CMS-2786Y FSES - Part III Chapter 7-101A - Board Care

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 FSES

Form Approved
OMB No. 0938-0242

1. (A) PROVIDER NO.

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

K1

K2

PART III — Chapter 7-101A 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. (A) MULTIPLE CONSTRUCTION (BLDGS)

2. NAME OF FACILITY

2. (B) ADDRESS OF FACILITY (STREET, CITY, STATE, ZIP CODE) A.

(All required areas are sprinklered)

A. BUILDING ________________
B. WING

________________

C. FLOOR

________________

■ MEDICARE
E-SCORE

■

4. DATE OF SURVEY

DATE OF PLAN APPROVAL

Sprinklered
■ Partially
(Not all required areas are sprinklered)

C.

■ None (No sprinkler system)

K4

K6

SURVEY UNDER:
5.

MEDICAID
E-Score
≤ 1.5

B.

K0180

K3

3. SURVEY FOR

■ Fully 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

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-2786Y (03/04) Previous Versions Obsolete

Page 1

Fire Safety Evaluation Worksheet for a
Small Facility

Facility Identification ___________________________________________________________________________________
Evaluator _________________________________________

Date __________________________________________

(Complete one worksheet for each individual residence or apartment used as a board and care home. A small facility normally means a capacity for 16 or fewer residents.)
First complete Worksheet 7.3.1. Continue with Worksheets 7.3.3, 7.3.4, 7.3.5 and 7.3.6. Then return to this page to obtain the Equivalency Conclusions.

TURN TO NEXT PAGE

Part 1E. Equivalency Conclusions.
Complete Worksheets 7.3.1 through 7.3.6 before doing this part.
1. ■ All of the checks in Worksheet 7.3.7 are in the “YES” column. The level of fire safety is at least equivalent to that prescribed by the Life Safety Code.*
2. ■ One or more of the checks in Worksheet 7.3.7 is in the “NO” column. The level of fire safety is not shown by this system to be equivalent to that prescribed
for small dwelling units.
* 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.

Form CMS-2786Y (03/04) Previous Versions Obsolete

Page 2

-4

-7

0

-1

-2

w/ Alt.
Means

-3

-4

<2 Remote Routes
w/o Alt.
Means

0

2 Remote
Routes

-1

0

w/ Alt.
Means

< 2 Remote Routes
w/o Alt
Means

Form CMS-2786Y (03/04) Previous Versions Obsolete

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

2(1)a

1/2 hr
w/ Door
Closer

2(0)b

2 Remote
Routes

3(0)b

Page 3

Direct Exit from
Each Bdrm.

1

Smoke Res.
w/ Door
Closer

0

<25

10

Primary Route Protected

2(0)b

2(0)a

1(0)b

1(0)a

1/2 hr.

1/2 hr
Auto
Closing

2 Remote Routes
Separated

0

Smoke
Resisting

Total Coverage
System
4

2

Quick-Response or
Residential Sprinklers

2 Remote Routes
Unseparated

None or
Incomp.

Primary Route Not Protected

w/ Alt.
Means

-4
0(0)
<2 Remote Routes
w/o Alt.
Means

-6

c

Smoke
Resisting
w/ Closers

-1

-3
Unprotected
Vertical Openings
Smoke
Resisting
w/o Closers

>25 to <75
>75 to <200

None or
Incomp.

8
Flame-Spread Ratings

0

0
w/ F.D. Notification

Protected Vertical Openingsd

Standard Sprinklers

Single Lev. Det./
Limited Warning
0

Protected
1 hr
3
None or No Deficiency

1
Warning to All Bedrooms
Every Lev. Plus
e
Det. in Each Bdrm.
Every Lev. Det.
2
3(4)f

Nonsprinklered

None or
Incomplete
-4

0

w/o F.D. Notification

1
Single Deficiency

0
Double Deficiency
None or Incomplete

Protected
15 min

Exposed Structural
Members

Parameter Values

NOTES:
a
Use ( ) if Parameter 1 is 0 and Parameter 5 is 0.
b
use (0) if Parameter 7 is based on a “none or incomplete” situation.
c
Use (0) if door is 20 minute and has automatic closer.
d
Consider a single level building as having protected vertical openings.
e
Every level detection is permitted to be omitted with a quick-response automatic sprinklers throughout; however,
detection in each bedroom is required.
f
Use (4) in existing buildings if detection in each bedroom and quick-response automatic sprinklers throughout.

Means of
Escape Not
on All
Sleeping
Levels

8. Means
Means of
of Escape Escape on
All Sleeping
Levels

7. Separation of
Sleeping Rooms
(from other levels
and from corridors)

6. Interior Finish

5. Automatic Sprinklers

4. Smoke Detection
and Alarm

3. Manual Fire Alarm

2. Hazardous Areas

1. Construction/
Fire Resistance

Safety Parameters

WORKSHEET 7.3.2 SAFETY PARAMETER VALUES — SMALL FACILITY

Evaluator _________________________________________Date _________________________________

Building Identification ____________________________________________________________________

Fire Safety Evaluation Worksheet for Small Facility

WORKSHEET 7.3.1 COVER SHEET

Figure 7.3 Worksheets for evaluating fire safety in a small facility.

S1=

Slow

S3=

–: 2 =

Refuge
(S3)

9

6

7

4

11

11

a

11(21/2)

9

2

4

2

12

11

7(2)

a

10

5

7

1

Form CMS-2786Y (03/04) Previous Versions Obsolete

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

In existing buildings only, use these mandatory safety requirements if evacuation time is 8 minutes or less or if the
evacuation capability score is 3 or less as determined by Chapter 6.

a

General Fire Safety
Requirements (Sd)
New
Exist.

b

10

9

5(5)

Refuge
Requirements (Sc)
New
Exist.

Use ( ) for small board and care facility conversion serving eight or fewer residents with an evacuation capability rating
of “prompt.”

8

1

2

0

Egress
Requirements (Sb)
New
Exist.

S4=

General
Fire Safety
(S4)

a

Impractical

10

10

Slow
b

10(1/2)

a

Control
Requirements (Sa)
New
Exist.

Prompt

Level of Evacuation
Difficulty

S2=

–: 2 =

(See note)

–: 2 =

Egress
(S2)

WORKSHEET 7.3.4 MANDATORY SAFETY REQUIREMENTS

NOTE: Maximum value of manual fire alarm for means of escape is 1.

Total

8. Means of Escape

7. Separation of Sleeping Rooms

6. Interior Finish

–: 2 =

–: 2 =

4. Smoke Detection and Alarm
5. Automatic Sprinklers

–: 2 =

3. Manual Fire Alarm

2. Hazardous Areas

1. Construction

Safety Parameters

Fire Control
(S1)

WORKSHEET 7.3.3 INDIVIDUAL SAFETY EVALUATIONS — SMALL FACILITY

Figure 7.3 Continued

Page 4

minus

minus

Refuge
Provided (S3)
General
Fire Safety (S4)

>

>

Required General
Fire Safety (Sd)

>

Required
Refuge (Sc)

Required
Egress (Sb)

>

0

0

0

0

S4

S3

S2

–

–

–

–

Sd

Sc

Sb

Sa

=

=

=

=

YES

WORKSHEET 7.3.7 CONCLUSIONS

Complies with the applicable requirements of Sections 32.7 and 33.7. (NFPA 101).

CONSIDERATIONS

MET

NOT
MET

NO

Form CMS-2786Y (03/04) Previous Versions Obsolete

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

* 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 7.3.6, “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 7.3.5 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 small dwelling units.

1. ❑ All of the checks in Worksheet 7.3.5 are in the “YES” column. The level of fire safety is at least equivalent to that
prescribed by NFPA 101, Life Safety Code.*

A.

minus

Egress
Provided (S2)

Required
Control (Sa)

S1

WORKSHEET 7.3.5 EQUIVALENCY EVALUATION

WORKSHEET 7.3.6 FACILITY FIRE SAFETY REQUIREMENTS WORKSHEET

minus

Control
Provided (S1)

Figure 7.3 Continued

Page 5

DATE OF PLAN
APPROVAL

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

14
15

16
17

SELECT NUMBER OF FORM USED FROM ABOVE

ASC Form
2000 EXISTING
2000 NEW

12
13

NUMBER OF THIS BUILDING

(COMP. WITH
ALL PROVISIONS)

A1.

(ACCEPTABLE POC)

A2.

Form CMS-2786Y (03/04) 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 6

(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

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)