardous area
and the sleeping area or primary escape route. Any doors in
such separation shall be self-closing or automatic closing in
accordance with 7.2.1.8,
32.2.3.2.2.

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K211

NO
MET MET

N/A

REMARKS

2000 EXISTING
Where Alcohol Based Hand Rub (ABHR) dispensers are
installed:
❏ The corridor is at least 6 feet wide
❏ The maximum individual fluid dispenser capacity shall be 1.2 liters
(2 liters in suites of rooms)
❏ The dispensers shall have a minimum spacing of 4 ft from each other
❏ Not more than 10 gallons are used in a single smoke
compartment outside a storage cabinet.
❏ Dispensers are not installed over or adjacent to an ignition source.
❏ If the floor is carpeted, the building is fully sprinklered. 19.3.2.7,
CFR 483.70
2000 NEW
Where Alcohol Based Hand Rub (ABHR) dispensers are
installed:
❏ The corridor is at least 6 feet wide
❏ The maximum individual fluid dispenser capacity shall be 1.2 liters
(2 liters in suites of rooms)
❏ The dispensers shall have a minimum spacing of 4 ft from each other
❏ Not more than 10 gallons are used in a single smoke
compartment outside a storage cabinet.
❏ Dispensers are not installed over or adjacent to an ignition source.
❏ If the floor is carpeted, the building is fully sprinklered. 18.3.2.7,
CFR 483.470

K119

2000 EXISTING
Other hazardous areas shall be protected in accordance with
33.2.3.2.3 by one of the following:
(1) An enclosure having a fire resistance rating of not less than
1
/2 hour, with a self-closing or automatic-closing door in
accordance with 7.2.1.8 that is equivalent to not less than a
13/4 inch (4.4 cm) thick, solid-bonded wood core construction.
(2) Automatic sprinkler protection in accordance with 33.2.3.5,
regardless of enclosure.

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REMARKS

2000 NEW
Other hazardous areas shall be protected in accordance with
32.2.3.2.3 by one of the following:
(1) An enclosure having a fire resistance rating of not less than
1
/2 hour, with a self-closing or automatic closing door in
accordance with 7.2.1.8 that is equivalent of not less than
13/4 inch (4.4 cm) thick, solid-bonded wood core construction
and is protected by an automatic fire detection system
connected to the fire alarm system provided in 32.2.3.1.
(2) Automatic sprinkler protection in accordance with 32.2.3.5,
regardless of enclosure.
FIRE ALARM SYSTEMS
K51

2000 EXISTING
A manual fire alarm system shall be provided in accordance with
Section 9.6, 33.2.3.4.1.
❑ Exception No 1: Where there are interconnected smoke detectors
meeting the requirements of 33.2.3.4.3 and there is not less than
one manual fire alarm box per floor arranged to continuously
sound the smoke detector alarms.
❑ Exception No. 2: Other manually activated continuously sounding
alarms acceptable to the authority having jurisdiction.
2000 NEW
A manual fire alarm system shall be provided in accordance with
Section 9.6, 32.2.3.4.1.

K155

Where a required fire alarm system is out of service for more than 4
hours in a 24-hour period, the authority having jurisdiction shall be
notified, and the building shall be evacuated or an approved fire
watch shall be provided for all parties left unprotected by the shutdown until the fire alarm system has been returned to service. 9.6.1.8

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SMOKE SYSTEMS
K53

2000 EXISTING
Approved smoke alarms shall be provided in accordance with
9.6.2.10. These alarms shall be powered from the building electrical
system and when activated, shall initiate an alarm that is audible in all
sleeping areas. Smoke alarms shall be installed on all levels, including
basement but excluding crawl spaces and unfinished attics. Additional
smoke alarms shall be installed for living rooms, dens, day rooms,
and similar spaces. 33.2.3.4.3.
❑ Exception No 1: Buildings protected throughout by an approved
automatic sprinkler system, in accordance with 33.2.3.5, that uses
quick response or residential sprinklers, and protected with
approved smoke alarms installed in each sleeping room in
accordance with 9.6.2.10, that are powered by the building
electrical system.
❑ Exception No. 2: Where buildings are protected throughout by an
approved automatic sprinkler system, in accordance with 33.3.2.5,
that uses quick-response or residential sprinklers, with existing
battery-powered smoke alarms in each sleeping room, and where,
in the opinion of the authority having jurisdiction, the facility has
demonstrated that testing, maintenance, and a battery replacement
program ensure the reliability of power to smoke alarms.
2000 NEW
Approved smoke alarms shall be provided in accordance with
9.6.2.10, 32.2.3.4.3.1. Smoke alarms shall be installed on all levels,
including basements but excluding crawl spaces and unfinished attics.
Additional smoke alarms shall be installed for all living areas as
defined in 3.3.119.
❑ Exception: Smoke alarms shall not be required in buildings
protected throughout by an approved automatic sprinkler system
in accordance with 32.2.3.5.

K56

2000 EXISTING
Where an automatic sprinkler system is installed, for either total or
partial building coverage, the system shall be in accordance with
Section 9.7, 33.2.3.5.2 and shall activate the fire alarm system in
accordance with 33.2.3.4.1. The adequacy of the water supply shall
be documented to the authority having jurisdiction.

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REMARKS

❑ Exception No. 1: In prompt evacuation facilities, an automatic
sprinkler system in accordance with NFPA 13D, Standard for the
Installation of Sprinkler Systems in One and two Family Dwellings
and Manufactured Homes, shall be permitted. Automatic sprinklers
shall not be required in closets not exceeding 24 sq. ft. and in
bathrooms not exceeding 55 sq. ft., provided that such spaces are
finished with lath and plaster or materials providing a 15 minute
thermal barrier.
❑ Exception No. 2: Not applicable
❑ Exception No. 3: In prompt and slow evacuation capability
facilities where an automatic sprinkler system is in accordance
with NFPA 13, Standard for the Installation of Sprinkler Systems,
automatic sprinklers shall not be required in closets not exceeding
24 sq. ft and in bathrooms not exceeding 55 sq. ft., provided that
such spaces are finished with lath and plaster or material providing
a 15 minute thermal barrier.
❑ Exception No. 4: In prompt and slow evacuation capability
facilities up to and including four stories in height, systems in
accordance with NFPA 13R, Standard for the Installation of
Sprinkler Systems in Residential Occupancies up to and Including
Four Stories in Height, shall be permitted.
❑ Exception No. 5: Not applicable
❑ Exception No. 6: Initiation of the fire alarm system shall not be
required for existing installations in accordance with 33.2.3.5.5.
2000 NEW
Where an automatic sprinkler system is installed, for either total or
partial building coverage, the system shall be in accordance with
Section 9.7 and shall initiate the fire alarm system in accordance with
32.2.3.4.1, 32.2.3.5.2. The adequacy of the water supply shall be
documented to the authority having jurisdiction.
❑ Exception No. 1: In prompt evacuation facilities, an automatic
sprinkler system in accordance with NFPA 13D, Standard for the
Installation of Sprinkler Systems in One and Two Family Dwellings
and Manufactured Homes, shall be permitted. Facilities with more
than eight residents shall be permitted. Facilities with more than
eight residents shall be treated as two-family dwellings with regard
to water supply. Additionally entrance foyers shall be sprinklered.

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❑ Exception No. 2: Not applicable
❑ Exception No. 3: In prompt and slow evacuation capability
facilities where an automatic sprinkler system is in accordance
with NFPA 13, Standard for the Installation of Sprinkler Systems,
automatic sprinklers shall not be required in closets not exceeding
24 sq. ft and in bathrooms not exceeding 55 sq. ft., provided that
such spaces are finished with lath and plaster or material
providing a 15 minute thermal barrier.
❑ Exception No. 4: In prompt and slow evacuation capability
facilities up to and including four stories in height, systems in
accordance with NFPA 13R, Standard for the Installation of
Sprinkler Systems in Residential Occupancies up to and Including
Four Stories in Height, shall be permitted.
❑ Exception No. 5: Not applicable
❑ Exception No. 6: Initiation of the fire alarm system shall not be
required for existing installations in accordance with 32.2.3.5.5.
K154

Where a required automatic sprinkler system is out of service for more
than 4 hours in a 24-hour period, the authority having jurisdiction shall
be notified, and the building shall be evacuated or an approved fire watch
system be provided for all parties left unprotected by the shutdown
until the sprinkler system has been returned to service. 9.7.6.1
A. Date sprinkler system last checked and necessary maintenance
provided. _____________________________________________
B. Show who provided the service. __________________________
C. Note the source of the water supply for the automatic sprinkler
system._______________________________________________
(Provide, in REMARKS, information on coverage for any
non-required or partial automatic sprinkler system.)

K144

2000 NEW
All facilities shall be protected throughout by an approved automatic
sprinkler system in accordance with 32.2.3.5.2, 32.2.3.5.1. Quick
response or residential sprinklers shall be provided.
❑ Exception No. 1: In conversions, sprinklers shall not be required in
small board and care homes with a rating of prompt evacuation
capability and serving eight or fewer residents.
❑ Exception No. 2: Standard response sprinklers shall be permitted
for use in hazardous areas in accordance with 32.2.3.2.

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INTERIOR FINISH
K14

2000 EXISTING
Interior wall and ceiling finish shall be Class A or Class B in
accordance with section 10.2, 33.2.3.3. There shall be no requirements
for interior floor finish.
❑ Exception: Class C interior wall and ceiling finish shall be
permitted in prompt evacuation capability facilities.
2000 NEW
Interior wall and ceiling finish materials complying with 10.2.3 shall
be Class A or Class B. 32.2.3.3.2.
❑ Exception: Class C interior wall and ceiling finish shall be
permitted in prompt evacuation capability facilities.
SEPARATION OF SLEEPING ROOMS

K17

2000 EXISTING
The separation walls of sleeping rooms shall be capable of resisting
fire for not less than 1/2 hour, which is considered to be achieved if the
partitioning is finished on both sides with lath and plaster or materials
providing a 15 minute thermal barrier. Sleeping room doors shall be
substantial doors, such as those of 13/4 inch thick, solid-bonded wood
core construction or other construction of equal or greater stability
and fire integrity. Any vision panels shall be fixed fire window
assemblies in accordance with 8.2.3.2.2 or shall be wired glass not
exceeding 1296 sq. in. each in area and installed in approved frames.
33.2.3.6.1, 33.2.3.6.2.
❑ Exception No. 1: In prompt evacuation facilities, all sleeping
rooms shall be separated from the escape route by smoke
partitions in accordance with 8.2.4. Door closing shall be
regulated by 33.2.3.6.4.
❑ Exception No. 2: This requirement shall not apply to corridor
walls that are smoke partitions in accordance with 8.2.4 and that
are protected by automatic sprinklers in accordance with 33.2.3.5
on both sides of the wall and door. In such instances, there shall
be no limitation on the type or size of glass panels. Door closing
shall be regulated by 33.2.3.6.4.
❑ Exception No. 3: Sleeping arrangements that are not located in
sleeping rooms shall be permitted for nonresident staff members,
provided that the audibility of the alarm in the sleeping area is
sufficient to awaken staff that might be sleeping.

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❑ Exception No. 4: In previously approved facilities, where the group
achieves an E-score of three or less using the board and care
methodology of NFPA 101A. Guide on Alternative Approaches to
Life Safety, sleeping rooms shall be separated from escape routes
by walls and doors that are smoke resistant.
No louvers or operable transoms or other air passages shall penetrate
the wall, except properly installed heating and utility installations
other than transfer grilles. Transfer grilles shall be prohibited.
2000 NEW
The separation walls of sleeping rooms shall be capable of resisting
fire for not less than 1/2 hour, which is considered to be achieved if the
partitioning is finished on both sides with lath and plaster or materials
providing a 15 minute thermal barrier.
Sleeping room doors shall be substantial doors, such as those of 13/4
inch thick, solid-bonded wood core construction or other construction
of equal or greater stability and fire integrity. Any vision panels shall
be fixed fire window assemblies in accordance with 8.2.3.2.2. or shall
be wired glass not exceeding 1296 sq. in. each in area and installed in
approved frames. 32.2.3.6.1 and 32.2.3.6.2.
❑ Exception No. 1: In prompt evacuation capability facilities, all
sleeping rooms shall be separated from the escape route by smoke
partitions in accordance with 8.2.4. Door closing shall be
regulated by 32.2.3.6.4.
❑ Exception No. 2: This requirement shall not apply to corridor
walls that are smoke partitions in accordance with 8.2.4 and that
are protected by automatic sprinklers in accordance with 32.2.3.5
on both sides of the wall and door. In such instances, there shall be
no limitation on the type or size of glass panels. Door closing shall
be regulated by 32.2.3.6.4.
❑ Exception No. 3: Sleeping arrangements that are not located in
sleeping rooms shall be permitted for nonresident staff members,
provided that the audibility of the alarm in the sleeping area is
sufficient to awaken staff that might be sleeping.
No louvers or operable transoms or other air passages shall penetrate
the wall, except properly installed heating and utility installations
other than transfer grilles. Transfer grilles shall be prohibited.

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K18

NO
MET MET

N/A

REMARKS

Doors shall be provided with latches or other mechanisms suitable for
keeping the doors closed. No doors shall be arranged to prevent the
occupant from closing the door. 32.2.3.6.3, 32.2.3.6.4, 33.2.3.6.3,
33.2.3.6.4
Doors shall be self-closing or automatic closing in accordance with 7.2.1.8
❑ Exception: Door closing devices shall not be required in buildings
protected throughout by an approved automatic sprinkler system in
accordance with 32.2.3.5.1 and 33.2.3.5.2.
EGRESS

K41

Every sleeping room and living area shall have access to a primary
means of escape located to provide a safe path of travel to the outside.
33.2.2.2.1.
Where sleeping rooms or living areas are above or below the level of
exit discharge, the primary means of escape shall be an interior stair
in accordance with 32.2.2.4 and 33.2.2.4, an exterior stair, a horizontal
exit, or a fire escape stair. 32.2.2.2.

K120

2000 EXISTING
In addition to the primary route, each sleeping room shall have a
second means of escape that consists of one of the following:
(a) It shall be a door, stairway, passage, or hall providing a way
of unobstructed travel to the outside of the dwelling at street
or ground level that is independent of and remotely located
from the primary means of escape.
(b) It shall be a passage through an adjacent nonlockable space,
independent of and remotely located from the primary means
of escape, to approved means of escape.
(c) It shall be an outside window or door operable from the
inside without the use of tools, keys, or special effort that
provides a clear opening of not less than 5.7 sq. ft. The width
shall be not less than 20 inches. The height shall be not less
than 24 inches. The bottom of the opening shall be not more
than 44 inches above the floor. Such means of escape shall
be acceptable where one of the following criteria are met:

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(1) The window shall be within 20 ft of grade.
(2) The window shall be directly accessible to fire
department rescue apparatus as approved by the
authority having jurisdiction.
(3) The window or door shall open onto an exterior
balcony. 33.2.2.3
❑ Exception No. 1: If the sleeping room has a door leading directly
to the outside of the building with access to grade or to a stairway
that meets the requirements of exterior stairs in 33.2.3.1.2, that
means of escape shall be considered as meeting all the escape
requirements for the sleeping room.
❑ Exception No. 2: A second means of escape from each sleeping
room shall not be required where the facility is protected throughout
by approved automatic sprinkler system in accordance with 33.2.3.5.
❑ Exception No. 3: Existing approved means of escape shall be
permitted to continue to be used.
2000 NEW
In addition to the primary route, each sleeping room in facilities that
use Exception No. 1 to 32.2.3.5.1 shall have a second means of
escape that consists of one of the following:
(d) It shall be a door, stairway, passage, or hall providing a way of
unobstructed travel to the outside of the dwelling at street or
ground level that is independent of and remotely located from
the primary means of escape.
(e) It shall be a passage through an adjacent nonlockable space,
independent of and remotely located from the primary means
of escape, to approved means of escape.
(f) It shall be an outside window or door operable from the inside
without the use of tools, keys, or special effort that provides a
clear opening of not less than 5.7 sq. ft. The width shall be not
less than 20 inches. The height shall be not less than 24 inches.
The bottom of the opening shall be not more than 44 inches
above the floor. Such means of escape shall be acceptable
where one of the following criteria are met:
(1) The window shall be within 20 ft of grade.
(2) The window shall be directly accessible to fire
department rescue apparatus as approved by the
authority having jurisdiction.
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(3) The window or door shall open onto an exterior
balcony. 33.2.2.3
❑ Exception: If the sleeping room has a door leading directly
to the outside of the building with access to grade or to a stairway
that meets the requirements of exterior stairs in 32.2.3.1.2, that
means of escape shall be considered as meeting all the escape
requirements for the sleeping room.
K20

2000 EXISTING
Interior stairs used as a primary means or escape shall be enclosed
with 1/2 hour fire barriers, with all openings equipped with smokeactuated automatic closing or self-closing doors having a fire
protection rating comparable to that required for the enclosure. Stairs
shall comply with 7.2.2.5.3. The entire primary means of escape shall
be arranged so that it is not necessary for the occupants to pass
through a portion of a lower story unless that route is separated from
all spaces on that story by construction having not less than a 1/2 hour
fire resistance rating. In buildings of construction other than Type II
(000), Type III (200), or Type V (000), the supporting construction
shall be protected to afford the required fire resistance rating of the
supported wall. 33.2.2.4.
❑ Exception No. 1: Stairs that connect a story at street level to only
one other story shall be permitted to be open to the story that is
not at street level.
❑ Exception No. 2: Stair enclosures shall not be required in buildings
of three or fewer stories that house prompt or slow evacuation
capability facilities protected through out by an approved automatic
sprinkler system in accordance with 33.2.3.5 that uses quick
response or residential sprinklers. This exception shall be permitted
only if a primary means of escape from each sleeping area still
exists that does not pass through a portion of a lower floor, unless
that route is separated from all spaces on that floor by construction
having a 1/2 hour fire resistance rating.
❑ Exception No. 3: Stair enclosures shall not be required in buildings
of two or fewer stories that house prompt evacuation capability
facilities with not more than eight residents and are protected by
an approved automatic sprinkler system in accordance with
33.2.3.5 that uses quick-response or residential sprinklers.
Exception No. 2 to 33.2.2.3 shall not be used in conjunction with
this exception. The exceptions to 33.2.3.4.3 shall not be used in
conjunction with this exception.

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❑ Exception No. 4: In buildings of three or fewer stories that house
prompt or slow evacuation capability facilities protected by an
approved automatic sprinkler system in accordance with 33.2.3.5
stairs shall be permitted to be open at the topmost story only. The
entire primary means of escape of which the stairs are a part shall
be separated from all portions of lower stories.
2000 NEW 32.2.2.4
Interior stairs shall be enclosed with 1/2 hour fire barriers, with all
openings equipped with smoke-actuated automatic closing or
self-closing doors having a fire protection rating comparable to that
required for the enclosure. Stairs shall comply with 7.2.2.5.3. The
entire primary means of escape shall be arranged so that it is not
necessary for the occupants to pass from all spaces on that story by
construction having not less than a 1/2 hour fire resistance rating. In
buildings of construction other than Type II (000), Type III (200), or
Type V (000), the supporting construction shall be protected to afford
the required fire resistance rating of the supported wall.
❑ Exception No. 1: Stairs that connect a story at street level to only
one other story shall be permitted to be open to the story that is
not at street level.
❑ Exception No. 2: Stair enclosures shall not be required for prompt
and slow evacuation capability facilities in buildings of three or
fewer stories that are protected with an approved automatic
sprinkler system in accordance with 32.2.3.5. This exception shall be
permitted only if a primary means of escape from each sleeping
area still exists that does not pass through a portion of a lower
floor, unless that route is separate from all spaces on that floor by
construction having a 1/2 hour fire resistance rating.
❑ Exception No. 3: Stair enclosures shall not be required in buildings
of two or fewer stories that house prompt evacuation capability
facilities with not more than eight residents. The exception to
32.2.3.4.3.1 shall not be used in conjunction with this exception.
Exception No. 1 to 32.2.3.5.1 shall not be used in conjunction with
this exception.

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K21

NO
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32.2.3.1.1, 33.2.3.1.1
Vertical openings shall be protected so as not to expose a primary
means of escape. Vertical openings shall be considered protected if
separated by smoke partitions in accordance with 8.2.4 that prevent
the passage of smoke from one story to any primary means of escape
on another story. Smoke partitions shall have a fire resistance rating
on not less than 1/2 hour. Any doors or openings to the vertical
opening shall be capable of resisting fire for not less than 20 minutes.
❑ Exception: Stairs shall be permitted to be open where complying
with Exception no. 2 or Exception No. 3 to 32.2.2.4, 33.2.2.4.

K40

2000 EXISTING 33.2.2.5.1
Doors or paths of travel to a means of escape shall not be less than
28 inches.
❑ Exception: Bathroom doors shall not be less than 24 inches.
2000 NEW 32.2.2.5.1
Doors or paths of travel to means of escape shall be not less than 32
inches.
❑ Exception No. 1: Bathroom doors shall be not less than 24 inches.
❑ Exception No. 2: In conversions (see 32.1.1.3), 28 inch doors shall
be permitted to continue in use.

K121

Winders complying with 7.2.2.2.4 shall be permitted 32.2.2.6.2.,
33.2.2.6.2

K122

Every closet door latch shall be readily opened from the inside in
case of an emergency. 32.2.2.5, 33.2.2.5.3

K123

Every bathroom door shall be designed to allow opening from the
outside during an emergency when locked. 32.2.2.5.4, 33.2.2.5.4

K43

No door in any means of escape shall be locked against egress when
the building is occupied.
❑ Exception: Delayed egress locks complying with 7.2.1.6.1 shall be
permitted on exterior doors. 32.2.2.5.5, 33.2.2.5.5.

If the level of evacuation difficulty is PROMPT, stop here.

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SMALL FACILITY – SLOW EVACUATION
BUILDING CONSTRUCTION
K11

2000 EXISTING 33.2.1.3.2
The facility shall be housed in a building where the interior is fully
sheathed with lath and plaster or other material providing a 15 minute
thermal barrier, including all portions of bearing walls, bearing
partitions, floor construction, and roofs. All columns, beams, girders,
and trusses shall be similarly encased or otherwise shall provide not
less than a 1/2 hour fire resistance rating. 33.2.1.3.2.
❑ Exception No. 1: Exposed steel or wood columns, girders, and
beams (but not joists) located in the basement.
❑ Exception No. 2: Buildings of Type I, Type II (2,2,2), Type II
(1,1,1), Type III (2,1,1), Type IV, Type V (1,1,1) construction
(See 8.2.1)
❑ Exception No. 3: Areas protected by approved automatic sprinkler
systems in accordance with 33.2.3.5.
❑ Exception No. 4: Unfinished, unused, and essentially inaccessible
loft, attic, or crawl space.
❑ Exception No. 5: Where the facility achieves an E-score of three or
less using the board and care occupancies evacuation capability
determination methodology of NFPA 101A, Guide on Alternative
Approaches to Life Safety.
Note: No requirement for New - Chapter 32
INTERIOR FINISH

K16

Interior wall and ceiling finish materials in accordance with 10.2 and
10.2.3 shall be Class A or Class B.
32.2.3.3.2, 33.2.3.3

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AUTOMATIC SPRINKLER SYSTEM
K145

2000 NEW 32.2.3.5.1
All facilities shall be protected throughout by an approved automatic
sprinkler system in accordance with 32.2.3.5.2. Quick response or
residential sprinklers shall be provided.
❑ Exception No. 1: In conversions, sprinklers shall not be required
in small board and care homes with a rating of prompt evacuation
capability and serving eight or fewer residents.
❑ Exception No. 2: Standard response sprinklers shall be permitted
for use in hazardous areas in accordance with 32.2.3.2.

K56

2000 EXISTING 33.2.3.5.2
Where an automatic sprinkler system is installed, for either total or
partial building coverage, the system shall be in accordance with
Section 9.7 and shall activate the fire alarm system in accordance
with 33.2.3.4.1. The adequacy of the water supply shall be
documented to the authority having jurisdiction.
❑ Exception No. 1: Not Applicable
❑ Exception No. 2: In slow and impractical evacuation capability
facilities, an automatic sprinkler system in accordance with NFPA
13D, Standard for the Installation of Sprinkler Systems in one-andtwo-Family Dwellings and Manufactured Homes, with a 30 minute
water supply, shall be permitted. All habitable areas and closets
shall be sprinklered. Automatic Sprinklers shall not be required in
bathrooms not exceeding 55 ft2 (5.1 m2), provided that such spaces
are finished with bath and plaster or materials provided a 15
minute thermal barrier.
❑ Exception No. 3: In prompt and slow evacuation capability facilities
where an automatic sprinkler system is in accordance with NFPA
13, Standard for the Installation of Sprinkler Systems, automatic
sprinklers shall not be required in closets not exceeding 24 sq. ft.
and in bathrooms not exceeding 55 sq. ft., provided that such
spaces are finished with lath and plaster or material providing a
15 minute thermal barrier.
❑ Exception No. 4: In prompt and slow evacuation capability facilities
up to and including four stories in height, systems in accordance
with NFPA 13R, Standard for the Installation of Sprinkler Systems
in Residential Occupancies up to and Including Four Stories in
Height, shall be permitted.
❑ Exception No. 5: Not Applicable

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❑ Exception No. 6: Initiation of the fire alarm system shall not be
required for existing installations in accordance with 33.2.3.5.5.
2000 NEW 32.2.3.5.2
Where an automatic sprinkler system is installed, for either total or partial building coverage, the system shall be in accordance with Section
9.7 and shall initiate the fire alarm system in accordance with
32.2.3.4.1. The adequacy of the water supply shall be documented to
the authority having jurisdiction.
❑ Exception No. 2: In slow and impractical evacuation capability
facilities, an automatic sprinkler system in accordance with NFPA
13D, Standard for the Installation of Sprinkler Systems in one-andtwo Family Dwellings and Manufactured Homes, with a 30 minute
water supply, shall be permitted. All habitable areas and closets
shall be sprinklered. Facilities with more than eight residents shall
be treated as two family dwellings with regard to water supply.
❑ Exception No. 3: In prompt and slow evacuation capability facilities
where an automatic sprinkler system is in accordance with NFPA
13, Standard for the Installation of Sprinkler Systems, automatic
sprinklers shall not be required in closets not exceeding 24 sq. ft.
and in bathrooms not exceeding 55 sq. ft., provided that such
spaces are finished with lath and plaster or material providing a
15 minute thermal barrier.
❑ Exception No. 4: In prompt and slow evacuation capability facilities
up to and including four stories in height, systems in accordance
with NFPA 13R, Standard for the Installation of Sprinkler Systems
in Residential Occupancies up to and Including Four Stories in
Height, shall be permitted.
❑ Exception No. 5: Not Applicable
❑ Exception No. 6: Initiation of the fire alarm system shall not be
required for existing installations in accordance with 32.2.3.5.5.
EGRESS
K32

2000 EXISTING (Only) 33.2.2.2.2
In slow and impractical evacuation capability facilities, the primary
means of escape for each sleeping room shall not be exposed to living
areas and kitchens.
❑ Exception: Buildings equipped with quick-response or residential
sprinklers throughout. Standard response sprinklers shall be
permitted for use in hazardous areas in accordance with 33.2.3.2.

If the level or evacuation capability is SLOW, stop here.
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SMALL FACILITY IMPRACTICAL EVACUATION CAPABILITY
BUILDING CONSTRUCTION
K12

2000 EXISTING
Buildings shall be of any construction type in accordance with 8.2.1
other than Type II (000), Type III (200), or Type V (000) construction.
33.2.1.3.3.
❑ Exception: Buildings protected throughout by an approved,
supervised automatic sprinkler system in accordance with 33.2.3.5
shall be permitted to be of any type of construction.
AUTOMATIC SPRINKLER SYSTEM

K56

2000 EXISTING
Where an automatic sprinkler system is installed, for either total or
partial building coverage, the system shall be in accordance with
Section 9.7 and shall activate the fire alarm system in accordance
with 33.2.3.4.1. The adequacy of the water supply shall be documented
to the authority having jurisdiction. 33.2.3.5.2.
❑ Exception No. 1: Not Applicable.
❑ Exception No. 2: In slow and impractical evacuation capability
facilities, an automatic sprinkler system in accordance with NFPA
13D, Standard for the Installation of Sprinkler Systems in One and
Two Family Dwellings and Manufactured Homes, with a 30 minute
water supply, shall be permitted. All habitable areas and closets
shall be sprinklered. Automatic sprinklers shall not be required in
bathrooms not exceeding 55 sq. ft., provided that such spaces are
finished with lath and plaster or materials providing a 15 minute
thermal barrier.
❑ Exception No. 3: Not Applicable.
❑ Exception No. 4: Not Applicable.
❑ Exception No. 5: In impractical evacuation capability facilities up
to and including four stories in height, systems in accordance with
NFPA 13R, Standard for the Installation of Sprinkler Systems in
Residential Occupancies up to and Including Four Stories in
Height, shall be permitted. All habitable areas and closets shall be
sprinklered. Automatic sprinklers shall not be required in
bathrooms not exceeding 55 sq. ft., provided that such spaces are
finished with lath and plaster or materials providing a 15 minute
thermal barrier.
❑ Exception No. 6: Initiation of the fire alarm system shall not be
required for existing installations in accordance with 33.2.3.5.5.

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2000 NEW
Where an automatic sprinkler system is installed, for either total or
partial building coverage, the system shall be in accordance with
Section 9.7 and shall initiate the fire alarm system in accordance with
32.2.3.4.1. The adequacy of the water supply shall be documented to
the authority having jurisdiction. 32.2.3.5.2.
❑ Exception No. 1: Not Applicable.
❑ Exception No. 2: In slow and impractical evacuation capability
facilities, an automatic sprinkler system in accordance with NFPA
13D, Standard for the Installation of Sprinkler Systems in One and
Two Family Dwellings and Manufactured Homes, with a 30 minute
water supply, shall be permitted. All habitable areas and closets
shall be sprinklered. Facilities with more than eight residents shall
be treated as two family dwellings with regard to water supply.
❑ Exception No. 3: Not Applicable.
❑ Exception No. 4: Not Applicable.
❑ Exception No. 5: In impractical evacuation capability facilities up
to and including four stores in height, systems in accordance with
NFPA 13R, Standard for the Installation of Sprinkler Systems in
Residential Occupancies up to and Including Four Stores in
Height, shall be permitted. All habitable areas and closets shall be
sprinklered.
❑ Exception No. 6: Initiation of the fire alarm system shall not be
required for existing installations in accordance with 32.2.3.5.5.
VERTICAL OPENINGS
K20

Vertical openings shall be protected so as not to expose a primary
means of escape. Vertical openings shall be considered protected if
separated by smoke partitions in accordance with 8.2.4 that prevent
the passage of smoke from one story to any primary means of escape
on another story. Smoke partitions shall have a fire resistance rating
of not less than a 1/2 hour. Any doors or openings to the vertical
opening shall be capable of resisting fire for not less than 20 minutes.
32.2.3.1.1, 33.2.3.1.1
❑ Exception: Stairs shall be permitted to be open where complying
with Exception No. 2 or Exception No. 3 to 32.2.2.4 and 33.2.2.4.

Note: Make sure you have completed PROMPT and
SLOW as well as this section.
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OPERATING FEATURES FOR ALL FACILITIES
K46

Utilities shall comply with Section 9.1. 32.2.5.1, 33.2.5.1

K147

The administration of every resident board and care facility shall have
in effect and available to all supervisory personnel written copies of a
plan for protecting all persons in the event of fire, for keeping
persons in place, for evacuating persons to areas of refuge, and for
evacuating person from the building when necessary. The plan shall
include special staff response, including fire protection procedures
needed to ensure the safety of any resident, and shall be amended or
revised whenever any resident with unusual needs is admitted to the
home. All employees shall be periodically instructed and kept
informed with respect to their duties and responsibilities under the
plan. Such instruction shall be reviewed by the staff not less than
every 2 months. A copy of the plan shall be readily available at all
times within the facility. 32.7.1, 33.7.1

K148

Smoking regulations shall be adopted by the administration of board
and care occupancies. 32.7.4.1, 33.7.4.1

K149

Where smoking is permitted, noncombustible safety type ashtrays or
receptacles shall be provided in convenient locations. 32.7.4.2, 33.7.4.2

K150

New draperies, curtains, and other similar loosely hanging furnishings
and decorations in board and care facilities shall be in accordance
with provisions of 10.3.1. 32.7.5.1, 33.7.5.1

K151

New upholstered furniture within board and care facilities shall be
tested in accordance with the provisions of 10.3.2(1) and 10.3.3.
❑ Exception: Upholstered furniture belonging to the resident in
sleeping rooms, provided that a smoke alarm is installed in such
rooms. Battery-powered single-station smoke alarms shall be
permitted. 32.7.5.2, 33.7.5.2

K152

CFR-42-483.470(i) Evacuation Drills
(1) The facility must hold evacuation drills at least quarterly for each
shift of personnel and under varied conditions to –
❑ (i) Ensure that all personnel on all shifts are trained to per
form assigned tasks:
❑ (ii) Ensure that all personnel on all shifts are familiar with the
use of the facility’s emergency and disaster plans and procedures.

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(2) The facility must –
❑ (i) Actually evacuate clients during at least one drill each
year on each shift;
❑ (ii) Make special provisions for the evacuation of clients with
physical disabilities:
❑ (iii) File a report and evaluation on each drill:
❑ (iv) Investigate all problems with evacuation drills, including
accidents and take corrective action: and
❑ (v) During fire drills, clients may be evacuated to a safe area
in facilities certified under the Health Care Occupancies
Chapter of the Life Safety Code.
(3) Facilities must meet the requirements of paragraphs (i) (1) and
(2) of this section for any live-in and relief staff that they utilize.

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DATE OF PLAN
APPROVAL

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

16
17

SELECT NUMBER OF FORM USED FROM ABOVE

2000 NEW

2786U

14
15

(COMP. WITH
ALL PROVISIONS)

A1.

(ACCEPTABLE POC)

A2.

Form CMS-2786V (xx/xx) Previous Versions Obsolete

* MANDATORY

B.

A.

7 PROMPT
8 SLOW
9 IMPRACTICAL

K5:

BUILDING
WING
FLOOR
APARTMENT UNIT

(FSES)

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

PARTIALLY SPRINKLERED

B.

A4.

e.g. 2.5

ENTER E – SCORE HERE

K8:

FULLY SPRINKLERED

K0180

4 PROMPT
5 SLOW
6 IMPRACTICAL

1 PROMPT
2 SLOW
3 IMPRACTICAL

(16 BEDS OR LESS)

APARTMENT HOUSE

K8:

LARGE

K8:

SMALL

(WAIVERS)

A3.

____________

A
B
C
D

* K4

SURVEY DATE

NONE

Page 26

(No sprinkler system)

C.

(PERFORMANCE
BASED DESIGN)

A5.

COMPLETE IF ICF/MR IS SURVEYED UNDER CHAPTER 21

FACILITY MEETS LSC BASED ON (Check all that apply)

K56:

FACILITY DOES NOT MEET LSC

*K9:

K29:

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

* K7

NUMBER OF THIS BUILDING

ASC Form
2000 EXISTING

12
13

MULTIPLE CONSTRUCTION

TOTAL NUMBER OF BUILDINGS ____________

K3

FACILITY NAME

Health Care Form
2786R
2000 EXISTING
2786R
2000 NEW

LSC FORM INDICATOR

K6

K1

PROVIDER NUMBER

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