CMS-2786W FSES - ICFs/MR - Larger 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

1. (A) PROVIDER NO.

LARGE

Form Approved
OMB No. 0938-0242

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

K1

K2

PART I — Figure 6.8 — A Procedure for Determining Evacuation Capability
PART II — Chapters 32 & 33 — Residential Board & Care Occupancies — Requirements
PART III — Figure 7.5 — Fire Safety Evaluation System for Board & Care (Optional) — CMS-2786T
Identifying information as shown in applicable records. Enter changes, if any, alongside each item, giving date of change.
2. (A) MULTIPLE CONSTRUCTION

2. NAME OF FACILITY

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

A. BUILDING

B.

Sprinklered
■ Partially
(Not all required areas are sprinklered)

C.

■ None (No sprinkler system)

B. WING
C. FLOOR

K0180

K3

4. DATE OF SURVEY

DATE OF PLAN APPROVAL

SURVEY UNDER:

K4

K6

K7

9.

E–Score

E–Score

Level of Evacuation Difficulty

< 1.5
> 1.5 < 5.0
> 5.0

Prompt
Slow
Impractical

■ 2000

■ Chapter 32 New

■ Chapter 33 Existing

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

4. Prompt

6. Impractical

5. Slow

K8

K5

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

7.

Sprinklered
■ Fully
(All required areas are sprinklered)

E. NUMBER OF BEDS
CERTIFIED FOR MEDICAID

A. THE FACILITY MEETS, BASED UPON (CHECK ALL APPROPRIATE BOXES)
1.

■

COMPLIANCE WITH ALL PROVISIONS

2.

■

ACCEPTANCE OF A PLAN OF CORRECTION

4.

■

FSES

5.

■

PERFORMANCE BASED DESIGN

B. THE FACILITY DOES NOT MEET THE STANDARDS
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.
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Page 1

INSTRUCTIONS FOR COMPLETING THE FORM (CMS-2786K)
LARGE FACILITIES — 17 BEDS OR MORE
1. DetermIne the Level of Evacuation Capability of the facility.
2. Transfer the E-Score obtained in Fig. 6.8 of page 1 of this form.
3. Complete either LSC Chapter 32 for (new) or LSC Chapter 33 for (existing) requirements of this form,
or Fig. 7.5 — Rating the Building.
A. If completing Chapter 32 or 33 Requirements:
1. PROMPT OR SLOW - Complete sections for PROMPT and SLOW
2. Impractical - Complete a CMS-2786R (Health Care) or FSES/Health Care (Optional) — see page 13.
B. If completIng the FSES/BC — Chapter 32 or 33 — Rating the Building
1. You MUST also complete the Chapter 32 or 33 requirements. An FSES building evacuation cannot be done
without completing the usual survey form pages for Chapter 32 or 33
2. You may use the FSES/Health Care to evaluate the building (Form CMS-2786T Chapter 4 & Fig. 4.7), but if you
choose to do so, you must use the LSC Survey Report for Health Care (CMS-2786R)

*Figures for FSES/HC are taken from NFPA 101 A 2001 Edition

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Page 2

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" (figure 6.8) 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.)
EVALUATOR'S NAME_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
(if other than Fire Authority Surveyor)
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DATE _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Page 3

score = 0

score = 0

score = 3

score = 6

score = 3

score = 40

score = 20

Yes
Remains at Designated
Location

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

Yes
Chooses and Completes
Back-up Strategy

Yes

score = 0

score = 0

No

No

No

score = 6

score = 4

score = 8

score = 20

Needs Full
Assistance or
Very Slow

score = 0

score = 10

Requires
Considerable
Attention/Might
Not Respond

Needs Full
Assistance
from 2 Staff

Totally Impaired

score = 6

Needs Limited
Assistance

score = 20

Risk of Strong
Resistance

(Without guidance
or advice from staff)

score = 6

Response
Not Probable

Requires
Supervision

score = 30

Needs Limited
Assistance from
2 Staff

score = 6

Partially Impaired

Slow

Risk of Mild
Resistance

Initiates and Completes
Evacuation Promptly

score = 0

Response Probable

score = 1

Follows Instructions

score = 0

Needs at Most
One Staff

score = 0

No Significant Risk

Self-Starting

Minimal Risk

VII. Response to Fire Drills

(Check only one)

VI. Waking
Response to
Alarm

(Check only one)

V. Response to
Instructions

(Check only one)

IV. Need for
Extra Help

(Check only one)

III. Impaired
Consciousness

(Check only one)

II. Impaired
Mobility

(Check only one)

I. Risk of
Resistance

Sum of
These
Three
Scores

Rate the resident on each of the factors below by checking the one circle for each risk factor that best
describes the resident. For the first six factors, write the scores for the circles checked in the appropriate
score boxes in the far right column. For “Response to Fire Drills,” write the three checked scores in the large
circles. Write the sum of the three scores in the large box on the right.

Worksheet 6.8.2 Rating the Resident on the Risk Factors

Page 4

Score
Boxes

Facility __________________________________________________________________________________________
Date ______________________________________________________________________________________
Zone ______________________________________________________________________________________
Write any explanatory remarks here:

Resident’s name___________________________________________________________________________________
Evaluator___________________________________________________________________________________

Worksheet 6.8.1 Cover Sheet

Total

Evac.
Assist.
Score

Evacuation
Assistance Score

Resident’s Name

Worksheet 6.8.4 Resident Scores

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

Evacuation
Assistance Score

Resident’s Name

Notes:

Total

Evacuation
Assistance Score

Compare the numbers in the seven score boxes filled in. Take the highest score from the score boxes
(Worksheet 6.8.2.) and write it in the box at the right.

Page 5

Evac.
Assist.
Score

Worksheet 6.8.3 Determining the Resident’s Overall Need for Assistance

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

Staff Shift Score

Resident’s Name

Staff Availability
Standby or asleep
Immediately available
Immediately available and close by

Alarm Effectiveness

Total

Promptness
of Response
Score

Staff Shift Score

Resident’s Name

Worksheet 6.8.8 Staff Scores

Assured
16
20
20

Total

Not Assured
2
2
10

Worksheet 6.8.7 Promptness of Response Scores

All items must score “Yes” before proceeding.

At least 12 fire drills were conducted during the previous year.
(See 6.5.2.5 and Exception)

All staff members considered in this rating are required to be in the facility when on
duty, except as permitted. (See 6.5.2.4 and Exceptions)

Every staff member considered in this rating can meaningfully participate in the evacuation of each resident. (See 6.5.2.3)

The total available staff at any given time is able to handle the individual evacuation
needs of each resident who is in the facility. (See 6.5.2.2. and Exception)

A protection plan has been promulgated and all staff members considered in this rating
have been trained in its implementation. (See 6.5.2.1)

Page 6

Promptness
of Response
Score

NO

To_____________________________________________

Staff Shift: From_________________________________

YES

Date ___________________________________________

Evaluator ______________________________________

Worksheet 6.8.6 Staff Response and Training

Zone __________________________________________

Facility ________________________________________

Staff Shift Score

Worksheet 6.8.5 Cover Sheet

Score 0.8

Score 1.0

Score 1.0

Any SR One Floor
from Exit

Score 1.2

Any SR Two or More
Floors from Exit

X
=

Prompt
Slow
Impractical

<1.5
>1. to <5.0
>5.0

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

Level of
Evacuation Capability

Evacuation
Capability Score

Evacuation Capability for
this Facility or Zone

Worksheet 6.8.11 Evacuation Capability Score

Page 7

(Go to Worksheet 6.8.11)

Evacuation
Capability Score

Vertical Distance from Sleeping Room
to Exit (Worksheet 6.8.9)

Staff Shift Score
(Worksheet 6.8.8)

Total Resident Evacuation
Assistance Score (Worksheet 6.8.4)

Worksheet 6.8.10 Calculation of Evacuation Capability Score

NOTE: Small facilities have 16 or fewer residents. See 6.6.6 for apartments.

Large Facility or Apartment

Small Facility

All SR on Floors with
Direct Exit

Vertical Distance from Sleeping Rooms to Exits

Worksheet 6.8.9 Rating the Facility

ID
PREFIX

LARGE FACILITY
PROMPT AND SLOW EVACUATION CAPABILITIES

MET NOT N/A
MET

REMARKS

LARGE
PROMPT & SLOW

BUILDING CONSTRUCTION (NEW & EXISTING)
K12

Minimum Construction Requirements: Based on highest story
normally used by residents
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 32.3.3.5, 33.3.3.5.
■ Exception:
One story any construction type and no more than 30
residents capable of prompt evacuation.
Three to Six Stories
■ Type I, II or Ill construction of one-hour or greater fire
resistance rating, or
■ Type IV construction with automatic sprinkler system
throughout in accordance with 32.3.3.5 or 33.3.3.5.
■ Exception:
Three or four story facilities of Type V (000), sheathed and
with automatic sprinkler system throughout, in accordance
with 32.3.3.5, 33.3.3.5.
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 32.3.3.5, 33.3.3.5.
32.3.1.3, 33.1.3.1
OCCUPANT LOAD
■ Not less than two exits shall be accessible from every floor and
in at least two different directions.
The occupant load, in number of persons for who means of
egress and other provisions are required, shall be determined
on the basis of the occupant load factors or Table 7.3.1.2 that
are characteristic of the use of the space or shall be determined
as the maximum probable population of the space under
consideration, whichever is greater.
33.3.1.4, 32.3.1.4

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ID
PREFIX

LARGE FACILITY
PROMPT AND SLOW EVACUATION CAPABILITIES

MET NOT N/A
MET

REMARKS

LARGE
PROMPT & SLOW

HAZARDOUS AREAS
K124

Any room containing high-pressure boilers, refrigerating machinery,
transformers, or other service equipment subject to possible
explosion shall not be located under or adjacent to exits.
All such rooms shall be effectively separated from other parts of
the building as specified in section 8.4.

K29

32.3.3.2.1, 33.3.2.1
All hazardous areas shall be separated with construction of a
minimum of one-hour fire resistance or automatic extinguishment
system with openings protected with self-closing fire doors.
■ Exception: Existing buildings may have hazardous areas
separated from other parts of the building by a smoke partition
in accordance with section 8.2.4.
Hazardous areas shall include but not be limited to the following:
boiler or heating rooms, laundries, repair shop, spaces storing
combustibles in quantities deemed hazardous by the authority
having jurisdiction.
32.3.3.2.2, 33.3.3.2.2

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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ID
PREFIX

K211

LARGE FACILITY
PROMPT AND SLOW EVACUATION CAPABILITIES

MET NOT N/A
MET

REMARKS

LARGE
PROMPT & SLOW

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

DETECTION ALARM & COMMUNICATIONS SYSTEMS
K51

A manual fire alarm system with approved component devices or
equipment, shall be installed in accordance with section 9.6.
■ Exception: Where each bedroom has an exterior exit access
in accordance with 7.5.3 and the building is not greater
than three stories.
INITIATION
The required fire alarm system shall be initiated by the
following means:
(1) Manual means in accordance with 9.6.2
■ Exception: A manual means, as specified in 9.6.2, in excess
of the manual fire alarm box at a constantly attended location
per 33.3.3.4.2(2) below shall not be required where there are
other effective means (such as a complete automatic sprinkler
or automatic detection system) for notification of fire as
required.
(2) A manual fire alarm box located at a convenient central control
point under continuous supervision of responsible employees.
(3) The automatic sprinkler system.

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ID
PREFIX

LARGE FACILITY
PROMPT AND SLOW EVACUATION CAPABILITIES

MET NOT N/A
MET

REMARKS

LARGE
PROMPT & SLOW

■ Exception: Automatic sprinkler systems that are not required by
another section of this Code shall not be required to initiate the
fire alarm system.
(4) Any required detection system.
■ Exception: Sleeping room smoke alarms shall not be required
to initiate the building fire alarm system.
32.3.3.4, 33.3.3.4
ANNUNCIATOR PANEL
■ An annunciator panel connected with the fire alarm system
shall be provided. The location of the annunciator shall be
approved by the authority having jurisdiction.
■ Exception: Buildings not more than two stories in height and
with not more than 50 sleeping rooms.
32.3.3.4.3
OCCUPANT NOTIFICATION
2000 EXISTING
■ Occupant notification shall be provided automatically, without
delay, by internal audible alarm in accordance with 9.6.3.
33.3.3.4.4
2000 NEW
■ Occupant notification shall be provided automatically, without
delay, in accordance with 9.6.3.
32.3.3.4.4
FIRE DEPARTMENT NOTIFICATION
■ In case of a fire, provisions shall be made for the immediate
notification of the public fire department by either telephone
or other means. Where there is no public fire department, this
notification shall be made to the private fire brigade.
32.3.3.4.6, 33.3.3.4.6
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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ID
PREFIX

LARGE FACILITY
PROMPT AND SLOW EVACUATION CAPABILITIES

MET NOT N/A
MET

REMARKS

LARGE
PROMPT & SLOW

SMOKE DETECTION AND ALARM
K109

SMOKE DETECTION
2000 EXISTING
Each sleeping room shall be provided with an approved smoke
alarm in accordance with 9.6.2.10 that is powered from the
building electrical system.
■ Exception No.1: Existing battery-powered smoke alarms, rather
than building electrical service-powered smoke alarms, shall
be accepted where, in the opinion of the authority having
jurisdiction, the facility has demonstrated that testing,
maintenance, and battery replacement programs ensure
the reliability of power to the smoke alarms.
■ Exception No. 2: Facilities having an existing corridor smoke
detection system in accordance with Section 9.6 that is
connected to the building fire alarm system.
33.3.3.4.7
2000 NEW
Each sleeping room shall be provided with an approved smoke
alarm in accordance with 9.6.2.10 that is powered from the
building electrical system.
32.3.3.4.7
■ All living areas as defined in 3.3.119 and corridors shall be
provided with smoke detectors in accordance NFPA 72,
National Fire Alarm Code, that are arranged to initiate an
alarm that is audible in all sleeping areas.
■ Exception No. 1: Detectors shall not be required in living areas
and kitchens in facilities protected throughout by an approved
automatic sprinkler system installed in accordance with
33.3.3.5.
■ Exception No. 2: Unenclosed corridors, passageways, balconies, colonnades, or other arrangements with one or more
sides along the long dimension fully or extensively open to the
exterior at all times.
32.3.3.4.8, 33.3.3.4.8

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ID
PREFIX

LARGE FACILITY
PROMPT AND SLOW EVACUATION CAPABILITIES

MET

NOT
N/A
MET

REMARKS

LARGE
PROMPT & SLOW

AUTOMATIC SPRINKLERS
K56

2000 EXISTING
Where an automatic sprinkler system is installed for total or
partial building coverage, the system shall be in accordance
with Section 9.7.
■ Exception No. 1: In buildings not more than four stories in
height, a sprinkler system complying 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. 2: Automatic sprinklers shall not be required in
small clothes closets where the smallest dimension does not
exceed 3 ft (0.9m), the area does not exceed 24f 2 (2.2m 2),
and the walls and ceilings are finished with noncombustible or
limited-combustible material.
■ Exception No. 3: Initiation of the fire alarm system shall not be
required for existing installations in accordance with 33.3.3.5.4.
Automatic sprinkler systems shall be supervised in accordance
with Section 9.7. Waterflow alarms shall not be required to be
transmitted off-site.
Sprinkler piping serving not more than six sprinklers for any
isolated hazardous area in accordance with 9.7.1.2 shall be
permitted. In new installations where more than two sprinklers
are installed in a single area, waterflow detection shall be
provided to initiate the fire alarm system required by 33.3.3.4.1.
33.3.3.5.1, 33.3.3.5.2, 33.3.3.5.3, 33.3.3.5.4
2000 NEW
All buildings shall be protected throughout by an approved
automatic sprinkler system in accordance with Section 9.7.
Quick-response or residential sprinklers shall be provided
throughout.
■ Exception No. 1: In buildings not more than four stories in
height, a sprinkler system complying with NFPA 13R,
Standard for the Installation of Sprinkler Systems in Residential
Occupancies up to and Including Four Stories in Height, shall
be permitted

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ID
PREFIX

LARGE FACILITY
PROMPT AND SLOW EVACUATION CAPABILITIES

MET

NOT
N/A
MET

REMARKS

LARGE
PROMPT & SLOW

■ Exception No. 2: Automatic sprinklers shall not be required in
small clothes closets where the smallest dimension does not
exceed 24 ft2 (2.2m2), and the walls and ceilings are finished
with noncombustible or limited-combustible materials.
■ Exception No. 3: Standard response sprinklers shall be permitted
for use in hazardous areas in accordance with 32.3.3.2.
Automatic sprinkler systems shall be supervised in accordance
with Section 9.7.
32.3.3.5.1, 32.3.3.5.3
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.)

PORTABLE FIRE EXTINGUISHERS
K64

Portable fire extinguishers shall be provided near hazardous
areas in accordance with 9.7.4.1.
33.3.3.5.5, 32.3.3.5.5

SEPARATION OF SLEEPING ROOMS FROM EXIT ACCESS
K17

2000 EXISTING
Access shall be provided from every resident use area to not less
than one means of egress that is separated from all other rooms
or spaces by walls complying with 33.3.3.6.3 through 33.3.3.6.6.

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ID
PREFIX

LARGE FACILITY
PROMPT AND SLOW EVACUATION CAPABILITIES

MET NOT N/A
MET

REMARKS

LARGE
PROMPT & SLOW

■ Exception No. 1: Rooms or spaces, other than sleeping rooms,
protected throughout by an approved automatic sprinkler
system in accordance with 33.3.3.5.
■ Exception No. 2: Prompt evacuation capability facilities in
buildings not over two stories in height where not less than one
required means of egress from each sleeping room provides a
path of travel to the outside without traversing any corridor or
other spaces exposed to unprotected vertical openings, living
areas, and kitchens.
■ Exception No. 3: Rooms or spaces, other than sleeping rooms,
provided with a smoke detection and alarm system connected
to activate the building evacuation alarm. Furnishings, finishes,
and furniture, in combination with all other combustibles within
the spaces, shall be of minimum quantity and arranged so that
a fully developed fire is unlikely to occur.
Sleeping rooms shall be separated from corridors, living areas,
and kitchens by walls complying with 33.3.3.6.3 through
33.3.3.6.6.
Walls required by 33.3.3.6.1 or 33.3.3.6.2 shall have a fire
resistance rating of not less than 1/2 hour.
■ Exception No. 1: In buildings protected throughout by an
approved automatic sprinkler system in accordance with
33.3.35, walls shall be smoke partitions in accordance with
8.2.4. The provisions of 8.2.4.3.5 shall not apply.
■ Exception No. 2: In buildings not more than two stories in height
that are classified as prompt evacuation capability and that
house not more than 30 residents, walls shall be smoke
partitions in accordance with 8.2.4. The provisions of 8.2.4.3.5
shall not apply.
Doors in walls required by 33.3.3.6.1 or 33.3.3.6.2 shall have a
fire protection rating of not less than 20 minutes.
■ Exception No. 1: Solid-bonded wood core doors of not less than
13/4 in. (4.4cm) thickness shall be permitted to continue to be used.
■ Exception No. 2: In buildings protected throughout by an
approved automatic sprinkler system in accordance with
33.3.3.5, doors that are nonrated shall be permitted to
continue to be used.
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ID
PREFIX

LARGE FACILITY
PROMPT AND SLOW EVACUATION CAPABILITIES

MET NOT N/A
MET

REMARKS

LARGE
PROMPT & SLOW

■ Exception No. 3: Where automatic sprinkler protection is
provided in the corridor with 31.3.5.2 through 31.3.5.4, doors
shall not be required to have a fire protection rating but shall
be in accordance with 8.2.4.3. The provisions of 8.2.4.3.5 shall
not apply. Doors shall be equipped with latches for keeping the
doors tightly closed.
Walls and doors required by 33.3.3.6.1 and 33.3.3.6.2 shall be
constructed as smoke partitions in accordance with 8.2.4. The
provisions of 8.2.4.3.5 shall not apply. No louvers, transfer grilles,
operable transoms, or other air passages shall penetrate such
walls or doors, except properly installed heating and utility installations.
Doors in walls required by 33.3.3.6.1 and 33.3.3.6.2 shall be
self-closing or automatic-closing in accordance with 7.2.1.8.
Doors in walls separating sleeping rooms from corridors shall be
automatic-closing in accordance with 7.2.1.8.
■ Exception No. 1: Doors to sleeping rooms that have occupantcontrol locks such that access is normally restricted to the occupants or staff personnel shall be permitted to be self-closing.
■ Exception No. 2: In buildings protected throughout by an
approved automatic sprinkler system installed in accordance
with 33.3.3.5, doors, other than doors to hazardous areas,
vertical openings, and exit enclosures, shall not be required to
be self-closing or automatic-closing.
33.3.3.6.6
2000 NEW
Access shall be provided from every resident use area to not
less than one means of egress that is separated from all sleeping
rooms by walls complying with 32.3.3.6.3 through 32.3.3.6.6.
Sleeping rooms shall be separated from corridors, living areas,
and kitchens by walls complying with 32.3.3.6.3 through
32.3.3.6.6.
Walls required by 32.3.3.6.1 or 32.3.3.6.2 shall have a fire
resistance rating of not less than 1/2 hour.
■ Exception: In conversions (see 32.1.1.3), no fire resistance rating
shall be required, but the wall shall be a smoke partition in
accordance with 8.2.4. The provisions of 8.2.4.3.5 shall not apply.
Form CMS-2786W (xx/xx) Previous Versions Obsolete

Page 16

ID
PREFIX

LARGE FACILITY
PROMPT AND SLOW EVACUATION CAPABILITIES

MET

NOT
N/A
MET

REMARKS

LARGE
PROMPT & SLOW

Doors in walls required by 32.3.3.6.1 or 32.3.3.6.2 shall
have a fire protection rating of not less than 20 minutes.
■ Exception: Doors in renovations and conversions (see
32.1.1.3) that are nonrated doors that resist the passage
of smoke shall be permitted to continue to be used.
Doors to hazardous areas, vertical openings, exits, and exit
passageways shall be self-closing or automatic-closing.
32.3.3.6.6
K18

Doors in walls separating sleeping rooms from corridors
shall have a fire protection rating of not less than 20 minutes.
Doors shall be equipped with latches for keeping the doors
tightly closed.
■ Exception No. 1: Existing 13/4 inch solid bonded wood
core doors shall be permitted.
■ Exception No. 2: Where walls are only required to resist
the passage of smoke, doors without fire rating and
which resist the passage of smoke are permitted.
■ Exception No. 3: Where automatic sprinkler protection is
provided in the corridor in accordance with 31.3.5.3
through 31.3.5.4, doors shall not be required to have a
fire protection rating but shall be in accordance with
8.2.4.3. The provisions of 8.2.4.3.5 shall not apply. Doors
shall be equipped with latches for keeping the doors
tightly closed.
32.3.3.6.4, 33.3.3.6.4
Walls and doors required by 32.3.3.6.1 and 32.3.3.6.2. shall
be constructed as smoke partitions in accordance with
8.2.4. The provisions of 8.2.4.3.5 shall not apply. No louvers, transfer grilles, operable transoms, or other air passages shall penetrate such walls or doors, except properly
installed heating and utility installations.
32.3.3.6.5, 33.3.3.6.5

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Page 17

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PREFIX

LARGE FACILITY
PROMPT AND SLOW EVACUATION CAPABILITIES

MET

NOT
N/A
MET

REMARKS

LARGE
PROMPT & SLOW

EXIT SYSTEM
K34

Exits or exit components, arranged in accordance with Chapter 7,
shall be of types in accordance with 32.3.2 or 33.3.2.

K35

Capacity of means of egress shall be in accordance with 7.3.

K38

Access to all required exits shall be in accordance with 7.3.
32.3.2.5.1, 33.3.2.5.1

K43

DOORS
2000 Existing
Doors in means of egress shall be as follows:
(1) Doors complying with 7.2.1 shall be permitted.
(2) Doors within individual rooms and suites of rooms shall be
permitted to be swinging or sliding.
(3) No door in any means of egress shall be locked against
egress when the building is occupied.
■ Exception No. 1: The requirement of 33.3.2.2.2(3) shall not
apply to delayed-egress locks in accordance with 7.2.1.6.1,
provided that not more than one device exists in a means of
egress.
■ Exception No. 2: The requirement of 33.3.2.2.2(3) shall not
apply to access-controlled egress doors in accordance with
7.2.1.6.2.
(4) Revolving doors complying with 7.2.1.10 shall be permitted.
33.3.2.2.2, 32.3.2.2.2
2000 NEW
(5) Every bathroom door shall be designed to allow opening from
the outside during an emergency when locked.
32.3.2.2.2

K32

Not less than two exits shall be accessible from every story,
including floors below the level of exit discharge and floors
occupied from public purposes.
33.3.2.4, 32.3.2.4

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Page 18

ID
PREFIX

LARGE FACILITY
PROMPT AND SLOW EVACUATION CAPABILITIES

MET

NOT
N/A
MET

REMARKS

LARGE
PROMPT & SLOW

The width of corridors shall be sufficient for the occupant load
served but shall be not less than 44 in. (112cm).
■ Exception: Corridors serving an occupant load fewer than 50
shall be not less than 36 in. (91cm) wide.
33.3.2.3.3, 32.3.2.3.3
Stairs complying with 7.2.2 shall be permitted.
33.3.2.2.3, 32.3.2.2.3

ARRANGEMENT OF MEANS OF EGRESS
K40

2000 EXISTING
Common paths of travel shall not exceed 110 ft (33.5m)
■ Exception: In buildings protected throughout by automatic
sprinkler systems in accordance with 33.3.3.5, common path
of travel shall not exceed 160ft (48.8m).
Dead-end corridors shall not exceed 50 ft (15m).
33.3.2.5
2000 NEW
Common paths of travel shall not exceed 125ft (38.1m).
Dead end corridor shall not exceed 50ft (15m).
32.3.2.5.2

SUBDIVISION OF BUILDING SPACES
K120

Every sleeping room floor shall be divided into not less than two
smoke compartments of approximately the same size, with
smoke barriers in accordance with 8.3. Smoke dampers shall not
be required.
Additional smoke barriers shall be provided such that the travel
distance from a sleeping room corridor door to a smoke barrier
shall not exceed 150 ft (45m).
■ Exception No. 1: Buildings protected throughout by an
approved automatic sprinkler system installed in accordance
with 33.3.3.5.
■ Exception No. 2: Where each sleeping room is provided with
exterior ways of exit access arranged in accordance with 7.5.3.

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

Page 19

ID
PREFIX

LARGE FACILITY
IMPRACTICAL EVACUATION

MET

NOT
N/A
MET

REMARKS

LARGE
IMPRACTICAL

■ Exception No. 3: Smoke barriers shall to be required where the
aggregate corridor length on each floor is not more than 150 ft
(45m). 33.3.3.7
K36

2000 EXISTING
Travel distance from the corridor door of any room to nearest exit
shall be a maximum of 100 feet.
33.3.2.6.2
2000 NEW
Travel distance from the corridor door of any room to the nearest
exit, measured in accordance with 7.6, shall not exceed 200 feet
(60m).
32.3.2.6.2
2000 EXISTING
Travel distance from the door or most remote room in a suite or
apartment to the corridor shall not exceed 75 feet (23m).
■ Exception: Travel distance may be 125ft (48m) in building
protected throughout by an approved automatic sprinkler
system in accordance with 33.3.3.5.
33.3.2.6.1
2000 NEW
Travel distance within a room, suite, or living unit to a corridor
door shall not exceed 125 ft (38.1m)
32.3.2.6.1.

INTERIOR FINISH
K14

2000 EXISTING
Interior wall and ceiling finish shall be Class A or Class B in
accordance with Section 10.2. Interior floor finish in accordance
with 10.2.7 shall be Class I or Class II in corridors and exits.
■ Exception: Previously installed floor coverings, subject to the
approval of the authority having jurisdiction.
33.3.3.3

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

Page 20

ID
PREFIX

LARGE FACILITY
IMPRACTICAL EVACUATION

MET

NOT
N/A
MET

REMARKS

LARGE
IMPRACTICAL

2000 NEW
Interior finish shall be in accordance with10.2.
10.2, 32.3.3.3.1.
K15

Interior wall and ceiling finish materials complying with 10.2.3
shall be permitted as follows:
(1) Exit enclosures - Class A
(2) Lobbies and corridors - Class A or Class B
(3) Other spaces - Class A or Class B
32.3.3.3.2

K16

Interior floor finish in corridors and exits shall be class I or II in
accordance with 10.2.7, 32.3.3.3.3.

K20

2000 EXISTING
Any vertical opening shall be enclosed or protected in accordance
with 8.2.5.
■ Exception No. 1: Unprotected vertical openings not part of
required egress shall be permitted to be waived by the
authority having jurisdiction where such openings do not
endanger required means of egress. This exception shall
apply only in buildings protected throughout by an approved
automatic sprinkler system in accordance with 33.3.3.5.1 and
in which exits and required ways of travel thereto are
adequately safeguarded against fire and smoke within the
building, or in which every individual room has direct access
to an exterior exit without passing through a public corridor.
■ Exception No. 2: In buildings not more than two stories in
height, unprotected vertical openings shall be permitted by
the authority having jurisdiction if the building is protected
throughout by an approved automatic sprinkler system in
accordance with 33.3.3.5.1
No floor below the level of exit discharge used only for storage,
heating equipment, or purposes other than residential occupancy
shall have unprotected openings to floors used for residential
occupancy.
32.3.3.1.1, 32.3.3.1.2, 33.3.3.1.1, 33.3.3.1.2

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Page 21

ID
PREFIX

K21

LARGE FACILITY
IMPRACTICAL EVACUATION

MET

NOT
N/A
MET

REMARKS

LARGE
IMPRACTICAL

Building Services
2000 EXISTING
Utilities shall comply with the provisions of 9.1.
Heating, ventilating, and air conditioning equipment shall comply
with the provisions of 9.2.
No stove or combustion heater shall be located to block escape in
case of fire caused by the malfunction of the stove or heater.
Unvented fuel-fired heaters shall not be used in any board and
care occupancy.
Elevators, dumbwaiters, and vertical conveyors shall comply with
the provisions of 9.4.
Rubbish chutes, incinerators, and laundry chutes shall comply with
the provisions of 9.5.
33.3.6.1, 33.3.6.2, 33.3.6.2.1, 33.3.6.2.2, 33.3.6.2.3. 33.3.6.3,
33.3.6.4
2000 NEW
In high-rise buildings, one elevator shall be provided with a
protected power supply and shall be available for use by the fire
department in case of emergency.
32.3.6.1, 32.3.6.2, 32.3.6.2.1, 32.3.6.2.2, 32.3.6.2.3, 32.3.6.3.1,
32.3.6.3.2, 32.3.6.4
Facilities housing groups of persons classed as IMPRACTICAL
TO EVACUATE shall meet the requirements for custodial care
facilities, Chapter 18 or 19 as appropriate.
■ Exception: Facilities found to have equivalent safety. Example
7.5 Using the applicable mandatory safety requirement.
32.3.1.2.2 See CMS-2786R

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

Page 22

Fire Safety Evaluation Worksheet for a Large Facility

Fig. 7.5
Facility Identification ______________________________________________________________________________________________________________
Evaluator______________________________________________________________________Date _____________________________________________
(Complete one worksheet for each large facility. This normally means a capacity for more than 16 residents.)
First complete Fig. 7.5.1. Continue with Fig. 7.5.2, 7.5.3, 7.5.4A, 7.5.4B, 7.5.5. Then return to this page to obtain the Equivalency Conclusions.

TURN TO NEXT PAGE
Part 2E. Equivalency Conclusions
Complete Fig. 7.5.1 through 7.5.5 before doing this part.
1. All of the checks in Fig. 7.5.5 are in the “YES” column. The level of fire safety is at least equivalent to that prescribed for large residentail facilities.*
2. One or more of the checks in Fig. 7.5.5 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 large residential facilities.
*The equivalency covered by this worksheet includes the majority of consideratons covered by the Life Safety Code. There are a few consideratons 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

Not Applicable

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, incineratiors, and laundry chutes comply
with the provisions of 9.5.
E. Complies with the applicable requirements of Sections 32.7
and/or 33.7.
Form CMS-2786W (xx/xx) Previous Versions Obsolete

Page 23

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-2786W (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 24

(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)