CMS-2786X FSES - ICFs/MR Worksheet for Rating Residents

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
APARTMENT HOUSE

Form Approved
OMB No. 0938-0242

1. (A) PROVIDER NO.

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

K1

K2

PART I — 32 or 33 — Residential Board & Care Occupancies — Requirements
PART II — 7.7 (101A, 2001) — Fire Safety Evaluation System for Board & Care (Optional)
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.

(All required areas are sprinklered)

A. BUILDING ________________
B. WING

________________

C. FLOOR

________________

4. DATE OF SURVEY

DATE OF PLAN APPROVAL

Sprinklered
■ Partially
(Not all required areas are sprinklered)

C.

■ None (No sprinkler system)

SURVEY UNDER:
9.

K4

E-Score
≤ 1.5

B.

K0180

K3

E-SCORE

■ Fully Sprinklered

K6

Level of Evacuation Difficulty
Prompt

> 1.5 ≤ 5.0

■ Chapter 32 New

■ Chapter 33 Existing

K7

5. SURVEY FOR CERTIFICATION OF: APARTMENT HOUSE LEVEL OF EVACUATION DIFFICULTY (check one)

Slow

> 5.0

■ 2000

7.

■ Prompt

8.

■

Slow

9.

■

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

e. NUMBER OF ICF/MR BEDS
CERTIFIED FOR MEDICAID

7. A.

4.

■

FSES

5.

■

PERFORMANCE BASED DESIGN

K9

SURVEYOR (Signature)

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.
FORM CMS-2786X (xx/xx) Previous Versions Obsolete

Page 1

INSTRUCTIONS FOR COMPLETING THIS FORM (CMS-2786X)
SUITABILITY OF AN APARTMENT BUILDING TO HOUSE A BOARD AND CARE OCCUPANCY

1. FIRST complete FORM CMS-2786Y (Small Facility Survey Report)
2. NEXT complete THIS form, to rate the suitability of the Apartment Building to House a Board and Care Occupancy.
NOTE: The items on this form refer to the part of the building the Board and Care Occupancy (Apartment).
3. If using NFPA 101A Figure 7.7 — FSES/BC — Rating the Building, complete Part I of this form FIRST.
NOTE: When using this form, you must also complete a CMS 2786Y.

FORM CMS-2786X (xx/xx) Previous Versions Obsolete

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ID
PREFIX

SUITABILITY OF AN APARTMENT BUILDING TO HOUSE
A BOARD AND CARE OCCUPANCY

MET

NOT
MET

N/A

REMARKS

APARTMENT
HOUSE

NOTE: You must complete a CMS-2786Y for each Apartment
unit with a Board & Care Occupancy.
BUILDING CONSTRUCTION
K12

Minimum Construction Requirements: (Based on highest story normally
used by residents) PROMPT and SLOW
One and Two Story
❑ Any construction type of one-hour or greater fire rating or,
❑ Type IV (2HH) or,
❑ Fully sheathed or,
❑ With automatic sprinkler system throughout, in accordance
with Section 9.6 and 9.7.
❑ Exception: One story any construction type and no more than
30 residents capable of prompt evacuation.
Three to Six Stories
❑ Type I, II or III construction of one-hour or greater fire rating or,
❑ Type IV construction with automatic sprinkler system throughout
in accordance with Section 9.6 or 9.7.
❑ Exception: Three or four story facilities of type V (000), sheathed
and with automatic sprinkler system throughout, in accordance
with Sections 9.6 and 9.7.
More than Six Stories
❑ Type I or II (222) construction or,
❑ Type II (111) construction or,
❑ Type III (211) construction or,
❑ Type IV (2HH) with automatic sprinkler system throughout in
accordance with Sections 9.6 and 9.7.
Minimum Construction Requirements: (Based on highest story normally
used by residents) PROMPT and SLOW
❑ Type I or II (222) construction, beyond 75 feet in height with
automatic sprinkler protection throughout in accordance with
Section 9.6 and 9.7.
❑ Type II (111) construction, limited to three stories with automatic
sprinkler protection throughout in accordance with Sections 9.6
and 9.7
❑ Type II (000), III (211), IV (2HH), V (111) limited to one story
with automatic sprinkler protection throughout in accordance with
Section 9.6 and 9.7. 32.3.1.3, 33.3.1.3

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PREFIX

SUITABILITY OF AN APARTMENT BUILDING TO HOUSE
A BOARD AND CARE OCCUPANCY

MET

NOT
MET

N/A

REMARKS

APARTMENT
HOUSE

HAZARDOUS AREAS (Outside B & C Units)
K29

Where buildings are without suppression or detection systems, or have
total automatic detection or partial sprinkler protection every hazardous
area shall be separated by construction of one-hour fire rating. Openings
shall be protected by smoke-actuated automatic or self-closing fire doors,
with a 3/4 hour fire rating or the area is equipped with an automatic
sprinkler system.
Hazardous areas include, but are not limited to:
❑ Boiler and heater rooms
❑ Laundries
❑ Repair shop
❑ Rooms or spaces used for storage of combustibles or equipment
deemed hazardous by the authority having jurisdiction.
Where buildings have an automatic extinguishment system installed in
accordance with NFPA 13, areas may be smoke-resisting construction.
30.3.2, 31.3.2, 8.4

K211

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 483.470

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K211

SUITABILITY OF AN APARTMENT BUILDING TO HOUSE
A BOARD AND CARE OCCUPANCY

MET

NOT
MET

N/A

REMARKS

APARTMENT
HOUSE

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
MANUAL FIRE ALARM

K51

Apartment buildings with more than three stories or more than eleven
units shall have a fire alarm system, not a presignal type, with occupant
notification accomplished automatically and without delay in accordance
with Section 9.6, 30.3.4, 31.3.4.
An annunciator panel shall be provided.
31.3.4.3.2.

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 untilt e fire
alarm system has been returned to service. 9.6.1.8
SMOKE DETECTION AND ALARM (Outside B & C)

K109

Every living unit within the apartment building regardless of number of
stories, number of apartments, sprinkler system or other detection system
shall have approved single or multiple station smoke detectors installed,
powered by house electrical service.
❑ Exception: Where the building is equipped with a total automatic
smoke detection system throughout.
30.3.5, 31.3.4.4

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PREFIX

SUITABILITY OF AN APARTMENT BUILDING TO HOUSE
A BOARD AND CARE OCCUPANCY

MET

NOT
MET

N/A

REMARKS

APARTMENT
HOUSE

AUTOMATIC SPRINKLER (Outside B & C)
K56

Where buildings are required to be protected throughout by an approved
automatic sprinkler system and where a partial system is required, the
system shall be in accordance with Section 9.7.
30.3.5

K64

Portable fire extinguishers shall be provided in hazardous areas in
accordance with Section 9.7.4.1 unless the building is provided with an
appropriate supervised automatic sprinkler system.
30.3.5.7

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.)
SEPARATION OF B. C. UNIT AND ITS EXIT ROUTES

K38

2000 EXISTING
Exit access corridors shall be protected as follows:
❑ 1. Where buildings do not have an automatic sprinkler or detection
system, corridor walls shall have one-hour fire rating.
❑ 2. Where buildings have a partial sprinkler or detection system,
corridor walls shall have 3/4 hour fire rating.
❑ 3. Where buildings have an automatic sprinkler system through,
corridor walls shall have 1/2 hour fire ratings.
31.3.6

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PREFIX

SUITABILITY OF AN APARTMENT BUILDING TO HOUSE
A BOARD AND CARE OCCUPANCY

MET

NOT
MET

N/A

REMARKS

APARTMENT
HOUSE

2000 New
Exit access corridor walls shall consist of fire barriers in accordance with
8.2.3 that have no less than 1/2 hour fire resistance rating.
Exception: In buildings protected throughout by an approved automatic
sprinkler system in accordance with 29.3.5, no fire resistance rating shall
be required, but the walls and all openings therein shall resist the passage
of smoke.
30.3.6, 32.4.2, 31.3.6
K18

Doors between apartments and corridors shall be self-closing and have a
minimum 20 minute fire rating. 30.3.6.2, 31.3.6.2
EXIT SYSTEM

K32

At least two acceptable exits, remote from each other, are provided for
each floor or fire section. At least half of the required number of units of
exit width shall lead directly to the street.
❑ Exception No. 1: A living unit with direct exit to street at ground level
or an outside stairway or an enclosed stairway, of one hour fire rating,
serving that unit only, may have a single exit.
❑ Exception No. 2: Where there are a maximum of four living units per
floor with no more than 20 feet from each unit’s entrance door to an
exit, may have a single exit of a smokeproof tower or outside stair in
accordance with 5.2.3.
❑ Exception No. 3: Where there is no more than three stories and living
units are separated, vertically and horizontally by 3/4 hour fire rating,
may have a single exit if the stairway is of one hour construction,
serving as access with a maximum of 35 feet from each unit’s
entrance door to exit.
7.3, 30.2.4, 31.2.4, 32.3.2.4

K35

Capacity of exits in number of persons per unit of exit width is in
accordance with 7.3.
30.2.3.1, 31.2.3.1
EXIT ACCESS

K36

Travel distance from the door of a room in a living unit to a corridor door
and a living unit entrance door to the nearest exit are in accordance with
Table A.31.1.
30.2.6.

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PREFIX

SUITABILITY OF AN APARTMENT BUILDING TO HOUSE
A BOARD AND CARE OCCUPANCY

MET

NOT
MET

N/A

REMARKS

APARTMENT
HOUSE

INTERIOR FINISH
K14

Interior finish on walls, ceilings and floors are in accordance with and
shall apply to the parts of means of egress serving the apartments used as
a residential board and care occupancy.
30.3.3, 31.3.3.
VERTICAL OPENINGS

K20

Stairways, elevator shafts and other vertical openings are in accordance
with 30.3.1, 29.3.1, 31.3.1
SMOKE CONTROL

K24

Exit access corridors shall be provided with smoke barriers in accordance
with Section 8.3. The maximum length of each smoke compartment shall
be 200 feet. Smoke dampers are not required.
❑ Exception No. 1: Where buildings have an automatic sprinkler
system throughout.
❑ Exception No. 2: Where exit access is through an atrium 8.2.5.6.
❑ Exception No. 3: Where exterior exit access provides access to
two exits 7.5.3.
❑ Exception No. 4: Buildings complying with 31.3.7, Exceptions 1,2,
and 3.
❑ Exception No. 5: Buildings with exits maximum 50 feet apart.
❑ Exception No. 6: Where each dwelling unit has direct access to
exterior at grade. 31.3.7, 33.4.3.3.

K44

Horizontal exits required to limit maximum gross area shall be as
specified in 7.2.4.2.
31.2.2.5
SPECIAL FEATURES

K126

Where buildings are greater than six stories with 1 total automatic fire
detection system per N.F.P.A. 72E, but without an automatic sprinkler
system, the interior exit access corridors shall be continuously pressurized
at a minimum of 0.01 inches water, measured at any living unit door.
31.2.11, 7.2.3

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PREFIX

SUITABILITY OF AN APARTMENT BUILDING TO HOUSE
A BOARD AND CARE OCCUPANCY

MET

NOT
MET

N/A

REMARKS

APARTMENT
HOUSE

BUILDING SERVICES EQUIPMENT
K117

Utilities shall comply with provision of Section 9.1.
32.3.6.1, 33.3.6.1.

K67

Heating, ventilating and air conditioning equipment shall comply with
the provisions of Section 9.2.
32.3.6.2, 33.3.6.2

K118

Elevators, dumbwaiters and vertical conveyors shall comply with the
provisions of Section 9.4.
32.3.6.3, 32.3.6.3.2, 33.3.6.3

K71

Rubbish chutes, incinerators and laundry chutes shall comply with the
provisions of Section 9.5.
32.3.6.4, 33.3.6.4
OPERATING FEATURES

K127

Every required automatic sprinkler system, fire detection and alarm
system, smoke control system, exit lighting, fire door and other item of
equipment required by this code shall be continuously maintained in
proper operating condition.
4.6.12

K72

No furnishings, decorations or other objects are placed to obstruct exits
or visibility of exits. 7.5.2.2
32.7.5

K73

No furnishings or decorations of an explosive or highly flammable
character are used.
18.7.5.4, 19.7.5.4
EMERGENCY PLAN, FIRE DRILLS

K48

There is a written plan for the protection of all persons and for their
evacuation in the event of an emergency. All employees shall be instructed
and reviewed as to their duties and responsibilities under the plan.
32.7.1, 33.7.1

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K128

SUITABILITY OF AN APARTMENT BUILDING TO HOUSE
A BOARD AND CARE OCCUPANCY

MET

NOT
MET

N/A

REMARKS

APARTMENT
HOUSE

All residents capable of assisting in their evacuation shall be trained in
the proper actions to take in the event of a fire.
32.7.2, 33.7.2

K50

Fire exit drills shall be conducted twelve times per year, quarterly on each
shift. Drills shall involve actual evacuation to a selected assembly point
and provide experience in exiting through all exits. Exits not used in any
fire drill shall not be credited in meeting the requirements of the code.
42 CFR 483.470 Subpart L

K66

Where smoking is permitted, noncombustible safety-type ash trays or
receptacles shall be provided in convenient locations.
32.7.4, 33.7.4
ILLUMINATION AND EMERGENCY POWER

K45

Every public space, hallway, stairway and other means of egress shall
have illumination in accordance with Section 7.8.
30.2.8, 31.2.8

K46

Any apartment building with more than twelve living units or greater
than three stories shall have emergency lighting in accordance with
Section 7.8.
❑ Exception: Where every living unit has a direct exit to the outside
at grade level.

K47

Signs marking means of egress shall be in accordance with section 7.10
and provided in all apartment buildings requiring more than one exit.
30.2.10, 31.2.10

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Page 10

FIRE SAFETY EVALUATION WORKSHEET FOR AN APARTMENT BUILDING
WITH BOARD AND CARE OCCUPANCIES

G3
Building Identification ____________________________________________________________________________________________________
Evaluator ________________________________________________________________Date ___________________________________________
(Complete one worksheet for each apartment house containing one or more apartment units with a board and care occupancy.)
First complete Table 7.7. Continue with Fig. 7.7.1 through 7.7.5. Then return to this page to obtain the Equivalency Conclusions.
TURN TO NEXT PAGE

Part 3E. Equivalency Conclusions
Complete Tables 7.7.2 through 7.7.7 before doing this part.
1. ❑ All of the checks in Table 7.7.7 are in the “YES” column. The level of fire safety is at least equivalent to that prescribed for apartments.*
2. ❑ One or more of the checks in Table 7.7.7 is 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 for apartments.
*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 the “Facility Fire Safety Requirements Worksheet.” One copy of this separate
worksheet is to be completed for each facility.

FACILITY FIRE SAFETY REQUIREMENTS WORKSHEET
CONSIDERATIONS

MET

NOT
MET

N/A

A. Utilities comply with provisions of 9.1
B. Heating, ventilating, and air conditioning equipment
comply with provisions of 9.2.
C. Elevators, dumbwaiters, and vertical conveyors comply
with the provisions of 9.4.
D. Rubbish chutes, incinerators, and laundry chutes comply
with the provisions of 9.5.
E. Complies with the applicable requires of 32.7, 33.7
(Operating Features).
FORM CMS-2786X (xx/xx) Previous Versions Obsolete

Page 11

0
0
-2(0)k
-2(0)k
-4
Double
Deficiency
-4(-7)b.g
None or
Incomplete
0(2)i

-2( )a
-6( )a
-8( )a
-8
-10

-2( )a
-6( )a
-8( )a
-8( )a
-10

Type III
(200)

0
0
-2(0)k
-2(0)k
-4(0)k

Type IV
(2HH)

Single
Deficiency
0(-4)g

0
0
0
0
-2(0)k

Type III
(211)

Parameter Values
Combustible
0
-5( )a
-6( )a
-6( )a
-8

Type II
(000)

2
2
2
2
2

Type II (222)
& Type I

2
2
2
2
0
None or No
Deficiency
0

Type II
(111)

Noncombustible

Page 12

Manual Alarm
w/o F.D. Notification
w/F.D. Notification
2
3
Interconnected System
Single Station
Corrs. &
Corrs., Common
None or
Living Units Only
Common
Spaces, & Living
Total
Incomplete
Single Level
Every Level
Spaces
Units
Building
-4(0)j
0
-2(0)e
-3(0)3
4
6
None or
Corrs., Public
Living Units
Corrs., Hab., &
Total
Incomplete
Space
Only
Public Spaces
Building
4(0)c
6
8
0
2(0)c
Walls <30 min
Walls>30 min to <1 hr
Walls>1 hr
Doors<20
Doors>20
Doors<20
Doors>20
Doors <20
Doors>20
None or
min w/o
min w/o
min
min
min
min
Incomplete
Closer
Closer
w/Closer
w/Closer
w/Closer
w/Closer
1(-2)b
2(-2)b
1(-2)b
4(-2)b
-6
-2
0(-2)b
Multiple Routes
<2 Standard
Routes
Deficient
w/o Horiz.Exit w/Horiz. Ext Smokeproof Enclosure Direct Exit
-6
-2
0
2
2
4
No Dead End > 50 ft and
Max. Dead End Is
>150 ft
>100 ft
>50 ft
>50 ft or corridor
>100 ft
common path >35 ft >200 ft
to <200 ft
to <150 ft
to <100 ft <50 ft
-1
0
1
2
-6(0)d
-4(0)d
-2
Flame-Spread Rating
>75 to <200
>25 to <75
<25
-1
0
-3

Type V
(111)

Type V
(000)

FORM CMS-2786X (xx/xx) Previous Versions Obsolete

9. Interior Finish (egress
routes serving board &
care home units)

7. Exit System (serving
board & care home
units)
8. Exit Access (serving
board & care home
units)

5. Automatic Sprinklers
(outside board & care
home units)
6. Separation of
Board & Care Home
Unit and Its Exit Route
from Other Spaces

4. Smoke Detection and
Alarm (outside board
& care home units)

3. Manual Fire Alarm

Building Height
1 Story
2 Stories
3-4 Stories
5-6 Stories
Over 6 Stories
2. Hazardous Areas
(outside board &
care home units)

1. Construction

Safety Parameters

WORKSHEET 7.7.2 SAFETY PARAMETER VALUES — APARTMENT BUILDING

Evaluator _________________________________________Date _________________________________

Building Identification ____________________________________________________________________

Fire Safety Evaluation Worksheet for an Apartment Building with Board and Care Occupancies

WORKSHEET 7.7.1 COVER SHEET

Worksheets for evaluating fire safety for an apartment building with board and care occupancies.

Table G-3A

Use ( ) if Parameter 1 is based on Type V(000),
Type III(200), or Type II(000).
Use ( ) if Parameter 7 is -6.
Use ( ) if Parameter 6 is based on “None or Incomplete,”
or “Walls or Doors are 1/2 hour walls /20 minute doors and
Parameter 5 is <4.

c

d
e

Use (2) in 1-3 story buildings with <12 living units.
Use ( ) if Parameter 5 is >6
Use (0) if Parameter 5 is 8.
Use ( ) where exceptions to 31.3.7 (NFPA 101) apply.

i
j
k
l

For SI units: 1 ft = 0.348m.

Use 0 in 1 story building

h

Use ( ) if hazardous area is on exit route or in refuge area
serving group home unit.

g

S1=

S2=

S3=

–: 2 =

–: 2 =

(See note)

Refuge Provided
(S3)

FORM CMS-2786X (xx/xx) Previous Versions Obsolete

NOTE: Use full value if Safety Parameter 1 is based on Type V(000), Type III(200), or Type II(000) construction.
Divide by 2 (–2)
: in all other cases.

Total

11. Smoke Control

10. Vertical Openings

9. Interior Finish

8. Exit Access

–: 2 =

–: 2 =
6. Separation of Living Units
7. Exit system

–: 2 =

–: 2 =
4. Smoke Detection and Alarm

–: 2 =

Egress Provided
(S2)

5. Automatic Sprinklers

–: 2 =

3. Manual Fire Alarm

2. Hazardous Areas

1. Construction

Safety Parameters

Fire Control
(S1)

S4=

General Fire
Safety Provided
(S4)

WORKSHEET 7.7.3 INDIVIDUAL INSERT SAFETY EVALUATIONS — APARTMENT BUILDINGS

Transfer the resulting values for S1, S2, S3 and S4 to Table G-3D.

2. Add the four columns, keeping in mind that any negative numbers deduct.

Page 13

1. Transfer each of the 8 circled safety parameter values from Table G-3A to every unshaded block in the line with the corresponding
safety parameter in Table G-3B. Where the block is indicated (–:2) enter only one half the value shown in Table G-3A.

Part 3B. Complete Individual Safety Evaluations – Use Worksheet 7.7.3

Use ( ) if Parameter 1 is based on Type V(000),
Type III(200), or Type II(000), if Note a does not apply,
and if parameter 5 is <4.

b

>30 min in existing building.

f

Open or Incomplete Enclosure
Enclosedh
Thru 5 or More Floors
3-4 Floors
2 Floors
<1 hr f
>1hr f
-10
-7
-2
0
1(0)b’
Smoke
Mechanically Assisted Systems
None
Barriers
By Zone
By Unit
By Corridor
l
0(2)
2
3
3
4

WORKSHEET 7.7.2 (continued)

NOTES:
a
Use (-1X height in stories) if building is fully sheathed
with plaster, gypsum board, or similar materials but not
<-2 if parameter 5 is 8.

11. Smoke Control
(serving floors having
board & care home units)

10. Vertical Openings

Table G-3A

Prompt/Slow
Impractical
Prompt/Slow
Impractical

2–6 Stories
>6 Stories

12.5
14.5

10.5
14.5

10
11

11.5
13.5

4.5
6.5

3
6

Control
Requirements (Sa)
New
Exist.

6
6

6
6

4.5
4.5

7.5
7.5

7
7

6
6

Egress
Requirements (Sb)
New
Exist.

7
9

9
9

8
5

8
10

5
7

3
6

Refuge
Requirements (Sc)
New
Exist.

11
13

9
13

8
9

Prompt/Slow
Prompt/Slow
Prompt/Slow
Prompt/Slow

1 Story
2 Stories
3–6 Stories
>6 Stories

8.5

6.5

2.5

5

Control
Requirements (Sa)

11

11

8

10

Egress
Requirements (Sb)

9

7

3

5

Refuge
Requirements (Sc)

Prompt/Slow
Prompt/Slow

2 Stories
3–6 Stories

6.5

4.5

4
5

Control
Requirements (Sa)

11

7

6
6

Egress
Requirements (Sb)

7

3

2
3

Refuge
Requirements (Sc)

Prompt/Slow/Impractical
Prompt/Slow
Impractical
Prompt/Slow
Impractical
Prompt/Slow
Impractical

1 Story
2 Stories
3–6 Stories
>6 Stories

12.5
14.5

10.5
14.5

10.5
12.5

FORM CMS-2786X (xx/xx) Previous Versions Obsolete

9

Control
Requirements (Sa)

(For use with NFPA 101A-2001/NFPA 101-2000, B& C Apts.)

Level of Evacuation
Difficulty
Building Height

6
6

6
6

6
6

4.5

Egress
Requirements (Sb)

7
9

9
9

5
7

3

Refuge
Requirements (Sc)

11
13

9
13

9
11

7

Page 14

General Fire Safety
Requirements (Sd)

13

7

6
7

General Fire Safety
Requirements (Sd)

WORKSHEET 7.7.4D MANDATORY REQUIREMENTS — NEW FACILITIES
LOCATED IN EXISTING NONSPRINKLERED APARTMENT BUILDINGS

Prompt <30 residents
Prompt >30 residents or slow

Level of Evacuation
Difficulty

1 Story

Building Height

15

13

7

11

General Fire Safety
Requirements (Sd)

WORKSHEET 7.7.4C MANDATORY REQUIREMENTS — NEW FACILITIES
LOCATED IN EXISTING NONSPRINKLERED APARTMENT BUILDINGS

Level of Evacuation
Difficulty

Building Height

10
14

8
10

6
9

General Fire Safety
Requirements (Sd)
New
Exist.

WORKSHEET 7.7.4B MANDATORY REQUIREMENTS — NEW NONSPRINKLERED
APARTMENT BUILDINGS MEETING EXCEPTION TO 30.3.5.2 (NFPA 101)

Prompt/Slow
Impractical

1 Story

Building Height

Level of Evacuation
Difficulty

WORKSHEET 7.7.4A MANDATORY REQUIREMENTS — SPRINKLERED
AND NONSPRINKLERED APARTMENT BUILDINGS

2. Transfer the circled values from Table 7.74A to the blocks marked for Sa, Sb, Sc and Sd to Table G-3D.

1. Using the level of requirement based on evacuation capability (see 21-1.3) to select the proper row of Figure 7.7.4.
Circle the appropriate values.

Determine Mandatory Requirements — Use Figure 7.7.4

minus
minus

minus

Egress
Provided (S2)
Refuge
Provided (S3)
General
Fire Safety (S4)

Required General
Fire Safety (Sd)

Required
Refuge (Sc)

Required
Egress (Sb)

Required
Control (Sa)

>

>

>

>

0

0

0

0

S4

S3

S2

S1

–

–

–

–

Sd

Sc

Sb

Sa

=

=

=

=

Heating, ventilating, and air conditioning equipment comply with the provisions of 32.3.6.2
and 33.3.6.2, except for enclosure of vertical openings, which have been considered in Safety
Parameter 10 of Worksheet 7.7.2.
Elevators, dumbwaiters, and vertical conveyors comply with the provisions of 32.3.6.3
and 33.3.6.3.
Rubbish chutes, incinerators, and laundry chutes comply with the provisions of 32.3.6.4
and 33.3.6.5.
Complies with the applicable requirements of Sections 32.7 and 33.7.

B.

D.

E.

MET

NOT
MET

N/A

NO

FORM CMS-2786X (xx/xx) Previous Versions Obsolete

Page 15

*The equivalency covered by this worksheet includes the majority of considerations covered by NFPA 101, Life Safety Code.
There are some considerations that are not evaluated by this method. These must be considered separately. These additional
considerations are covered in Worksheet 7.7.6, “Facility Fire Safety Requirements Worksheet.” One copy of this worksheet is
to be completed for each facility.

2. ❑ One or more of the checks in Worksheet 7.7.5 are in the “NO” column. The level of fire safety is not shown by this
system to be equivalent to that prescribed by NFPA 101 for apartments to house board and care occupancy.

1. ❑ All of the checks in Worksheet 7.7.5 are in the “YES” column. The level of fire safety is at least equivalent to that
prescribed by NFPA 101, Life Safety Code, for apartments to house a board and care occupancy.*

WORKSHEET 7.7.7 CONCLUSIONS

All references are to NFPA 101, Life Safety Code

C.

Utilities comply with the provisions of 32.3.6.1 and 33.3.6.1.

A.

CONSIDERATIONS

WORKSHEET 7.7.6 FACILITY FIRE SAFETY REQUIREMENTS WORKSHEET

minus

Control
Provided (S1)

YES

2. 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.

1. Perform the indicated subtractions in Table G-2D. Enter the differences in the appropriate answer blocks.

WORKSHEET 7.7.5 EQUIVALENCY EVALUATION

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-2786X (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 16

(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)