Life Safety Codes
LONG-TERM CARE SURVEY MANUAL
PREPARED BY MU NHA CONSULTANT
SECTION 2 - LIFE SAFETY CODES
Life Safety Codes - This section can be used as a reference for possible K-tag citations and
includes checklists for self-assessment.
SECTION
K-Tags and Definitions
Life Safety Code Check List
Fire Safety Survey Worksheet for Rating Residents
(Form CMS-2786M)
Fire Safety Survey Report Medicare-Medicaid
(Form CMS-2786R)
Fire Safety Survey Report Short Form Medicare-Medicaid
(Form CMS-2786S)
Fire/Smoke Zone Evaluation Worksheet for Health
Care Facilities (Form CMS-2786T)
Fire Safety Survey Report - Intermediate Care Facilities for
the Mentally Retarded (Small) (Form CMS-2786V)
Fire Safety Survey Report - Intermediate Care Facilities for
the Mentally Retarded (Large) (Form CMS-2786W)
Updated March 2015
PAGE #
2.2-2.3
2.4-2.6
Appendix 2-A
Appendix 2-B
Appendix 2-C
Appendix 2-D
Appendix 2-E
Appendix 2-F
K-TAGS AND DEFINITIONS
K011
K012
K014
K015
K016
K017
K018
K019
K020
K021
K022
K023
K024
K025
K027
K028
K029
K031
K032
K033
K034
K036
K037
K038
K039
K040
K041
K042
K043
K044
K045
K046
K047
K048
K049
K050
K051
K052
K053
K054
K055
K056
K059
K060
K061
Common Wall
Construction Type
Interior Finish for Corridors
Interior Finish for Rooms
Newly Installed Floor Finish
Corridors Separated with Fire Walls
Construction of Doors
Vision Panels in Corridor Walls
Vertical Openings - Fire Walls
Doors in Fire Separation Walls
Enclosure Doors Serving Exits
Smoke Barriers (at least 2 Smoke compartments)
Smoke Compartments
Smoke Barriers (1/2 Hr Fire Resistance Rating)
Doors in Smoke Barriers (20 Min Fire Protection)
Doors in Smoke Barriers (34 Inches Wide)
Hazardous Areas Separated by Construction
Laboratories Employing Flammable Materials
Two Acceptable Exits Provided on Each Floor
Exit Components - Fire Walls
Stairways and Smoke proof Towers
Travel Distances to Exits
Exit does not have Dead End Exceeding 30 feet
Exit Accessible at all Times
Width of Aisles or Corridors
Exit Access Doors are Swinging Type
Sleeping Rooms have Access to Exits
At Least Two Exits
Keyless Egress
Horizontal Exits
Illumination of Means of Egress
Emergency Lighting One Hour Duration
Exit Signs Display Continuous Illumination
Written Plan - Fire Drill
Evacuation Plan Posted
Fire Drills Held at Unexpected Times
Fire Alarm Sys to Provide Effective Warning
Fire Alarm Tested Monthly
Automatic Smoke Detection Sys
All Smoke Detectors Inspected and Tested
Patient Sleeping Rooms - Outside Windows
Auto Sprinkle System of Standard Approved Type
Automatic Sprinkler - Water Flow Devices
Automatic Sprinkler - Central Fire Alarm
Automatic Sprinkler - Main Control Valve
2.2
K062
K063
K064
K065
K066
K067
K068
K069
K070
K071
K072
K073
K074
K075
K076
K077
K078
K080
K081
K082
K083
K103
K104
K105
K106
K107
K108
K109
K118
K144
K147
Automatic Sprinkler - Maintenance
Automatic Sprinkler - Water Supply
Portable Fire Extinguishers
Maintenance of Fire Extinguishers
Smoking Regulations are Adopted
Air Conditioning and Ventilating Equipment
Combustion and Ventilation Air
Commercial Cooking Equip. Meets Requirements
Fuel Burning Space Heaters
Linen and Trash Chutes
No Objects Placed to Obstruct Exits or Visibility
Nothing of Explosive or Flammable Character Used
Flame Retardant Curtains
Wastebaskets in Patients rooms are Non-Combustible
Nonflammable Medical Gas Systems
Medical Gas Systems
Anesthetizing Areas and Rooms for Storage
Hazardous Areas - Sprinklers
Automatic Fire Detection Devices Installed
Patients Rooms Separated by Construction Fire Resist
Fire Department Response Time is Adequate
Interior Walls of Non-Combustible Materials
Penetrations of Smoke Barriers
Life Support Systems - Egress
Life Support Systems - Electrical
Require Alarm and Detection Systems
Alarms, Emergency Communications Systems
Automatic Smoke Detector
Elevators and Conveyors
Generator Inspection & Load Testing
Electrical Wiring & Equipment
2.3
LIFE SAFETY CODE CHECK LIST
Mechanical Rooms
1. High/low ventilation and combustion ductwork.
2. All ceiling and wall penetration sealed with fire rated caulking.
3. Doors - Self-closing and latch automatically.
4. Not used for storage.
5. Ceiling installed completely.
6. Fire dampers installed at duct penetrations of walls.
7. No grills or vents in doors.
8. Separated with one-hour fire rated construction to roof deck.
Kitchen
1. Doors - Self-closing and latch automatically.
2. Fusible links - On all doors held open.
Laundry
1. Dryers enclosed.
2. High/low ventilation and combustion ductwork behind dryers.
3. Doors - Self-closing and latch automatically.
Soiled Linen Rooms
1. Doors - Self-closing and latch automatically.
2. Soiled linen receptacle capacity greater than 32 gallons - room shall be
separated by one-hour fire rated construction, self-closing automaticallylatching door, and sprinklered.
Oxygen Storage
1. Vented to outside.
2. Storage greater than 3000 cu.ft. - Room separated by one-hour fire rated
construction and self-closing automatically-latching door.
Storage Rooms
1. 50 to 100 sq.ft. - Separated by one-hour fire rated construction and selfclosing automatically-latching door.
2. Greater than 100 sq.ft. - Separated by one-hour fire rated construction, selfclosing automatically-latching door, and sprinklered.
Patient Rooms
1. Window or outside door.
2. Window and cubicle curtains flame retardant.
3. No furnishings and decorations of highly-flammable character.
4. Corridor door closes and latches without impediment, gaps, and against
jamb.
5. No portable space heaters.
6. Class A or B flame spread rating.
Corridors and Exitways
1. Class A or B rating - Walls and ceiling.
2. Continuously maintained free of all obstructions or impediments.
3. Handrails secure and without damage.
4. No items on wall extending out beyond the handrail below seven feet.
Stairways
1. One hour fire rated construction - Up to three stories.
Four stories or more - Two hour fire rated construction.
2. All penetrations sealed.
3. Self-closing automatically-latching doors.
4. No storage.
Exit Lights
1. Illuminated.
2. Signs located to show direction to exit from any point in a corridor - Two
directions.
2.4
3. Illuminated by emergency power within ten seconds of loss of normal
power.
Alcohol-based Hand Rub
1. The corridor is at least six feet wide.
2. The maximum individual fluid dispenser capacity shall be1.2 liters (2 liters
in suites of rooms).
3. The dispensers shall have a minimum spacing of four feet from each other.
4. Not more than ten gallons are used in a single smoke compartment outside
a storage cabinet.
5. Dispensers are not installed over or adjacent to an ignition source.
6. If the floor is carpeted, the building is fully sprinklered.
Smoking Regulations
1. Smoking shall be prohibited in any room, ward or compartment where
flammable liquids, combustible gases or oxygen is used or stored in any other
hazardous location, and such area shall be posted with signs that read NO
SMOKING or shall be posted with the international symbol for no smoking.
2. Smoking by patients classified as not responsible shall be prohibited,
except when under direct supervision.
3. Ashtrays of noncombustible material and safe design shall be provided in
all areas where smoking is permitted.
4. Metal containers with self-closing cover devices into which ashtrays can be
emptied shall be available to all areas where smoking is permitted.
Electrical
1. All switch and outlet covers installed. None damaged.
2. Panels installed on all electrical equipment.
3. Three foot clearance on all four sides of main electrical panels.
4. Circuit breaker panels labeled.
5. Ground Fault Circuit Interrupters installed in all outlets - Within six feet of
any sink, bathrooms, garages, electrical vehicle charging systems, elevators,
wet areas (utility rooms-outlets serving counter tops, janitor closets, dish
washing rooms), kitchen (outlets serving counter tops), roof tops, and
outdoor outlets.
Kitchen Range Hood Fire
Suppression System
1. Inspected monthly - Grease buildup on nozzles and ductwork.
2. Inspected annually - Licensed individual.
3. Eight inch shield installed between fryer and stove - on tallest appliance not required if fryer is sixteen inches from stove.
Fire Extinguishers
1. Inspect monthly - Proper location, not obstructed, operating instructions on
nameplate facing outward, safety seal not broken, unit is full, obvious
physical damage, pressure gauge reading in operable range - Document
inspections.
2. Annual inspection by licensed individual.
Fire Alarm System
1. Annual inspection by licensed individual - Report available.
2. Semi-annually - Visual inspection of fire alarm components.
Single Station Smoke
Detectors
1. Inspect and test according to manufacturer's instructions; at least monthly.
2. Replace batteries according to manufacturer' instructions;
3. Document testing and maintenance;
Sprinkler System
1. Annual inspection by a Licensed individual - Report available.
2. Test tamper and flow switches quarterly - Document.
3. Storage eighteen inches below sprinkler head deflector.
2.5
4. Sprinkler heads free of lint and corrosion, pipes not used for clothes
hangers.
5. Sprinkler heads not obstructed.
Emergency Generator
1. Annual inspection by licensed individual - Report available.
2. Maintenance scheduled per manufacturer's requirement - Keep log.
3. Monthly recordings of battery electrolyte specific gravity - lead acid
batteries- all others weekly recording of battery voltage.
4. Monthly load test (30%) for thirty minutes - Record time and voltage.
5. Switch to emergency power within ten seconds.
6. Outlets connected to emergency power identified by distinctive color
unless total building on generator.
Fire Drills
1. A drill for each shift during each quarter.
2. At unannounced times, not during shift change, not all on same day, 90%
attendance.
3. Do not mix drills and inservices.
4. Document each drill with time, date, shift, procedures used, reactions of
staff, and signatures of staff participating.
Corridor, Fire, and
Smoke Barrier walls
Exits
All penetrations sealed with fire rated caulking or foam. Check behind
service personnel. Maximum half-inch gap around penetrations.
1. Doors open without impediment.
2. Discharge path smooth hard surface. Maximum half-inch elevation
between surfaces. If higher, 20:1 ramp.
3. Dual bulb outside light fixture.
In General
Facility shall be maintained according to all applicable codes.
Any renovations or alterations to the facility shall be submitted to OLTC for
approval.
rev. 05/22/09
2.6
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Form Approved
OMB No. 0938-0242
FIRE SAFETY SURVEY — 2000 LIFE SAFETY CODE
F-1
Worksheet for Rating Residents
SIDE 1
Complete one Worksheet for each resident.
Read Instruction Manual before filling out this form.
Base ratings on commonly observed examples of poor performance.
Resident’s Name
Rater
Facility
Date
Write any explanatory remarks you may wish to make here:
Surveyor (Signature)
Title
Date
Title
Date
Surveyor ID
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-2786M (03/04) Previous Versions Obsolete
Appendix 2-A
Page 1
Form Approved
OMB No. 0938-0242
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
F-1
COMPLETE OTHER SIDE FIRST
Worksheet for Rating Residents
SIDE 2
Read Instruction Manual before filling out this form.
Base ratings on commonly observed examples of poor performance.
F-1A Rating the Resident on the Risk Factors
Rating the resident on each of the factors below by checking the one circle in each risk factor that best describes the resident. For the first six
factors, write the scores for the circles you 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 3 scores in the large box on the right.
SCORE
BOXES
I. Risk of
Resistance
(Check only one)
II. Impaired
Mobility
(Check only one)
Minimal
Risk
score = 0
SelfStarting
IV. Need for
Extra Help
(Check only one)
V. Response to
Instructions
(Check only one)
VI. Waking
Response to
Alarm
(Check only one)
VII. Response
to Fire Drills
(Without
Guidance or
Advice from
Staff)
Slow
score = 3
Needs Limited
Assistance
from 2 Staff
score = 1
Response
Probable
score = 20
score = 20
Needs Full
Assistance
from 2 Staff
score = 40
Requires Considerable Attention/May
Not Respond
score = 3
score = 10
Response
Not Probable
score = 0
Initiates and
Completes
Evacuation
Promptly
score = 6
score = 30
Requires
Supervision
Needs Full
Assistance or
Very Slow
Totally
Impaired
score = 6
score = 0
Follows
Instructions
score = 20
Needs Limited
Assistance
Partially
Impaired
score = 0
Needs at Most
One Staff
Risk of Strong
Resistance
score = 6
score = 0
No Significant
III. Impaired
Consciousness Risk
(Check only one)
Risk of Mild
Resistance
score = 6
Yes
No
score = 0
Chooses and
Completes
Back-up
Strategy
Yes
Stays at
Designated
Location
Yes
score = 8
No
score = 0
+
score = 4
No
score = 0
+
score = 6
F-1B Finding the ResIdent’s Overall Need
For AssIstance
Compare the numbers in the 7 score boxes you have filled in.
Take the one highest score from the score boxes and write it in this box:
Form CMS-2786M (03/04) Previous Versions Obsolete
SUM OF
THESE
THREE
ITEMS
EVACUATION
ASSISTANCE
SCORE
Page 2
Appendix 2-A
FIRE SAFETY SURVEY REPORT
CRUCIAL DATA EXTRACT
(TO BE USED WITH CMS-2786 FORMS)
PROVIDER NUMBER
FACILITY NAME
SURVEY DATE
K1
K6
* K4
K3
DATE OF PLAN
APPROVAL
MULTIPLE CONSTRUCTION
TOTAL NUMBER OF BUILDINGS ____________
NUMBER OF THIS BUILDING
LSC FORM INDICATOR
____________
12
13
14
15
ASC Form
2000 EXISTING
2000 NEW
SMALL
(16 BEDS OR LESS)
K8:
1 PROMPT
2 SLOW
3 IMPRACTICAL
LARGE
K8:
ICF/MR Form
2786V, W, X
2000 EXISTING
2786V, W, X
2000 NEW
16
17
SELECT NUMBER OF FORM USED FROM ABOVE
*K9:
7 PROMPT
8 SLOW
9 IMPRACTICAL
ENTER E – SCORE HERE
(Check if K29 or K56 are marked as not applicable
in the 2786 M, R, T, U, V, W, X and Y.)
K29:
4 PROMPT
5 SLOW
6 IMPRACTICAL
APARTMENT HOUSE
K8:
* K7
BUILDING
WING
FLOOR
APARTMENT UNIT
COMPLETE IF ICF/MR IS SURVEYED UNDER CHAPTER 21
Health Care Form
2786R
2000 EXISTING
2786R
2000 NEW
2786U
2786U
A
B
C
D
K5:
K56:
e.g. 2.5
FACILITY MEETS LSC BASED ON (Check all that apply)
A1.
(COMP. WITH
ALL PROVISIONS)
A2.
A3.
(ACCEPTABLE POC)
FACILITY DOES NOT MEET LSC
B.
A4.
(WAIVERS)
A5.
(FSES)
(PERFORMANCE
BASED DESIGN)
K0180
A.
FULLY SPRINKLERED
B.
PARTIALLY SPRINKLERED
(All required areas are sprinklered) (Not all required areas are sprinklered)
C.
NONE
(No sprinkler system)
* MANDATORY
Form CMS-2786M (03/04) Previous Versions Obsolete
Page 3
Appendix 2-A
2000 CODE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
FIRE SAFETY SURVEY REPORT 2000 CODE - HEALTH CARE
Medicare – Medicaid
1. (A) PROVIDER NUMBER
1. (B) MEDICAID I.D. NO.
K1
K2
Form Approved
OMB Exempt
PART I — Life Safety Code, New and Existing
PART IV — Waiver Recommendation Form
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
MEDICAID
Partially Sprinklered
B.
(Not all required areas are sprinklered)
None
C.
K3
3. SURVEY FOR
Fully Sprinklered
(No sprinkler system)
K0180
4. DATE OF SURVEY
DATE OF PLAN APPROVAL
K4
K6
SURVEY UNDER
5.
2000 EXISTING
6.
2000 NEW
K7
5. SURVEY FOR CERTIFICATION OF
1.
HOSPITAL
2.
SKILLED/NURSING FACILITY
4.
ICF/MR UNDER HEALTH CARE
IF “2” OR “5” ABOVE IS MARKED, CHECK APPROPRIATE ITEM(S) BELOW
1.
ENTIRE FACILITY 2.
6. BED COMPOSITION
a. TOTAL NO. OF BEDS
IN THE FACILITY ______
7. A.
B.
IF DISTINCT PART OF HOSPITAL, IS HOSPITAL ACCREDITED?
a.
c. NUMBER OF SKILLED BEDS
CERTIFIED FOR MEDICARE _____
HOSPICE
YES
b.
NO
d. NUMBER OF SKILLED BEDS
CERTIFIED FOR MEDICAID ______
e. NUMBER OF NF or ICF/MR BEDS
CERTIFIED FOR MEDICAID_______
THE FACILITY MEETS, BASED UPON (CHECK ALL APPROPRIATE BOXES)
1.
K9
3.
DISTINCT PART OF (SPECIFY) __________________________________
b. NUMBER OF HOSPITAL BEDS
CERTIFIED FOR MEDICARE ____
5.
COMPLIANCE WITH ALL PROVISIONS
2.
ACCEPTANCE OF A PLAN OF CORRECTION
3.
RECOMMENDED WAIVERS
4.
FSES
5.
PERFORMANCE BASED DESIGN
THE FACILITY DOES NOT MEET THE STANDARD
SURVEYOR (Signature)
TITLE
OFFICE
DATE
TITLE
OFFICE
DATE
SURVEYOR ID
K10
FIRE AUTHORITY OFFICIAL (Signature)
Form CMS-2786R (02/2013)
Appendix 2-B
Page 1
Name of Facility
2000 CODE
ID
PREFIX
MET NOT
MET
N/A
REMARKS
PART I - LSC REQUIREMENTS - Items in italics relate to the FSES
BUILDING CONSTRUCTION
K11
If the building has a common wall with a nonconforming building,
the common wall is a fire barrier having at least a two hour fire
resistance rating constructed of materials as required for the
addition. Communicating openings occur only in corridors and
shall be protected by approved self-closing fire doors with at
least 1½ hour fire resistance rating
18.1.1.4.1, 18.1.1.4.2, 18.2.3.2, 19.1.1.4.1, 19.1.1.4.2
K12
2000 EXISTING
Building construction type and height meets one of the following:
19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1
1
I (443), I (332), II (222)
Any Height
2
II (111)
One story only
(non-sprinklered).
3
II (111)
Not over three stories with
complete automatic
sprinkler system.
4
III (211)
5
V (111)
6
IV (2HH)
7
II (000)
8
III (200)
9
V (000)
Not over two stories with
complete automatic
sprinkler system.
Not over one story with
complete automatic
sprinkler system.
Building contains fire treated wood.
Give a brief description, in REMARKS, of the construction, the
number of stories, including basements, floors on which patients
are located, location of smoke or fire barriers and dates of
approval. Complete sketch or attach small floor plan of the
building as appropriate.
Form CMS-2786R (02/2013)
Appendix 2-B
Page 2
Name of Facility
2000 CODE
ID
PREFIX
K12
MET NOT
MET
N/A
REMARKS
2000 NEW
Building construction type and height meets one of the following:
18.1.6.2, 18.1.6.3, 18.3.5.1.
1
I (443), I (332), II (222)
Any height with complete
automatic sprinkler system
2
II (111)
Not over three stories
with complete automatic
sprinkler system
3
III (211)
4
V (111)
5
IV (2HH)
6
II (000)
7
III (200)
8
V (000)
Not over one story with
complete automatic
sprinkler system.
Not Permitted
Building contains fire treated wood.
Give a brief description, in REMARKS, of the construction, the
number of stories, including basements, floors on which patients
are located, location of smoke or fire barriers and dates of
approval. Complete sketch or attach small floor plan of the
building as appropriate.
K103 Interior walls and partitions in buildings of Type I or Type II
construction shall be noncombustible or limited-combustible
materials. 18.1.6.3, 19.1.6.3
(Indicate N/A for existing buildings using listed fire retardant
treated wood studs within non-load bearing one-hour rated
partitions.)
Form CMS-2786R (02/2013)
Appendix 2-B
Page 3
Name of Facility
2000 CODE
ID
PREFIX
MET NOT
MET
N/A
REMARKS
INTERIOR FINISH
K14
2000 EXISTING
Interior finish for means of egress, including exposed interior
surfaces of buildings such as fixed or movable walls, partitions,
columns, and ceilings has a flame spread rating of Class A or
Class B. Interior finishes existing before December 17, 2010 that
are applied directly to wall and ceilings with a thickness of less
than ½8 inch shall be permitted to remain in use without flame
spread rating documentation. 10.2, 19.3.3.1, 19.3.3.2,
NFPA TIA 00-2
Indicate flame spread rating/s _________
2000 NEW
Interior finish for means of egress, including exposed interior
surfaces of buildings such as fixed or movable walls, partitions,
columns, and ceilings has a flame spread rating of Class A or
Class B. Lower half of corridor walls, not exceeding 4ft in height,
may have a Class C flame spread rating. 10.2, 18.3.3.1, 18.3.3.2,
NFPA TIA 00-2
Indicate flame spread rating/s_________
K15
2000 EXISTING
Interior finish for rooms and spaces not used for corridors or
exitways, including exposed interior surfaces of buildings such
as fixed or movable walls, partitions, columns, and ceilings has
a flame spread rating of Class A or Class B. (In fully-sprinklered
buildings, flame spread rating of Class C may be continued in
use within rooms separated in accordance with 19.3.6 from the
exit access corridors.) 19.3.3.1, 19.3.3.2
Indicate flame spread rating/s_________
2000 NEW
Interior finish for rooms and spaces not used for corridors or
exitways, including exposed interior surfaces of buildings such
as fixed or movable walls, partitions, columns, and ceilings has
a flame spread rating of Class A or Class B. (Rooms not over
4 persons in capacity may have a flame spread rating of Class A,
Class B, or Class C). 18.3.3.1, 18.3.3.2.
Indicate flame spread rating/s_________
Form CMS-2786R (02/2013)
Appendix 2-B
Page 4
Name of Facility
2000 CODE
ID
PREFIX
K16
MET NOT
MET
N/A
REMARKS
2000 EXISTING
Newly installed interior floor finish complying with 10.2.7 shall be
permitted in corridors and exits if Class I. 19.3.3.3
In smoke compartments protected throughout by an approved,
supervised automatic sprinkler system in accordance with
19.3.5.2, no interior floor finish requirements shall apply.
CORRIDOR WALLS AND DOORS
K17
2000 EXISTING
Corridors are separated from use areas by walls constructed with
at least ½ hour fire resistance rating. In fully sprinklered smoke
compartments, partitions are only required to resist the passage
of smoke. In non-sprinklered buildings, walls extend to the
underside of the floor or roof deck above the ceiling. (Corridor
walls may terminate at the underside of ceilings where
specifically permitted by Code. Charting and clerical stations,
waiting areas, dining rooms, and activity spaces may be open to
corridor under certain conditions specified in the Code. Gift
shops may be separated from corridors by non-fire rated walls
if the gift shop is fully sprinklered.)
19.3.6.1, 19.3.6.2, 19.3.6.4, 19.3.6.5
If the walls have a fire resistance rating, give rating _________
if the walls terminate at the underside of a ceiling, give a brief
description in REMARKS, of the ceiling, describing the ceiling
throughout the floor area.
2000 NEW
Corridor walls shall form a barrier to limit the transfer of smoke.
Such walls shall be permitted to terminate at the ceiling where
the ceiling is constructed to limit the transfer of smoke. No fire
resistance rating is required for the corridor walls.
18.3.6.1, 18.3.6.2, 18.3.6.4, 18.3.6.5
Form CMS-2786R (02/2013)
Appendix 2-B
Page 5
Name of Facility
ID
PREFIX
K18
2000 CODE
MET NOT
MET
N/A
REMARKS
2000 EXISTING
Doors protecting corridor openings in other than required
enclosures of vertical openings, exits, or hazardous areas shall
be substantial doors, such as those constructed of 13/4 inch
solid-bonded core wood, or capable of resisting fire for at least
20 minutes. Clearance between bottom of door and floor covering
is not exceeding 1 inch. Doors in fully sprinklered smoke
compartments are only required to resist the passage of smoke.
There is no impediment to the closing of the doors. Hold open
devices that release when the door is pushed or pulled are
permitted. Doors shall be provided with a means suitable for
keeping the door closed. Dutch doors meeting 19.3.6.3.6 are
permitted. Door frames shall be labeled and made of steel or
other materials in compliance with 8.2.3.2.1. Roller latches are
prohibited by CMS regulations in all health care facilities. 19.3.6.3
Show in REMARKS, details of doors, such as fire protection
ratings, automatic closing devices, etc.
2000 NEW
Doors protecting corridor openings shall be constructed to resist
the passage of smoke. Clearance between bottom of door and
floor covering is not exceeding 1 inch. There is no impediment to
the closing of the doors. Hold open devices that release when
the door is pushed or pulled are permitted. Doors shall be
provided with positive latching hardware. Dutch doors meeting
18.3.6.3.6 are permitted. Roller latches shall be prohibited.
18.3.6.3
Show in REMARKS, details of doors, such as fire protection
ratings, automatic closing devices, etc.
K19
Vision panels in corridor walls or doors shall be fixed window
assemblies in approved frames. (In fully sprinklered smoke
compartments, there are no restrictions in the area and fire
resistance of glass and frames.) In other than smoke
compartments containing patient bedrooms, miscellaneous
opening are permitted in vision panels or doors provided the
aggregate area of the opening per room does not exceed 20 in.2
and the opening is installed in bottom half of the wall (80 in.2 in
fully sprinklered buildings).
18.3.6.5, 19.3.6.2.3, 19.3.6.3.8, 19.3.6.5
Form CMS-2786R (02/2013)
Appendix 2-B
Page 6
Name of Facility
2000 CODE
ID
PREFIX
MET NOT
MET
N/A
REMARKS
VERTICAL OPENINGS
K20
2000 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes,
and other vertical openings between floors are enclosed with
construction having a fire resistance rating of at least one hour.
An atrium may be used in accordance with 8.2.5, 8.2.5.6, 19.3.1.1
If all vertical openings are properly enclosed with construction
providing at least a two hour fire resistance rating, also check
this box.
If enclosures are less than required, give a brief description and
specific location in REMARKS.
2000 NEW
Stairways, elevator shafts, light and ventilation shafts, chutes,
and other vertical openings between floors are enclosed with
construction having a fire resistance rating of at least two hours
connecting four stories or more. (One hour for single story
building and buildings up to three stories in height.) An atrium
may be used in accordance with 8.2.5.6, 8.2.5, 18.3.1.1.
If enclosures are less than required, give a brief description and
specific location in REMARKS.
K21
Doors in an exit passageway, stairway enclosure, horizontal exit,
smoke barrier or hazardous area enclosure are self-closing
and kept in the closed position, unless held open by as release
device complying with 7.2.1.8.2 that automatically closes all such
doors throughout the smoke compartment or entire facility upon
activation of:
(a) The required manual fire alarm system and
(b) Local smoke detectors designed to detect smoke
passing through the opening or a required smoke
detection system and
(c) The automatic sprinkler system, if installed
18.2.2.2.6, 18.3.1.2, 19.2.2.2.6, 19.3.1.2, 7.2.1.8.2
Door assemblies in vertical openings are of an approved type
with appropriate fire protection rating. 8.2.3.2.3.1
Boiler rooms, heater rooms, and mechanical equipment rooms
doors are kept closed.
Form CMS-2786R (02/2013)
Appendix 2-B
Page 7
Name of Facility
ID
PREFIX
2000 CODE
MET NOT
MET
N/A
REMARKS
Describe method used in REMARKS
SMOKE COMPARTMENTATION AND CONTROL
K23
2000 EXISTING
Smoke barriers shall be provided to form at least two smoke
compartments on every sleeping room floor for more than 30
patients. 19.3.7.1, 19.3.7.2
2000 NEW
Smoke barriers shall be provided to form at least two smoke
compartments on every floor used by inpatients for sleeping or
treatment, and on every floor with an occupant load of 50 or
more persons, regardless of use. Smoke barriers shall also be
provided on floors that are usable, but unoccupied. 18.3.7.1,
18.3.7.2
K24
The smoke compartments shall not exceed 22,500 square feet and
the travel distance to and from any point to reach a door in the
required smoke barrier shall not exceed 200 feet. 18.3.7.1, 19.3.7.1
Detail in REMARKS zone dimensions including length of zones
and dead end corridors.
K25
2000 EXISTING
Smoke barriers shall be constructed to provide at least a one
half hour fire resistance rating and constructed in accordance
with 8.3. Smoke barriers shall be permitted to terminate at an
atrium wall. Windows shall be protected by fire-rated glazing or
by wired glass panels and steel frames. 8.3, 19.3.7.3, 19.3.7.5
2000 NEW
Smoke barriers shall be constructed to provide at least a one
hour fire resistance rating and constructed in accordance with
8.3. Smoke barriers shall be permitted to terminate at an atrium
wall. Windows shall be protected by fire-rated glazing or by wired
glass panels in approved frames. 8.3, 18.3.7.3, 18.3.7.5
K26
Space shall be provided on each side of smoke barriers to
adequately accommodate the total number of occupants in
adjoining compartments. 18.3.7.4, 19.3.7.4
Form CMS-2786R (02/2013)
Appendix 2-B
Page 8
Name of Facility
2000 CODE
ID
PREFIX
K27
MET NOT
MET
N/A
REMARKS
2000 EXISTING
Doors in smoke barriers have at least a 20 minute fire protection
rating or are at least 13/4 inch thick solid bonded core wood.
Non-rated protective plates that do not exceed 48 inches from
the bottom of the door are permitted. Horizontal sliding doors
comply with 7.2.1.14. Doors shall be self-closing or automaticclosing in accordance with 19.2.2.2.6. Swinging doors are not
required to swing with egress and positive latching is not
required. 19.3.7.5, 19.3.7.6, 19.3.7.7
2000 NEW
Doors in smoke barriers have at least a 20 minute fire protection
rating or are at least 13/4 inch thick solid bonded core wood. Nonrated protective plates that do not exceed 48 inches from the bottom
of the door are permitted. Horizontal sliding doors comply with
7.2.1.14. Swinging doors shall be arranged so that each door swings
in an opposite direction. Doors shall be self-closing and rabbets,
bevels or astragals are required at the meeting edges. Positive
latching is not required. 18.3.7.5, 18.3.7.6, 18.3.7.8
K28
2000 EXISTING
Door openings in smoke barriers shall provide a minimum clear
width of 32 inches (81 cm) for swinging or horizontal doors.
19.3.7.7
2000 NEW
Door openings in smoke barriers are installed as swinging or
horizontal doors shall provide a minimum clear width as follows:
Provider Type
Swinging Doors
Horizontal Sliding Doors
Hospitals and
Nursing Facilities
41.5 inches
(105 cm)
83 inches
(211 cm)
Psychiatric Hospitals and
Limited Care Facilities
32 inches
(81 cm)
64 inches
(163 cm)
18.3.7.7
Form CMS-2786R (02/2013)
Appendix 2-B
Page 9
Name of Facility
2000 CODE
ID
PREFIX
K104
MET NOT
MET
N/A
REMARKS
Penetrations of smoke barriers by ducts are protected in
accordance with 8.3.5. Dampers are not required in duct
penetrations of smoke barriers in fully ducted HVAC systems
where a sprinkler system in accordance with 18/19.3.5 is
provided for adjacent smoke compartments. 18.3.7.3, 19.3.7.3.
Hospitals may apply a 6-year damper testing interval conforming
to NFPA 80 & NFPA 105. All other health care facilities must
maintain a 4-year damper maintenance interval. 8.3.5
Describe any mechanical smoke control system in REMARKS.
HAZARDOUS AREAS
K29
2000 EXISTING
One hour fire rated construction (with 3/4 hour fire-rated doors) or
an approved automatic fire extinguishing system in accordance
with 8.4.1 and/or 19.3.5.4 protects hazardous areas. When the
approved automatic fire extinguishing system option is used, the
areas shall be separated from other spaces by smoke resisting
partitions and doors. Doors shall be self-closing and non-rated or
field-applied protective plates that do not exceed 48 inches from
the bottom of the door are permitted. 19.3.2.1
Area
a. Boiler and Fuel-Fired Heater Rooms
c. Laundries (greater than 100 sq feet)
d. Repair Shops and Paint Shops
e. Laboratories (if classified a Severe Hazard - see K31)
f. Combustible Storage Rooms/Spaces (over 50 sq feet)
g. Trash Collection Rooms
i. Soiled Linen Rooms
Automatic Sprinkler
Separation
N/A
Describe the floor and zone locations of hazardous areas that
are deficient in REMARKS.
Form CMS-2786R (02/2013)
Appendix 2-B
Page 10
Name of Facility
2000 CODE
ID
PREFIX
MET NOT
MET
N/A
REMARKS
Area
a. Boiler and Fuel-Fired Heater Rooms
c. Laundries (greater than 100 sq feet)
d. Repair, Maintenance and Paint Shops
e. Laboratories (if classified a Severe Hazard - see K31)
f. Combustible Storage Rooms/Spaces
(over 50 and less than 100 sq feet)
g. Trash Collection Rooms
i. Soiled Linen Rooms
m. Combustible Storage Rooms/Spaces (over 100 sq feet)
Area
L. Gift Shop storing hazardous quantities
of combustibles
Form CMS-2786R (02/2013)
Automatic Sprinkler
Separation
N/A
Automatic Sprinkler Separation N/A
Appendix 2-B
Page 11
Name of Facility
2000 CODE
ID
PREFIX
K211
MET NOT
MET
N/A
REMARKS
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 403.744, 418.110, 460.72, 482.41, 483.70, 485.623
EXITS AND EGRESS
K22
Access to exits shall be marked by approved, readily visible
signs in all cases where the exit or way to reach exit is not
readily apparent to the occupants. Doors, passages or stairways
that are not a way of exit that are likely to be mistaken for an exit
have a sign designating “No Exit”. 7.10, 18.2.10.1, 19.2.10.1
K32
Not less than two exits, remote from each other, are provided for
each floor or fire section of the building. Not less than one exit
from each floor or fire section shall be a door leading outside,
stair, smoke-proof enclosure, ramp, or exit passageway. Only
one of these two exits may be a horizontal exit. Egress shall not
return through the zone of fire origin. 18.2.4.1, 18.2.4.2, 19.2.4.1,
19.2.4.2
K33
2000 EXISTING
Exit enclosures (such as stairways) are enclosed with
construction having a fire resistance rating of at least one hour,
are arranged to provide a continuous path of escape, and provide
protection against fire or smoke from other parts of the building.
7.1.3.2, 8.2.5.2, 8.2.5.4, 19.3.1.1
If all vertical openings are properly enclosed with construction
providing at least a two hour fire resistance rating, also check
this box.
If enclosures are less than required, give a brief description and
specific location in REMARKS.
Form CMS-2786R (02/2013)
Appendix 2-B
Page 12
Name of Facility
ID
PREFIX
2000 CODE
MET NOT
MET
N/A
REMARKS
2000 NEW
Exit enclosures (such as stairways) in buildings four stories or
more are enclosed with construction having a fire resistance
rating of at least two hours, are arranged to provide a continuous
path of escape, and provide a protection against fire and smoke
from other parts of the building. In all buildings less than four
stories, the enclosure is at least one hour. 7.1.3.2, 8.2.5.2,
8.2.5.4, 18.3.1.1, 18.2.2.3
If enclosures are less than required, give a brief description and
specific location in REMARKS.
K34
Stairways and smokeproof enclosures used as exits are in
accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4
K35
The capacity of required mean of egress is based on its width, in
accordance with 7.3.
K36
Travel distance (exit access) to exits are measured in
accordance with 7.6.
• Room door to exit ≤ 100 ft (≤ 150 ft sprinklered)
• Point in room or suite to exit ≤ 150 ft (≤ 200 ft sprinklered)
• Point in room to room door ≤ 50 ft
• Point in suite to suite door ≤ 100 ft
18.2.6, 19.2.6
K37
2000 EXISTING
Existing dead-end corridors shall be permitted to be continued to
be used if it is impractical and unfeasible to alter them so that
exists are accessible in not less than two different directions
from all points in aisles, passageways, and corridors. 19.2.5.10
2000 NEW
Every exit and exit access shall be arranged so that no corridor,
aisle or passageway has a pocket or dead-end exceeding
30 feet. 18.2.5.10
K38
Exit access is so arranged that exits are readily accessible at all
times in accordance with 7.1. 18.2.1, 19.2.1
K39
2000 EXISTING
Width of aisles or corridors (clear and unobstructed) serving as
exit access shall be at least 4 feet. 19.2.3.3
Form CMS-2786R (02/2013)
Appendix 2-B
Page 13
Name of Facility
ID
PREFIX
2000 CODE
MET NOT
MET
N/A
REMARKS
2000 NEW
Width of aisles or corridors (clear and unobstructed) serving as
exit access in hospitals and nursing homes shall be at least
8 feet. In limited care facility and psychiatric hospitals, width of
aisles or corridors shall be at least 6 feet. 18.2.3.3, 18.2.3.4
K40
2000 EXISTING
Exit access doors and exit doors used by health care occupants
are of the swinging type and are at least 32 inches in clear width.
An exception is provided for existing 34-inch doors in existing
occupancies. 19.2.3.5
2000 NEW
Exit access doors and exit doors used by health care occupants
are of the swinging type and are at least 41.5 inches in clear width.
Doors in exit stairway enclosures shall be no less than 32 inches
in clear width. In psychiatric hospitals or limited care facilities
(e.g.,ICF/MD providing medical treatment) doors are at least
32 inches wide. 18.2.3.5
K41
All sleeping rooms have a door leading to a corridor providing
access to an exit or have a door leading directly to grade. One
room may intervene in accordance with 18.2.5.1, 19.2.5.1
If doors lead directly to grade from each room, check this box.
K42
Any patient sleeping room or suite of rooms of more than
1,000 sq. ft. has at least 2 exit access doors remote from each
other. 18.2.5.2, 19.2.5.2
K43
Patient room doors are arranged such that the patients can open
the door from inside without using a key.
Special door locking arrangements are permitted in facilities.
18.2.2.2.4, 18.2.2.2.5, 19.2.2.2.4, 19.2.2.2.5
If door locking arrangement without delay egress is used
indicate in REMARKS
18.2.2.2.2, 19.2.2.2.2
K44
Horizontal exits, if used, are in accordance with 7.2.4.
18.2.2.5, 19.2.2.5
K47
Exit and directional signs are displayed in accordance with 7.10
with continuous illumination also served by the emergency
lighting system. 18.2.10.1, 19.2.10.1
(Indicate N/A in one story existing occupancies with less than
30 occupants where the line of exit travel is obvious.)
Form CMS-2786R (02/2013)
Appendix 2-B
Page 14
Name of Facility
2000 CODE
ID
PREFIX
K72
MET NOT
MET
N/A
REMARKS
Means of egress shall be continuously maintained free of all
obstructions or impediments to full instant use in the case of fire
or other emergency. No furnishings, decorations, or other objects
shall obstruct exits, access thereto, egress there from, or visibility
thereof shall be in accordance with 7.1.10. 18.2.1, 19.2.1
ILLUMINATION
K45
Illumination of means of egress, including exit discharge, is
arranged so that failure of any single lighting fixture will not
leave the area in darkness. Lighting system shall be either
continuously in operation or capable of automatic operation
without manual intervention. 18.2.8, 19.2.8, 7.8
K46
Emergency lighting of at least 1½ hour duration is provided
automatically in accordance with 7.9.
18.2.9.1, 19.2.9.1.
K105
2000 NEW (INDICATE N/A FOR EXISTING)
Buildings equipped with or requiring the use of life support
systems (electro-mechanical or inhalation anesthetics) have
illumination of means of egress, emergency lighting equipment,
exit, and directional signs supplied by the Life Safety Branch of
the electrical system described in NFPA 99. 18.2.9.2., 18.2.10.2
(Indicate N/A if life support equipment is for emergency purposes
only).
EMERGENCY PLAN AND FIRE DRILLS
K48
There is a written plan for the protection of all patients and for
their evacuation in the event of an emergency.
18.7.1.1, 19.7.1.1
K50
Fire drills include the transmission of a fire alarm signal and
simulation of emergency fire conditions. Fire drills are held at
unexpected times under varying conditions, at least quarterly on
each shift. The staff is familiar with procedures and is aware that
drills are part of established routine. Responsibility for planning
and conducting drills is assigned only to competent persons who
are qualified to exercise leadership. Where drills are conducted
between 9:00 PM and 6:00 AM a coded announcement may be
used instead of audible alarms.
18.7.1.2, 19.7.1.2
Form CMS-2786R (02/2013)
Appendix 2-B
Page 15
Name of Facility
2000 CODE
ID
PREFIX
MET NOT
MET
N/A
REMARKS
FIRE ALARM SYSTEMS
K51
A fire alarm system is installed with systems and components
approved for the purpose in accordance with NFPA 70, National
Electric Code and NFPA 72, National Fire Alarm Code to provide
effective warning of fire in any part of the building. Fire alarm
system wiring or other transmission paths are monitored for
integrity. Initiation of the fire alarm system is by manual means
and by any required sprinkler system alarm, detection device, or
detection system. Manual alarm boxes are provided in the path
of egress near each required exit. Manual alarm boxes in patient
sleeping areas shall not be required at exits if manual alarm
boxes are located at all nurse’s stations. Occupant notification is
provided by audible and visual signals. In critical care areas,
visual alarms are sufficient. The fire alarm system transmits the
alarm automatically to notify emergency forces in the event of
fire. The fire alarm automatically activates required control
functions. System records are maintained and readily available.
18.3.4, 19.3.4, 9.6
K52
A fire alarm system required for life safety shall be, tested, and
maintained in accordance with NFPA 70 National Electric Code
and NFPA 72 National Fire Alarm Code and records kept readily
available. The system shall have an approved maintenance and
testing program complying with applicable requirement of NFPA
70 and 72. 9.6.1.4, 9.6.1.7,
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
K53
2000 EXISTING (INDICATE N/A FOR HOSPITAL AND FULLY
SPRINKLERED NURSING HOMES)
In an existing nursing home, not fully sprinklered, the resident
sleeping rooms and public areas (dining rooms, activity rooms,
resident meeting rooms, etc) are to be equipped with single
station battery-operated smoke detectors. There will be a testing,
maintenance and battery replacement program to ensure proper
operation. CFR 483.70
Form CMS-2786R (02/2013)
Appendix 2-B
Page 16
Name of Facility
ID
PREFIX
2000 CODE
MET NOT
MET
N/A
REMARKS
2000 NEW (NURSING HOME AND EXISTING LIMITED
CARE FACILITIES)
An automatic smoke detection system is installed in all corridors.
(As an alternative to the corridor smoke detection system on
patient sleeping room floors, smoke detectors may be installed in
each patient sleeping room and at smoke barrier or horizontal
exit doors in the corridor.) Such detectors are electrically
interconnected to the fire alarm system. 18.3.4.5.3
K109
2000 EXISTING LIMITED CARE FACILITIES
(INDICATE N/A FOR HOSPITALS OR NURSING HOMES)
An automatic smoke detection system is installed in all corridors
with detector spacing no further apart than 30 ft on center in
accordance with NFPA 72. (As an alternative to the corridor
smoke detection system on patient sleeping room floors, smoke
detectors may be installed in each patient sleeping room and at
smoke barrier or horizontal exit doors in the corridors.) Such
detectors are electrically interconnected to the fire alarm system.
19.3.4.5.1
Smoke Detection System
Corridors
Rooms
Bath
K54
All required smoke detectors, including those activating door
hold-open devices, are approved, maintained, inspected and
tested in accordance with the manufacturer’s specifications.
9.6.1.3
Give a brief description, in REMARKS of any smoke detection
system which may be installed.
K55
2000 EXISTING
Every patient sleeping room shall have an outside window or
outside door. Except for newborn nurseries and rooms intended
for occupancy for less than 24 hours. 19.3.8
2000 NEW
Every patient sleeping room shall have an outside window or
outside door. The allowable sill height shall not exceed 36 inches
(91 cm) above the floor. Windows are not required for recovery
rooms, newborn nurseries, emergency rooms, and similar rooms
Form CMS-2786R (02/2013)
Appendix 2-B
Page 17
Name of Facility
2000 CODE
ID
PREFIX
MET NOT
MET
N/A
REMARKS
intended for occupancy for less than 24 hours. Window sill height
for limited care facilities shall not exceed 44 inches (112 cm)
above the floor. 18.3.8
K60
Initiation of the required fire alarm systems shall be by manual
fire alarm initiation, automatic detection, or extinguishing system
operation. 18.3.4.2, 19.3.4.2, 9.6.2.1
AUTOMATIC SPRINKLER SYSTEMS
K56
2000 EXISTING
Where required by section 19.1.6, Health care facilities shall be
protected throughout by an approved, supervised automatic
sprinkler system in accordance with section 9.7. Required
sprinkler systems are equipped with water flow and tamper
switches which are electrically interconnected to the building fire
alarm. In Type I and II construction, alternative protection
measures shall be permitted to be substituted for sprinkler
protection in specific areas where State or local regulations
prohibit sprinklers. 19.3.5, 19.3.5.1, NPFA 13
2000 NEW
There is an automatic sprinkler system installed in accordance
with NFPA13, Standard for the Installation of Sprinkler Systems,
with approved components, device and equipment, to provide
complete coverage of all portions of the facility. Systems are
equipped with waterflow and tamper switches, which are
connected to the fire alarm system. In Type I and II construction,
alternative protection measures shall be permitted to be
substituted for sprinkler protection in specific areas where State
or local regulations prohibit sprinklers. 18.3.5, 18.3.5.1.
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. _______________________________
Form CMS-2786R (02/2013)
Appendix 2-B
Page 18
Name of Facility
2000 CODE
ID
PREFIX
MET NOT
MET
N/A
REMARKS
B. Show who provided the service. _______________________
C. Note the source of water supply for the automatic
sprinkler system. ___________________________________
(Provide, in REMARKS, information on coverage for any
non-required or partial automatic sprinkler system.)
K61
Automatic sprinkler system supervisory attachments are installed
and monitored for integrity in accordance with NFPA 72, and
provide a signal that sounds and is displayed at a continuously
attended location or approved remote facility when sprinkler
operation is impaired. 9.7.2.1,
NFPA 72
K62
Automatic sprinkler systems are continuously maintained
in reliable operating condition and are inspected and tested
periodically. 18.7.6, 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5
K63
Required automatic sprinkler systems have an adequate and
reliable water supply which provides continuous and automatic
pressure. 9.7.1.1, NFPA 13
K64
Portable fire extinguishers shall be installed, inspected, and
maintained in all health care occupancies in accordance with
9.7.4.1, NFPA 10.
18.3.5.6, 19.3.5.6
SMOKING REGULATIONS
K66
Smoking regulations shall be adopted and shall include not less
than the following provisions: 18.7.4, 19.7.4, 8-6.4.2 (NFPA 99)
(1)
Smoking shall be prohibited in any room, ward, or
compartment where flammable liquids, combustible gases,
or oxygen is used or stored and in any other hazardous
location, and such area shall be posted with signs that
read NO SMOKING or shall be posted with the international
symbol for no smoking.
Exception: In facilities where smoking is prohibited and signs are
prominently placed at all major entrances, secondary signs that
prohibit smoking in use areas are not required. (Note: This
exception is not applicable to medical gas storage areas.)
8-3.1.11.3 (NFPA 99)
Form CMS-2786R (02/2013)
Appendix 2-B
Page 19
Name of Facility
ID
PREFIX
2000 CODE
MET NOT
MET
N/A
REMARKS
Form CMS-2786R (02/2013)
Appendix 2-B
Page 20
Name of Facility
ID
PREFIX
MET NOT
MET
(4)
K160
2000 CODE
N/A
REMARKS
Existing flue-fed incinerators shall be sealed by fire
resistive construction to prevent further use.
2000 EXISTING
Elevators comply with the provision of 9.4. Elevators are
inspected and tested as specified in A17.1, Safety Code for
Elevators and Escalators. Fire Fighter’s Service is operated
monthly with a written record.
Existing elevators conform to ASME/ANSI A17.3, Safety Code
for Existing Elevators & Escalators. All existing elevators, having
a travel distance of 25 ft or more above or below the level that
best serves the needs of emergency personnel for fire fighting
purposes, conform with Firefighter’s Service Requirements of
ASME/ANSI A17.3. 9.4.2, 9.4.3, 19.5.3
(Includes firefighters service phase I key recall and smoke
detector automatic recall, firefighters service phase II
emergency in-car key operation, machine room smoke detectors,
and elevator lobby smoke detectors.)
2000 NEW
Elevators comply with the provision of 9.4. Elevators are
inspected and tested as specified in A17.1, Safety Code for
Elevators and Escalators. Fire Fighter’s Service is operated
monthly with a written record.
New elevators conform to ASME/ANSI A17.1, Safety Code for
Elevators and Escalators, including Fire Fighter’s Service
Requirements. 9.4.2, 9.4.3, 18.5.3
(Includes firefighters service phase I key recall and smoke
detector automatic recall, firefighters service phase II
emergency in-car key operation, machine room smoke detectors,
and elevator lobby smoke detectors.)
K161
2000 EXISTING
Escalators, dumbwaiters, and moving walks comply with the
provisions of 9.4.
All existing escalators, dumbwaiters, and moving walks conform
to the requirements of ASME/ANSI A17.3, Safety Code for
Existing Elevators and Escalators. 19.5.3, 9.4.2.2
Form CMS-2786R (02/2013)
Appendix 2-B
Page 21
Name of Facility
ID
PREFIX
2000 CODE
MET NOT
MET
N/A
REMARKS
Newly introduced upholstered furniture shall meet the char
length and heat release criteria specified when tested in
accordance with the methods cited in 10.3.2 (2) and 10.3.3,
18.7.5.2, 19.7.5.2.
Newly introduced mattresses shall meet the char length and
heat release criteria specified when tested in accordance
with the method cited in 10.3.2 (3) and 10.3.4. 18.7.5.3,
19.7.5.3
Newly introduced upholstered furniture and mattresses means
purchased since March, 2003.
K75
Soiled linen or trash collection receptacles shall not exceed 32
gal (121 L) in capacity. The average density of container capacity
in a room or space shall not exceed .5 gal/ft2 (20.4 L/m2). A
Form CMS-2786R (02/2013)
Appendix 2-B
Page 22
Name of Facility
2000 CODE
ID
PREFIX
MET NOT
MET
N/A
REMARKS
capacity of 32 gal (121 L) shall not be exceeded within any 64-ft2
(5.9-m2) area. Mobile soiled linen or trash collection receptacles
with capacities greater than 32 gal (121 L) shall be located in a
room protected as a hazardous area when not attended.
18.7.5.5, 19.7.5.5
LABORATORIES
K31
Laboratories employing quantities of flammable, combustible, or
hazardous materials that are considered a severe hazard shall
be protected in accordance with NFPA 99. (Laboratories that are
not considered to be severe hazard shall meet the provision of
K29.) 18.3.2.2, 19.3.2.2, Chapter 10 (NFPA 99)
K136
Procedures for laboratory emergencies shall be developed. Such
procedures shall include alarm actuation, evacuation, and
equipment shutdown procedures, and provisions for control of
emergencies that could occur in the laboratory, including specific
detailed plans for control operations by an emergency control
group within the organization or a public fire department in
accordance with 10-2.1.3.1 (NFPA 99), 18.3.2.2., 19.3.2.1
K131
Emergency procedures shall be established for controlling
chemical spills in accordance with 10-2.1.3.2 (NFPA 99)
K132
Continuing safety education and supervision shall be provided,
incidents shall be reviewed monthly, and procedures reviewed
annually shall be in accordance with 10-2.1.4.2 (NFPA 99).
K133
Fume hoods shall be in accordance with 5-4.3, 5-6.2 (NFPA 99).
K134
Where the eyes or body of any person can be exposed to
injurious corrosive materials, suitable fixed facilities for quick
drenching or flushing of the eyes and body shall be provided
within the work area for immediate emergency use. Fixed eye
baths designed and installed to avoid injurious water pressure
shall be in accordance with 10-6 (NFPA 99).
K135
Flammable and combustible liquids shall be used from and
stored in approved containers in accordance with NFPA 30,
Flammable and Combustible Liquids Code, and NFPA 45,
Standard on Fire Protection for Laboratories Using Chemicals.
Form CMS-2786R (02/2013)
Appendix 2-B
Page 23
Name of Facility
ID
PREFIX
2000 CODE
MET NOT
MET
N/A
REMARKS
Storage cabinets for flammable and combustible liquids shall be
constructed in accordance with NFPA 30, Flammable and
Combustible liquids Code, 4-3 (NFPA 99), 10-7.2.1 (NFPA 99)
MEDICAL GASES AND ANESTHETIZING AREAS
K76
Medical gas storage and administration areas shall be protected
in accordance with NFPA 99, Standard for Health Care Facilities.
(a) Oxygen storage locations of greater than 3,000 cu.ft. are
enclosed by a one-hour separation.
(b) Locations for supply systems of greater than 3,000 cu.ft. are
vented to the outside.
4-3.1.1.2 (NFPA 99), 8-3.1.11.1 (NFPA 99), 18.3.2.4, 19.3.2.4
K77
Piped in medical gas, vacuum and waste anesthetic gas disposal
systems comply with NFPA 99, Chapter 4.
K78
Anesthetizing locations shall be protected in accordance with
NFPA 99, Standard for Health Care Facilities.
(a) Shutoff valves are located outside each anesthetizing
location and arranged so that shutting off one room or
location will not affect others.
(b) Relative humidity is maintained equal to or great
than 35% 4-3.1.2.3(n) and 5-4.1.1 (NFPA 99),
18.3.2.3, 19.3.2.3
Medical gas warning systems shall be in accordance with
NFPA 99, Standard for Health Care Facilities.
(a) Master alarm panels are in two separate locations and
have audible and visible signals.
(b) There are high/low alarms for +/- 20% operating pressure.
This section shall be in accordance with NFPA 99, 4-3.1.2.2
(c) Where a level 2 gas system is used, one alarm panel that
complies with 4-3.1.2.2(b)3a,b,c,d and with 4-3.1.2.2(c)2,5
shall be permitted. 4-4.1 (NFPA 99) exception No. 4.
K140
4-3.1.2.2 (NFPA 99)
K141
Medical gas storage areas shall have a precautionary sign,
readable from a distance of 5 ft, that is conspicuously displayed
on each door or gate of the storage room or enclosure. The
sign shall include the following wording as a minimum:
CAUSION, OXIDIZING GAS(ES) STORED WITHIN, NO
SMOKING. 18.3.2.4, 19.3.2.4, 8-3.1.11.3 (NFPA 99)
Form CMS-2786R (02/2013)
Appendix 2-B
Page 24
Name of Facility
ID
PREFIX
2000 CODE
MET NOT
MET
K142
All occupancies containing hyperbaric facilities shall comply with
NFPA 99, Standard for Health Care Facilities, Chapter 19.
K143
Transferring of liquid oxygen from one container to another shall
be accomplished at a location specifically designated for the
transferring that is as follows::
(a) separated from any portion of a facility wherein patients
are housed, examined, or treated by a separation of a fire
barrier of 1-hour fire-resistive construction; and
(b) the area that is mechanically ventilated, sprinklered, and
has ceramic or concrete flooring; and
(c) in an area that is posted with signs indicating that
transferring is occurring, and that smoking in the
immediate area is not permitted in accordance with
NFPA 99 and Compressed Gas Association.
8-6.2.5.2 (NFPA 99)
N/A
REMARKS
ELECTRICAL AND EMERGENCY POWER
K106
Hospitals and inpatient hospices with life support
equipment have an Type I Essential Electric System, and nursing
homes have a Type II ESS that are powered by a generator with
a transfer switch and separate power supply in accordance with
NFPA 99. 12-3.3.2, 13-3.3.2.1, 16-3.3.2 (NFPA 99)
K107
Required alarm and detection systems are provided with an
alternative power supply in accordance with NFPA 72.
9.6.1.4, 18.3.4.1, 19.3.4.1
K108
2000 NEW (INDICATE N/A FOR EXISTING)
Power for Alarms, emergency communication systems, and
illumination of generator set locations are in accordance with
essential electrical system of NFPA 99. 18.5.1.2
K144
Generators inspected weekly and exercised under load for
30 minutes per month and shall be in accordance with NFPA 99
and NFPA 110.
3-4.4.1 and 8-4.2 (NFPA 99), Chapter 6 (NFPA 110)
K145
The Type I EES is divided into the critical branch, life safety
branch and the emergency system and Type II EES is divided
into the emergency and critical systems in accordance with
3-4.2.2.2, 3-5.2.2 (NFPA 99)
Form CMS-2786R (02/2013)
Appendix 2-B
Page 25
Name of Facility
ID
PREFIX
2000 CODE
MET NOT
MET
K146
The nursing home/hospice with no life support equipment shall
have an alternate source of power separate and independent
from the normal source that will be effective for minimum of
11/2 hour after loss of the normal source 3-6. (NFPA 99)
K147
Electrical wiring and equipment shall be in accordance with
National Electrical Code. 9-1.2 (NFPA 99) 18.9.1, 19.9.1
K130
Miscellaneous
List in the REMARKS sections, any items that are not listed
previously, but are deficient. This information, along with the
applicable Life Safety Code or NFPA standard citation, should
be included on Form CMS-2567.
Form CMS-2786R (02/2013)
N/A
Appendix 2-B
REMARKS
Page 26
Name of Facility
2000 CODE
PART IV RECOMMENDATION FOR WAIVER OF SPECIFIC LIFE SAFETY CODE PROVISIONS
For each item of the Life Safety code recommended for waiver, list the survey report form item number and state the reason for the conclusion that: (a) the
specific provisions of the code, if rigidly applied, would result in unreasonable hardship on the facility, and (b) the waiver of such unmet provisions will not
adversely affect the health and safety of the patients. If additional space is required, attach additional sheet(s).
PROVISION NUMBER(S)
JUSTIFICATION
K84
Surveyor (Signature)
Title
Office
Date
Fire Authority Official (Signature)
Title
Office
Date
Form CMS-2786R (02/2013)
Appendix 2-B
Page 27
FIRE SAFETY SURVEY REPORT
CRUCIAL DATA EXTRACT
(TO BE USED WITH CMS-2786 FORMS)
FACILITY NAME
PROVIDER NUMBER
SURVEY DATE
K1
K6
* K4
K3
DATE OF PLAN
APPROVAL
MULTIPLE CONSTRUCTION
TOTAL NUMBER OF BUILDINGS ____________
NUMBER OF THIS BUILDING
LSC FORM INDICATOR
____________
12
13
Health Care Form
2786R
2000 EXISTING
2786R
2000 NEW
14
15
2786U
2786U
ASC Form
2000 EXISTING
2000 NEW
16
17
ICF/MR Form
2786V, W, X 2000 EXISTING
2786V, W, X 2000 NEW
SMALL
(16 BEDS OR LESS)
K8:
1 PROMPT
2 SLOW
3 IMPRACTICAL
LARGE
K8:
7 PROMPT
8 SLOW
9 IMPRACTICAL
ENTER E – SCORE HERE
(Check if K29 or K56 are marked as not applicable
in the 2786 M, R, T, U, V, W, X and Y.)
*K9:
4 PROMPT
5 SLOW
6 IMPRACTICAL
APARTMENT HOUSE
SELECT NUMBER OF FORM USED FROM ABOVE
K29:
BUILDING
WING
FLOOR
APARTMENT UNIT
COMPLETE IF ICF/MR IS SURVEYED UNDER CHAPTER 21
K8:
* K7
A
B
C
D
K5:
K56:
e.g. 2.5
FACILITY MEETS LSC BASED ON (Check all that apply)
A1.
(COMP. WITH
ALL PROVISIONS)
A2.
(ACCEPTABLE POC)
FACILITY DOES NOT MEET LSC
B.
A3.
A4.
(WAIVERS)
K0180
A.
FULLY SPRINKLERED
A5.
(FSES)
B.
PARTIALLY SPRINKLERED
(All required areas are sprinklered) (Not all required areas are sprinklered)
(PERFORMANCE
BASED DESIGN)
C.
NONE
(No sprinkler system)
* MANDATORY
Form CMS-2786R (02/2013)
Page 28
Appendix 2-B
2000 CODE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
FIRE SAFETY SURVEY REPORT SHORT FORM
Medicare – Medicaid
Form Approved
OMB No. 0938-0242
1. (A) PROVIDER NUMBER
1. (B) MEDICAID I.D. NO.
K1
K2
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
C.
 None (No sprinkler system)
K0180
4. DATE OF SURVEY

 Partially Sprinklered
(Not all required areas are sprinklered)
K3
3. SURVEY FOR
Sprinklered
 Fully
(All required areas are sprinklered)
SHORT FORM
CHECK HERE
MEDICAID
K4
SURVEY UNDER

5.
 2000 EXISTING
 2000 NEW
K5
5. SURVEY FOR CERTIFICATION OF
1.
K8

HOSPITAL
2.

SKILLED/NURSING FACILITY
IF “2” OR “3” ABOVE IS MARKED, CHECK APPROPRIATE ITEM(S) BELOW
1.
 ENTIRE FACILITY
2.
3.
 DISTINCT PART OF (SPECIFY)_____________________________

IF DISTINCT PART OF HOSPITAL, IS HOSPITAL ACCREDITED
BY JCAHO/AOA?
a.
YES
b.
NO


6. BED COMPOSITION
a. TOTAL NO. OF BEDS
IN THE FACILITY
b. NUMBER OF HOSPITAL BEDS
CERTIFIED FOR MEDICARE
c. NUMBER OF SKILLED BEDS
CERTIFIED FOR MEDICARE
d. NUMBER OF SKILLED BEDS
CERTIFIED FOR MEDICAID
K9: FOR STATE AGENCY USE ONLY
A.
The facility MEETS based upon:
I HAVE CONDUCTED A FIRE SAFETY SCREENING USING THE SHORT FORM:

 The facility meets all of the items on the form.
B.  The facility does not meet all of the items on the form.
C.  A complete fire safety survey is recommended.
A.
 Compliance with all provisions
 Acceptance of a Plan of Correction
3.  Recommended waivers.
1.
2.
B.
K9
SURVEYOR (Signature)
e. NUMBER OF ICF BEDS
CERTIFIED FOR MEDICAID
 The facility DOES NOT MEET THE STANDARD.
TITLE
OFFICE
DATE
TITLE
OFFICE
DATE
8. SURVEYOR I.D. NO
K10
REVIEW 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-2786S (06/07) EF 06/2007
Appendix 2-C
Page 1
Name of Facility
2000 CODE
ID
PREFIX
MET
NOT
MET
N/A
REMARKS
CORRIDOR WALLS AND DOORS
K18
2000 EXISTING
Doors protecting corridor openings in other than required
enclosures of vertical openings, exits, or hazardous areas shall
be substantial doors, such as those constructed of 13/4 inch
solid-bonded core wood, or capable of resisting fire for at least
20 minutes. Doors in fully sprinklered smoke compartments are
only required to resist the passage of smoke. There is no
impediment to the closing of the doors. Doors shall be provided
with a means suitable for keeping the door closed. Dutch
doors meeting 19.3.6.3.6 are permitted. 19.3.6.3 Roller latches
are prohibited by CMS regulations in all health care facilities.
Show in REMARKS, details of doors, such as fire protection
ratings, automatic closing devices, etc.
2000 New
Doors protecting corridor openings shall be constructed to resist
the passage of smoke. Doors shall be provided with positive
latching hardware. Dutch doors meeting 18.3.6.3.6 are permitted.
Roller latches shall be prohibited. 18.3.6.3
Show in REMARKS, details of doors, such as fire protection
ratings, automatic closing devices, etc.
K22
Access to exits shall be marked by approved, readily visible
signs in all cases where the exit or way to reach exit is not
readily apparent to the occupants. 7.10.1.4
VERTICAL OPENINGS
K20
2000 EXISTING
Stairways, elevator shafts, light and ventilation shafts, chutes,
and other vertical openings between floors are enclosed with
construction having a fire resistance rating of at least one hour.
An atrium may be used in accordance with 8.2.5.6, 19.3.1.1.
If all vertical openings are properly enclosed with construction
providing at least a two hour fire resistance rating, also check
this box. 
Form CMS-2786S (06/07) EF 06/2007
Appendix 2-C
Page 2
Name of Facility
ID
PREFIX
2000 CODE
MET
NOT
MET
N/A
REMARKS
If enclosures are less than required, give a brief description and
specific location in REMARKS.
2000 NEW
Stairways, elevator shafts, light and ventilation shafts, chutes,
and other vertical openings between floors are enclosed with
construction having a fire resistance rating of at least two hours
connecting four stories or more. (One hour for single story
building and sprinklered buildings up to three stories in height.)
18.3.1.1. An atrium may be used in accordance with 8.2.2.3.5.
If enclosures are less than required, give a brief description and
specific location in REMARKS.
SMOKE COMPARTMENTATION AND CONTROL
K23
2000 EXISTING
Smoke barriers shall be provided to form at least two smoke
compartments on every sleeping room floor for more than 30
patients. 19.3.7.1, 19.3.7.2
2000 NEW
Smoke barriers shall be provided to form at least two smoke
compartments on every floor used by inpatients for sleeping or
treatment, and on every floor with an occupant load of 50 or
more persons, regardless of use. Smoke barriers shall also be
provided on floors that are usable, but unoccupied. 18.3.7.1,
18.3.7.2
K28
2000 EXISTING
Door openings in smoke barriers shall provide a minimum clear
width of 32 inches (81 cm) for swinging or horizontal doors.
Vision panels are of fire-rated glazing or wired glass panels and
steel frames. 19.3.7.5, 19.3.7.7
Form CMS-2786S (06/07) EF 06/2007
Appendix 2-C
Page 3
Name of Facility
2000 CODE
ID
PREFIX
MET
NO
MET
N/A
REMARKS
2000 NEW
Door openings in smoke barriers are installed as swinging or
horizontal doors shall provide a minimum clear width as follows:
Provider Type
Swinging Doors
Horizontal Sliding Doors
Hospitals and
Nursing Facilities
41.5 inches
(105 cm)
83 inches
(211 cm)
Psychiatric Hospitals and
Limited Care Facilities
32 inches
(81 cm)
64 inches
(163 cm)
Vision panels of fire-rated glazing or wired panels in approved
frames are provided for each door. 18.3.7.5, 18.3.7.7
HAZARDOUS AREA
K29
2000 EXISTING
One hour fire rated construction (with 3/4 hour fire-rated doors) or
an approved automatic fire extinguishing system in accordance
with 8.4.1 and/or 19.3.5.4 protects hazardous areas. When the
approved automatic fire extinguishing system option is used, the
areas shall be separated from other spaces by smoke resisting
partitions and doors. Doors shall be self-closing and non-rated or
field-applied protective plates that do not exceed 48 inches from
the bottom of the door are permitted. 19.3.2.1
Area
Automatic Sprinkler
a. Boiler and Fuel-Fired Heater Rooms
c. Laundries (greater than 100 sq feet)
d. Repair Shops and Paint Shops
e. Laboratories (if classified a Severe Hazard - see K31)
f. Combustible Storage Rooms/Spaces (over 50 sq feet)
g. Trash Collection Rooms
i. Soiled Linen Rooms
Separation
N/A
Describe the floor and zone locations of hazardous areas that
are deficient in REMARKS.
Form CMS-2786S (06/07) EF 06/2007
Appendix 2-C
Page 4
Name of Facility
2000 CODE
ID
PREFIX
MET
NO
MET
N/A
REMARKS
2000 NEW
Hazardous areas are protected in accordance with 8.4. The
areas shall be enclosed with a one hour fire-rated barrier, with a
3
/4 hour fire-rated door, without windows (in accordance with 8.4).
Doors shall be self-closing or automatic closing in accordance
with 7.2.1.8. 18.3.2.1
Area
Automatic Sprinkler
a. Boiler and Fuel-Fired Heater Rooms
c. Laundries (greater than 100 sq feet)
d. Repair, Maintenance and Paint Shops
e. Laboratories (if classified a Severe Hazard - see K31)
f. Combustible Storage Rooms/Spaces
(over 50 and less than 100 sq feet)
g. Trash Collection Rooms
i. Soiled Linen Rooms
m.Combustible Storage Rooms/Spaces (over 100 sq feet)
Separation
N/A
Describe the floor and zone locations of hazardous areas that
are deficient in REMARKS.
K30
Gift shops shall be protected as hazardous areas when used for
storage or display of combustibles in quantities considered
hazardous. Non-rated walls may separate gift shops that are not
considered hazardous, have separate protected storage and that
are completely sprinkled. Gift shops may be open to the corridor
if they are not considered hazardous, have separate protected
storage, are completely sprinklered and do not exceed 500
square ºfeet. 18.3.2.5, 19.3.2.5
Area
L. Gift Shop storing hazardous quantities
of combustibles
Automatic Sprinkler
Separation
N/A
18.2.6, 19.2.6
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 482.41, 483.70, 483.623
Form CMS-2786S (06/07) EF 06/2007
Appendix 2-C
Page 5
Name of Facility
2000 CODE
ID
PREFIX
K211
MET
NO
MET
N/A
REMARKS
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 482.41, 483.70, 483.623
EXISTS AND EGRESS
K38
Exit access is so arranged that exits are readily accessible at all
times in accordance with 7.1.
18.2.1, 19.2.1
K39
2000 EXISTING
Width of aisles or corridors (clear and unobstructed) serving as
exit access shall be at least 4 feet. 19.2.3.3
2000 NEW
Width of aisles or corridors (clear and unobstructed) serving as
exit access in hospitals and nursing homes shall be at least 8
feet. In limited care facility and psychiatric hospitals, width of
aisles or corridors shall be at least 6 feet. 18.2.3.3, 18.2.3.4
K40
2000 EXISTING
Exit access doors and exit doors used by health care occupants
are of the swinging type and are at least 32 inches in clear width.
19.2.3.5
2000 NEW
Exit access doors and exit doors used by health care occupants
are of the swinging type, with openings of at least 41.5 inches
wide. Doors in exit stairway enclosures shall be no less than 32
inches in clear width. In ICFs/MR, doors are at least 32 inches
wide. 18.2.3.5
Form CMS-2786S (06/07) EF 06/2007
Appendix 2-C
Page 6
Name of Facility
2000 CODE
ID
PREFIX
K43
MET
NO
MET
N/A
REMARKS
Patient room doors are arranged such that the patients can open
the door from inside without using a key.
Special door locking arrangements are permitted in health
facilities. 18.2.2.2.4, 18.2.2.2.5
If door locking arrangement without delay egress is used
indicate in REMARKS
18.2.2.2.2, 19.2.2.2.2
ILLUMINATION AND EMERGENCY POWER
K45
Illumination of means of egress, including exit discharge, is
arranged so that failure of any single lighting fixture (bulb) will
not leave the area in darkness.
18.2.8, 19.2.8, 7.8
K47
2000 EXISTING
Exit and directional signs are displayed in accordance with 7.10
with continuous illumination also served by the emergency
lighting system.
19.2.10.1
(Indicate N/A in one story buildings with less than 30 occupants
where the line of exit travel is obvious.)
2000 NEW
Exit and directional signs are displayed with continuous
illumination also served by the emergency lighting, system in
accordance with 7.10.
18.2.10.1
K105
2000 NEW (INDICATE N/A FOR EXISTING)
Buildings equipped with or requiring the use of life support
systems (electro-mechanical or inhalation anesthetics) have
illumination of means of egress, emergency lighting equipment,
exit, and directional signs supplied by the Life Safety Branch of
the electrical system described in NFPA 99. 18.2.9.2., 18.2.10.2,
18.5.1.1, 18.5.1.2
(Indicate N/A if life support equipment is for emergency
purposes only).
Form CMS-2786S (06/07) EF 06/2007
Appendix 2-C
Page 7
Name of Facility
2000 CODE
ID
PREFIX
MET
NO
MET
N/A
REMARKS
EMERGENCY PLAN AND FIRE DRILLS
K48
There is a written plan for the protection of all patients and for
their evacuation in the event of an emergency.
18.7.1.1, 19.7.1.1
K50
Fire drills are held at unexpected times under varying conditions,
at least quarterly on each shift. The staff is familiar with
procedures and is aware that drills are part of established routine.
Responsibility for planning and conducting drills is assigned only
to competent persons who are qualified to exercise leadership.
Where drills are conducted between 9:00 PM and 6:00 AM a
coded announcement may be used instead of audible alarms.
18.7.1.2, 19.7.1.2
FIRE ALARM SYSTEMS
K51
2000 EXISTING
A fire alarm system with approved component, devices or
equipment installed according to NFPA 72, National Fire Alarm
Code to provide effective warning of fire in any part of the
building. Activation of the complete fire alarm system shall be by
manual fire alarm initiation, automatic detection or extinguishing
system operation. Pull stations in patient sleeping areas, may
be omitted provided that manual pull stations are within 200 ft of
nurse’s stations. Pull stations are located in the path of egress.
Electronic or written records of tests shall be available. A reliable
second source of power must be provided. Fire alarm systems
shall be in accordance with NFPA 72, and records of maintenance
kept readily available. There shall be annunciation of the fire
alarm system to an approved central station. 19.3.4, 9.6
2000 NEW
A fire alarm system with approved component, devices or
equipment installed according to NFPA 72, to provide effective
warning of fire in any part of the building. Activation of the
complete fire alarm system shall be by manual fire alarm initiation,
automatic detection or extinguishing system operation. Pull
stations are located in the path of egress. Electronic or written
records of tests shall be available. A reliable second source of
power must be provided. Fire alarm systems shall be maintained
in accordance with NFPA72, and records of maintenance kept
readily available. There shall be remote annunciation of the fire
alarm system to an approved central station. 18.3.4, 9.6
Form CMS-2786S (06/07) EF 06/2007
Appendix 2-C
Page 8
Name of Facility
ID
PREFIX
2000 CODE
MET
K52
A fire alarm system required for life safety shall be installed,
tested, and maintained in accordance with NFPA 70 National
Electrical Code and NFPA 72. The system shall have an
approved maintenance and testing program complying with
applicable requirement of NFPA 70 and 72. 9.6.1.4
K155
Where a required fires 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
K53
2000 EXISTING (INDICATE N/A FOR HOSPITALS AND
FULLY SPRINKLERED NURSING HOMES)
In an existing nursing home, not fully sprinklered, the resident
sleeping rooms and public areas (dining rooms, activity rooms,
resident meeting rooms, etc) are to be equipped with single
station battery-operated smoke detectors. There will be a testing,
maintenance and battery replacement program to ensure proper
operation. CFR 483.70
NO
MET
N/A
REMARKS
2000 NEW (NURSING HOME AND EXISTING LIMITED
CARE FACILITIES)
An automatic smoke detection system is installed in all corridors.
(As an alternative to the corridor smoke detection system on
patient sleeping room floors, smoke detectors may be installed in
each patient sleeping room and at smoke barrier or horizontal
exit doors in the corridor.) Such detectors are electrically
interconnected to the fire alarm system. 18.3.4.5.3
Form CMS-2786S (06/07) EF 06/2007
Appendix 2-C
Page 9
Name of Facility
2000 CODE
ID
PREFIX
K109
MET
NO
MET
N/A
REMARKS
2000 EXISTING LIMITED CARE FACILITIES
(INDICATE N/A FOR HOSPITALS OR NURSING HOMES)
An automatic smoke detection system is installed in all corridors,
with detector spacing no further apart than 30 ft on center in
accordance with NFPA 72. (As an alternative to the corridor
smoke detection system on patient sleeping room floors, smoke
detectors may be installed in each patient sleeping room and at
smoke barrier or horizontal exit doors in the corridors.) Such
detectors are electrically interconnected to the fire alarm system.
19.3.4.5.1
Smoke Detection System
 Corridors
 Rooms
 Bath
AUTOMATIC SPRINKLER SYSTEMS
K56
2000 EXISTING
Where required by section 19.1.6, Health care facilities shall be
protected throughout by an approved, supervised automatic
sprinkler system in accordance with section 9.7. Required
sprinkler systems are equipped with water flow and tamper
switches which are electrically interconnected to the building fire
alarm. 19.3.5, NPFA 13
2000 NEW
When required by construction type, there is an automatic
sprinkler system installed in accordance with NFPA13, Standard
for the Installation of Sprinkler Systems, with approved
components, device and equipment, to provide complete
coverage of all portions of the facility. Systems are equipped with
waterflow and tamper switches, which are connected to the fire
alarm system. 18.3.5.
A. Date sprinkler system last checked and necessary
maintenance provided. _______________________________
B. Show who provided the service. _______________________
Form CMS-2786S (06/07) EF 06/2007
Appendix 2-C
Page 10
Name of Facility
2000 CODE
ID
PREFIX
MET
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
K62
Automatic sprinkler systems are continuously maintained
in reliable operating condition and are inspected and tested
periodically. 18.7.6, 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5
K64
Portable fire extinguishers shall be provided in all health care
occupancies in accordance with 9.7.4.1, NFPA 10.
18.3.5.6, 19.3.5.6
NO
MET
N/A
REMARKS
SMOKING REGULATIONS
K66
Smoking regulations shall be adopted and shall include not less
than the following provisions: 18.7.4, 19.7.4
 (1) Smoking shall be prohibited in any room, ward, or
compartment where flammable liquids, combustible gases,
or oxygen is used or stored in any other hazardous location,
and such area shall be posted with signs that read NO
SMOKING or shall be posted with the international symbol
for no smoking.
 (2) Smoking by patients classified as not responsible shall be
prohibited, except when under direct supervision.
 (3) Ashtrays of noncombustible material and safe design shall
be provided in all areas where smoking is permitted.
 (4) Metal containers with self-closing cover devices into which
ashtrays can be emptied shall be readily available to all
areas where smoking is permitted.
Form CMS-2786S (06/07) EF 06/2007
Appendix 2-C
Page 11
Name of Facility
2000 CODE
ID
PREFIX
MET
NO
MET
N/A
REMARKS
BUILDING SERVICE EQUIPMENT
K70
Portable space heating devices shall be prohibited in all health
care occupancies. Except it shall be permitted to be used in
non-sleeping staff and employee areas where the heating
elements of such devices do not exceed 212oF (100oC).
18.7.8, 19.7.8
FURNISHINGS AND DECORATIONS
K72
Means of egress shall be continuously maintained free of all
obstructions or impediments to full instant use in the case of fire
or other emergency. No furnishings, decorations, or other objects
shall obstruct exits, access thereto, egress there from, or visibility
thereof shall be in accordance with 7.1.10
K74
Draperies, curtains, including cubicle curtains, and other loosely
hanging fabrics and films serving as furnishings or decorations in
health care occupancies shall be in accordance with provisions
of 10.3.1 and NFPA 13 Standard for the Installation of Sprinkler
Systems. Except shower curtains shall be in accordance with
NFPA 701.
 Newly introduced upholstered furniture shall meet the
criteria specified when tested in accordance with the methods
cited in 10.3.2 (2) and 10.3.1. 18.3.5.3 and NFPA 13
LABORATORIES
K31
Laboratories employing quantities of flammable, combustible, or
hazardous materials that are considered a severe hazard shall be
protected in accordance with NFPA 99. (Laboratories that are not
considered to be severe hazard shall meet the provision of K29.)
Laboratories in Health Care occupancies and medical and dental
offices shall be in accordance with NFPA 99, Standard for Health
Care Facilities 10.5.1.
Form CMS-2786S (06/07) EF 06/2007
Appendix 2-C
Page 12
Name of Facility
ID
PREFIX
2000 CODE
MET
K134
Emergency Shower:
Where the eyes or body of any person can be exposed to
injurious corrosive materials, suitable fixed facilities for quick
drenching or flushing of the eyes and body shall be provided
within the work area for immediate emergency use. Fixed eye
baths designed and installed to avoid injurious water pressure
shall be in accordance with NFPA 99, 10.6.
K135
Flammable and combustible liquids shall be used from and
stored in approved containers in accordance with NFPA 30,
Flammable and Combustible Liquids Code, and NFPA 45,
Standard on Fire Protection for Laboratories Using Chemicals.
Storage cabinets for flammable and combustible liquids shall be
constructed in accordance with NFPA 30, Flammable and
Combustible liquids Code NFPA 99, 4.3, 10.7.2.1.
NO
MET
N/A
REMARKS
MEDICAL GASES AND ANESTHETIZING AREAS
K76
Medical gas storage and administration areas shall be protected
in accordance with NFPA 99, Standard for Health Care Facilities.
(a) Oxygen storage locations of greater than 3,000 cu.ft. are
enclosed by a one-hour separation.
(b) Locations for supply systems of greater than 3,000 cu.ft. are
vented to the outside. NFPA 99, 4.3.1.1.2, 18.3.2.4, 19.3.2.4
K141
Non-smoking and no smoking signs in areas where oxygen is
used or stored shall be in accordance with 18.3.2.4, 19.3.2.4,
NFPA 99, 8.6.4.2
K143
Transferring of oxygen shall be:
(a) separated from any portion of a facility wherein patients
are housed, examined, or treated by a separation of a fire
barrier of 1-hour fire-resistive construction; and
(b) the area that is mechanically ventilated, sprinklered, and
has ceramic or concrete flooring; and
(c) in an area that is posted with signs indicating that
transferring is occurring, and that smoking in the
immediate area is not permitted in accordance with
NFPA 99 and Compressed Gas Association. 8.6.2.5.2
Form CMS-2786S (06/07) EF 06/2007
Appendix 2-C
Page 13
Name of Facility
2000 CODE
ID
PREFIX
MET
NO
MET
N/A
REMARKS
ELECTRICAL
K144
Generators inspected weekly and exercised under load for
30 minutes per month and shall be in accordance with NFPA 99,
3.4.4.1, NFPA 110, 8.4.2.
K146
The nursing home/hospice with no life support equipment shall
have an alternate source of power separate and independent
from the normal source that will be effective for minimum of 11/2
hour after loss of the normal source NFPA 99, 3.6
K130
Miscellaneous
List in the REMARKS sections, any items that are not listed
previously, but are deficient. This information, along with the
applicable Life Safety Code or NFPA standard citation, should
be included on Form CMS-2567.
Form CMS-2786S (06/07) EF 06/2007
Appendix 2-C
Page 14
FIRE SAFETY SURVEY REPORT
CRUCIAL DATA EXTRACT
(TO BE USED WITH CMS-2786 FORMS)
PROVIDER NUMBER
FACILITY NAME
SURVEY DATE
* K4
* K4 MULTIPLE
CONSTRUCTION
TOTAL NUMBER OF BUILDINGS ____________
NUMBER OF THIS BUILDING
____________
LSC FORM INDICATOR
1
2
3
4
5
6
7
8
9
*K7
BUILDING
WING
FLOOR
APARTMENT UNIT
COMPLETE IF ICF/MR IS SURVEYED UNDER CHAPTER 21
2786 A-67
EXISTING
A-67
NEW
B-73
EXISTING
B-73
NEW
F-81
EXISTING
F-81
NEW
C-SHORT
H-ASC
J, K, L
85-CHAPTER 21
(ICFs/MR ONLY)
P-85
EXISTING
P-85
NEW
10
11
A
B
C
D
SMALL
(16 BEDS OR LESS)
K8:
1 PROMPT
2 SLOW
3 IMPRACTICAL
LARGE
K8:
4 PROMPT
5 SLOW
6 IMPRACTICAL
APARTMENT HOUSE
7 PROMPT
SELECT NUMBER OF FORM USED FROM ABOVE
K8:
8 SLOW
9 IMPRACTICAL
(Check if not applicable)
ENTER E – SCORE HERE
K29:
K56:
K5:
e.g. 2.5
*K9: FACILITY MEETS LSC BASED ON: (Check all that apply)
A1.
(COMP. WITH ALL PROVISIONS)
FACILITY DOES NOT MEET LSC:
B.
A2.
A3.
(ACCEPTABLE POC)
A4.
(WAIVERS)
(FSES)
K0180
A.
FULLY SPRINKLERED
B.
PARTIALLY SPRINKLERED
(All required areas are sprinklered) (Not all required areas are sprinklered)
C.
NONE
(No sprinkler system)
* MANDATORY
Form CMS-2786S (06/07) EF 06/2007
Page 14
Appendix 2-C
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
Form Approved
OMB No. 0938-0242
ZONE __________ OF __________ ZONES
FIRE/SMOKE ZONE* EVALUATION WORKSHEET FOR HEALTH CARE FACILITIES
2000 LIFE SAFETY CODE
FACILITY
BUILDING
ZONE(S) EVALUATED
PROVIDER/VENDOR NO.
DATE OF SURVEY
COMPLETE THIS WORKSHEET FOR EACH ZONE. WHERE CONDITIONS ARE THE SAME IN SEVERAL ZONES,
ONE WORKSHEET CAN BE USED FOR THOSE ZONES.
Step 1: Determine Occupancy Risk Parameter Factors - Use Table 1.
A. For each Risk Parameter in Table 1, select and circle the appropriate risk factor value.
Choose only one for each of the five Risk Parameters.
TABLE 1. OCCUPANCY RISK PARAMETER FACTORS
Risk Parameters
Risk Factors Values
1. Patient
Mobility (M)
Mobility Status
Mobile
Limited Mobility
Not Mobile
Not Movable
Risk Factor
1.0
1.6
3.2
4.5
2. Patient
Density (D)
No. of Patients
1–5
6–10
11–30
>30
Risk Factor
1.0
1.2
1.5
2.0
3. Zone
Location (L)
4. Ratio of
Patients to
Attendants (T)
5. Patient
Average
Age (A)
Floor
1st
2nd or 3rd
4th to 6th
7th and Above
Basements
Risk Factor
1.1
1.2
1.4
1.6
1.6
Patients
Attendant
1–2
1
3–5
1
6–10
1
>10
1
One or More
None
Risk Factor
1.0
1.1
1.2
1.5
4.0
Age
Under 65 Years and Over 1 year
65 Years and Over 1 Year and Younger
Risk Factor
1.0
1.2
Step 2: Compute Occupancy Risk Factor (F) - Use Table 2.
A. Transfer the circled risk factor values from Table 1 to the corresponding blocks in Table 2.
B. Compute F by multiplying the risk factor values as indicated in Table 2.
TABLE 2. OCCUPANCY RISK FACTOR CALCULATION
M
OCCUPANCY RISK
Step 3:
A.
B.
C.
D
L
T
A
F
xxxx =
Compute Adjusted Building Status (R) - Use Table 2.
If building is classified as “NEW” use Table 3A. If building is classified as “Existing” use Table 3B.
Transfer the value of F from Table 2 to Table 3A or Table 3B as appropriate. Calculate R.
Transfer R to the block labeled R in Table 7 on page 4 of the work sheet.
TABLE 3A. (NEW BUILDINGS)
F
1.0
x
TABLE 3B. (EXISTING BUILDINGS)
R
F
=
0.6
x
R
=
* FIRE/SMOKE ZONE is a space separated from all other spaces by floors, horizontal exIts, or smoke barrIers.
SURVEYOR SIGNATURE
TITLE
DATE
FIRE AUTHORITY SIGNATURE
TITLE
DATE
Form CMS-2786T (06/07) EF 06/2007
Appendix 2-D
Page 1
Step 4: Determine Safety Parameter Values - Use Table 4.
A. Select and circle the safety value for each safety parameter in Table 4 that best describes the conditions
in the zone. Choose only one value for each of the 13 parameters. If two or more appear to apply, choose
the one with the lowest point value.
TABLE 4.
Safety Parameters
Safety Parameters Values
1. Construction
Floor or Zone
First
Second
Third
4th and Above
Combustible
Types III, IV, and V
000
-2
-7
-9
-13
NonCombustible
Types I and II
111
0
-2
-7
-7
200
-2
-4
-9
-13
211 + 2HH
0
-2
-7
-7
000
0
-2
-7
-9
111
2
2
2
-7
2. Interior Finish
(Corridors and Exits)
Class C
-5(0)f
Class B
0(3)f
Class A
3
3. Interior Finish
(Rooms)
Class C
-3(1)f
Class B
1(3)f
Class A
3
None or Incomplete
-10(0)a
<1/2 hour
0
>1/2 to <1 hour
1(0)a
>1 hour
2(0)a
No Door
<20 min FPR
>20 min FPR
>20 min FPR and
Auto Clos.
-10
0
1(0)d
2(0)d
4. Corridor
Partitions/Walls
5. Doors to Corridor
6. Zone Dimensions
7. Vertical Openings
>100 ft
Dead End
>50 ft to 100 ft
30 ft to 50 ft
-6(0)b
-4(0)b
-2(0)b
Open 4 or More
Floors
Open 2 or 3
Floors
-14
-10
8. Hazardous Areas
9. Smoke Control
10. Emergency
Movement
Routes
No Control
Smoke Barrier
Serves Zone
-5(0)c
0
13. Automatic
Sprinklers
NOTE:
2(0)e
3(0)e
0
No Manual Fire Alarm
No Deficiencies
0
1
Direct Exit(s)
5
Manual Fire Alarm
W/O F.D. Conn.
W/F.D. Conn
1
2
None
Corridor Only
Rooms Only
Corridor and
Habit. Spaces
Total Spaces
In Zone
0(3)g
2(3)g
3(3)g
4
5
None
Corridor and
Habit. Space
Entire
Building
0
8
10
Use (0) where parameter 5 is -10.
b
Use (0) where parameter 10 is -8.
c
Use (0) on floor with fewer than 31 patients
(existing buildings only)
d
Use (0) where parameter 4 is -10.
Form CMS-2786T (06/07) EF 06/2007
>2 hr
0
3
-2
a
For SI units: 1 ft = 0.3048 m
<1 hr
Multiple Routes
W/O Horizontal
Horizontal
Exit(s)
Exit(s)
-4
12. Smoke Detection
and Alarm
1
Mech. Assisted Systems
by Zone
Deficient
11. Manual Fire Alarm
0
Enclosed with Indicated Fire Resist.
>1 hr to <2 hr
Single Deficiency
In Zone
In Adjacent Zone
-6
-2
<2 Routes
-8
No Dead Ends >30 ft and Zone Length Is
>150 ft
100 ft to 150 ft
<100 ft
-2(0)c
Double Deficiency
In Zone
Outside Zone
-11
-5
222, 332, 433
2
4
4
4
e
Use (0) where Parameter 1 is based on first floor zone or on an
unprotected type of construction (columns marked “000” or “200”)
f
Use ( ) if the area of Class B or C interior finish in the corridor
and exit or room is protected by automatic sprinklers and
Parameter 13 is 0; use ( ) if the room with existing Class C
interior finish is protected by automatic sprinklers, Parameter 4
is greater than or equal to 1, and Parameter 13 is 0.
g
Use this value in addition to Parameter 13 if the entire zone is
protected with quick-response automatic sprinklers.
Appendix 2-D
Page 2
Step 5: Compute Individual Safety Evaluations – Use Table 5.
A. Transfer each of the 13 circled Safety Parameter Values from Table 4 to every unshaded block in the line
with the corresponding Safety Parameter in Table 5. For Safety Parameter 13 (Sprinklers) the value
entered in the People Movement Safety column is recorded in Table 5 as 1/2 the corresponding value
circled in Table 4.
B. Add the four columns, keeping in mind that any negative numbers deduct.
C. Transfer the resulting total values for S1, S2, S3, SG to blocks labeled S1, S2, S3, SG in Table 7 on page 4
of this sheet.
TABLE 5. INDIVIDUAL SAFETY EVALUATIONS
Containment
Safety (S1)
Safety Parameters
Extinguishment
Safety (S2)
People Movement
Safety (S3)
General
Safety (S4)
1. Construction
2. Interior Finish
(Corr. and Exit)
3. Interior Finish (Rooms)
4. Corridor Partitions/Walls
5. Doors to Corridor
6. Zone Dimensions
7. Vertical Openings
8. Hazardous Areas
9. Smoke Control
10. Emergency Movement Routes
11. Manual Fire Alarm
12. Smoke Detection and Alarm
–.. 2 =
13. Automatic Sprinklers
S1=
Total Value
S2=
S3=
S4=
TABLE 6.
MANDATORY SAFETY REQUIREMENTS (FOR USE IN HOSPITALS OR NURSING HOMES)
Containment
(Sa)
Zone Location
1st story
2nd or 3rd storyb
4th story or higher
Extinguishment
(Sb)
New
Exist.
11
15
18
5
9
9
New
15(12)a
17(14)a
19(16)a
People Movement
(Sc)
Exist.
New
Exist.
4
6
6
8(5)a
10(7)a
11(8)a
1
3
3
a. Use ( ) in zones that do not contain patient sleeping rooms.
b. For a 2nd story zone location in a sprinklered EXISTING facility, as an alternative to the mandatory safety
requirement values set specified in the table, the following mandatory values set shall be permitted to be
used: Sa=7, Sb=10, and Sc=7
Form CMS-2786T (06/07) EF 06/2007
Appendix 2-D
Page 3
Step 6: Determine Mandatory Safety Requirement Values - Use Table 6.
A. Using the classification of the building (i.e., New or Existing) and the floor where the zone is located circle the
appropriate value in each of the three columns in Table 6.
B. Transfer the three circled values from Table 6 to the blocks marked Sa, Sb, and Sc in Table 7.
C. For each row check “Yes” if the value in the answer block is zero or greater. Check “No” if the value in the
answer block is a negative number.
TABLE 7. ZONE FIRE SAFETY EQUIVALENCY EVALUATION
Containment
Safety (S1)
minus
Mandatory
Containment (S )
≥0
Extinguishment
Safety (S2)
minus
Mandatory
Extinguishment (S )
≥0
People Movement minus
Safety (S3)
Mandatory People
Movement (S )
≥0
General
Safety (S4)
Occupancy
Risk (R)
≥0
a
b
minus
c
-=
-=
-=
-=
S1
Sa
C
S2
Sb
E
S3
Sc
P
S4
R
G
No
Yes
TABLE 8. FACILITY FIRE SAFETY REQUIREMENTS WORKSHEET
Complete one copy of this worksheet for each facility.
For each consideration, select and mark the appropriate column.
A.
Building utilities conform to the requirements of Section 9.1.
B.
In new facilities only, life-support systems, alarms, emergency communication systems, and
illumination of generator set locations are powered as prescribed by 18.5.1.2 and 18.5.1.3.
C.
Heating and air conditioning systems conform with the air conditioning, heating, and ventilating
systems requirements within Section 9.2, except for enclosure of vertical openings, which have
been considered in Safety Parameter 7 of Worksheet 4.7.6.
D.
Fuel-burning space heaters and portable electrical space heaters are not used.
E.
There are no flue-fed incinerators.
F.
An evacuation plan is provided and fire drills conducted in accordance with 18.7.1/18.7.2 and
19.7.1/19.7.2.
G.
Smoking regulations have been adopted and implemented in accordance with 18.7.4 and 19.7.4.
H.
Draperies, upholstered furniture, mattresses, furnishings, and decoration combustibility is limited
in accordance with 18.7.5 and 19.7.5.
I.
J.
K.
Fire extinguishers are provided in accordance with the requirements of 18.3.5.4 and 19.3.5.6.
Exit signs are provided in accordance with the requirements of 18.2.10.1 and 19.2.10.
Emergency lighting is provided in accordance with 18.2.9.1 or 19.2.9.
L.
Standpipes are provided in all new high rise buildings as required by 18.4.2.
Met
Not
Met
Not
Applic.
CONCLUSIONS
1.
 All of the checks in Table 7 are in the “Yes” column. The level of fire safety is at least equivalent to that
prescribed by the Life Safety Code.*
2.
 One of more of the checks in Table 7
are in the “No” column. The level of fire safety is not shown by this
system to be equivalent to that prescribed by the Life Safety Code.*
*The equivalency covered by this worksheet includes the majority of considerations covered by the Life Safety Code. There are a few
considerations that are not evaluated by this method. These must be considered separately. These additional considerations are covered in
Table 8, the “Facility Fire Safety Requirements Worksheet.” One copy of this separate worksheet is to be completed for each facility.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid
OMB control number for this information collection is 0938-0242. The time required to complete this information collection is estimated to average 5 minutes per response,
including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments
concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard,
Baltimore, Maryland 21244-1850.
Form CMS-2786T (06/07) EF 06/2007
Appendix 2-D
Page 4
FIRE SAFETY SURVEY REPORT
CRUCIAL DATA EXTRACT
(TO BE USED WITH CMS-2786 FORMS)
PROVIDER NUMBER
FACILITY NAME
SURVEY DATE
K1
K6
* K4
K3
DATE OF PLAN
APPROVAL
MULTIPLE CONSTRUCTION
TOTAL NUMBER OF BUILDINGS ____________
NUMBER OF THIS BUILDING
LSC FORM INDICATOR
____________
12
13
14
15
ASC Form
2000 EXISTING
2000 NEW
SMALL
(16 BEDS OR LESS)
K8:
1 PROMPT
2 SLOW
3 IMPRACTICAL
LARGE
K8:
ICF/MR Form
2786V, W, X
2000 EXISTING
2786V, W, X
2000 NEW
16
17
SELECT NUMBER OF FORM USED FROM ABOVE
*K9:
7 PROMPT
8 SLOW
9 IMPRACTICAL
ENTER E – SCORE HERE
(Check if K29 or K56 are marked as not applicable
in the 2786 M, R, T, U, V, W, X and Y.)
K29:
4 PROMPT
5 SLOW
6 IMPRACTICAL
APARTMENT HOUSE
K8:
* K7
BUILDING
WING
FLOOR
APARTMENT UNIT
COMPLETE IF ICF/MR IS SURVEYED UNDER CHAPTER 21
Health Care Form
2786R
2000 EXISTING
2786R
2000 NEW
2786U
2786U
A
B
C
D
K5:
K56:
e.g. 2.5
FACILITY MEETS LSC BASED ON (Check all that apply)
A1.
(COMP. WITH
ALL PROVISIONS)
A2.
(ACCEPTABLE POC)
FACILITY DOES NOT MEET LSC
B.
A3.
A4.
(WAIVERS)
A5.
(FSES)
(PERFORMANCE
BASED DESIGN)
K0180
A.
FULLY SPRINKLERED
B.
PARTIALLY SPRINKLERED
(All required areas are sprinklered) (Not all required areas are sprinklered)
C.
NONE
(No sprinkler system)
* MANDATORY
Form CMS-2786T (06/07) EF 06/2007
Page 5
Appendix 2-D
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.
(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
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.
Form CMS-2786V (06/07) EF 06/2007
Appendix 2-E
Page 1
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.
Form CMS-2786V (06/07) EF 06/2007
Appendix 2-E
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” (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.)
Form CMS-2786V (06/07) EF 06/2007
Appendix 2-E
Page 3
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.
Form CMS-2786V (06/07) EF 06/2007
Appendix 2-E
Page 4
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).
CALCULATION OF E-SCORE
Scoresheet F-2C
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
Level of Evacuation Difficulty
≤ 1.5
Prompt
> 1.5 ≤ 5.0
Slow
> 5.0
Impractical
Form CMS-2786V (06/07) EF 06/2007
Level of Evacuation
Difficulty
Appendix 2-E
Page 5
ID
PREFIX
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.
Form CMS-2786V (06/07) EF 06/2007
Appendix 2-E
Page 6
ID
PREFIX
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.
Form CMS-2786V (06/07) EF 06/2007
Appendix 2-E
Page 7
ID
PREFIX
NO
MET MET
N/A
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
Form CMS-2786V (06/07) EF 06/2007
Appendix 2-E
Page 8
ID
PREFIX
NO
MET MET
N/A
REMARKS
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.
Form CMS-2786V (06/07) EF 06/2007
Appendix 2-E
Page 9
ID
PREFIX
NO
MET MET
N/A
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.
Form CMS-2786V (06/07) EF 06/2007
Appendix 2-E
Page 10
ID
PREFIX
NO
MET MET
N/A
REMARKS
 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.
Form CMS-2786V (06/07) EF 06/2007
Appendix 2-E
Page 11
ID
PREFIX
NO
MET MET
N/A
REMARKS
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.
Form CMS-2786V (06/07) EF 06/2007
Appendix 2-E
Page 12
ID
PREFIX
NO
MET MET
N/A
REMARKS
 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.
Form CMS-2786V (06/07) EF 06/2007
Appendix 2-E
Page 13
ID
PREFIX
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:
Form CMS-2786V (06/07) EF 06/2007
Appendix 2-E
Page 14
ID
PREFIX
NO
MET MET
N/A
REMARKS
(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.
Form CMS-2786V (06/07) EF 06/2007
Appendix 2-E
Page 15
ID
PREFIX
NO
MET MET
N/A
REMARKS
(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.
Form CMS-2786V (06/07) EF 06/2007
Appendix 2-E
Page 16
ID
PREFIX
NO
MET MET
N/A
REMARKS
 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.
Form CMS-2786V (06/07) EF 06/2007
Appendix 2-E
Page 17
ID
PREFIX
K21
NO
MET MET
N/A
REMARKS
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.
Form CMS-2786V (06/07) EF 06/2007
Appendix 2-E
Page 18
ID
PREFIX
NO
MET MET
N/A
REMARKS
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
Form CMS-2786V (06/07) EF 06/2007
Appendix 2-E
Page 19
ID
PREFIX
NO
MET MET
N/A
REMARKS
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
Form CMS-2786V (06/07) EF 06/2007
Appendix 2-E
Page 20
ID
PREFIX
NO
MET MET
N/A
REMARKS
 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.
Form CMS-2786V (06/07) EF 06/2007
Appendix 2-E
Page 21
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MET MET
N/A
REMARKS
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.
Form CMS-2786V (06/07) EF 06/2007
Appendix 2-E
Page 22
ID
PREFIX
NO
MET MET
N/A
REMARKS
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.
Form CMS-2786V (06/07) EF 06/2007
Appendix 2-E
Page 23
ID
PREFIX
NO
MET MET
N/A
REMARKS
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.
Form CMS-2786V (06/07) EF 06/2007
Appendix 2-E
Page 24
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N/A
REMARKS
(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.
Form CMS-2786V (06/07) EF 06/2007
Appendix 2-E
Page 25
FIRE SAFETY SURVEY REPORT
CRUCIAL DATA EXTRACT
(TO BE USED WITH CMS-2786 FORMS)
PROVIDER NUMBER
FACILITY NAME
SURVEY DATE
K1
K6
* K4
K3
DATE OF PLAN
APPROVAL
MULTIPLE CONSTRUCTION
TOTAL NUMBER OF BUILDINGS ____________
NUMBER OF THIS BUILDING
LSC FORM INDICATOR
____________
12
13
14
15
ASC Form
2000 EXISTING
2000 NEW
SMALL
(16 BEDS OR LESS)
K8:
1 PROMPT
2 SLOW
3 IMPRACTICAL
LARGE
K8:
ICF/MR Form
2786V, W, X
2000 EXISTING
2786V, W, X
2000 NEW
16
17
SELECT NUMBER OF FORM USED FROM ABOVE
*K9:
7 PROMPT
8 SLOW
9 IMPRACTICAL
ENTER E – SCORE HERE
(Check if K29 or K56 are marked as not applicable
in the 2786 M, R, T, U, V, W, X and Y.)
K29:
4 PROMPT
5 SLOW
6 IMPRACTICAL
APARTMENT HOUSE
K8:
* K7
BUILDING
WING
FLOOR
APARTMENT UNIT
COMPLETE IF ICF/MR IS SURVEYED UNDER CHAPTER 21
Health Care Form
2786R
2000 EXISTING
2786R
2000 NEW
2786U
2786U
A
B
C
D
K5:
K56:
e.g. 2.5
FACILITY MEETS LSC BASED ON (Check all that apply)
A1.
(COMP. WITH
ALL PROVISIONS)
A2.
(ACCEPTABLE POC)
FACILITY DOES NOT MEET LSC
B.
A3.
A4.
(WAIVERS)
A5.
(FSES)
(PERFORMANCE
BASED DESIGN)
K0180
A.
FULLY SPRINKLERED
B.
PARTIALLY SPRINKLERED
(All required areas are sprinklered) (Not all required areas are sprinklered)
C.
NONE
(No sprinkler system)
* MANDATORY
Form CMS-2786V (06/07) EF 06/2007
Page 26
Appendix 2-E
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. (B) ADDRESS OF FACILITY (STREET, CITY, STATE, ZIP CODE A.
2. (A) MULTIPLE CONSTRUCTION
2. NAME OF FACILITY
 Fully Sprinklered
(All required areas are sprinklered)
A. BUILDING
B.
C.
C. FLOOR
4. DATE OF SURVEY
DATE OF PLAN APPROVAL
SURVEY UNDER:
K4
K6
K7
9.
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.
 None (No sprinkler system)
K0180
K3
E–Score
 Partially Sprinklered
(Not all required areas are sprinklered)
B. WING
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.
Form CMS-2786W (06/07) EF 06/2007
Page 1
Appendix 2-F
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
Form CMS-2786W (06/07) EF 06/2007
Page 2
Appendix 2-F
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)
DATE
Form CMS-2786W (06/07) EF 06/2007
Page 3
Appendix 2-F
Worksheet 6.8.1 Cover Sheet
Resident’s name___________________________________________________________________________________
Evaluator___________________________________________________________________________________
Facility __________________________________________________________________________________________
Date ______________________________________________________________________________________
Zone ______________________________________________________________________________________
Write any explanatory remarks here:
Worksheet 6.8.2 Rating the Resident on the Risk Factors
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.
I. Risk of
Resistance
Minimal Risk
(Check only one)
II. Impaired
Mobility
IV. Need for
Extra Help
No Significant Risk
Follows Instructions
Response Probable
Needs Full
Assistance
from 2 Staff
score = 40
score = 30
Requires
Supervision
Requires
Considerable
Attention/Might
Not Respond
score = 3
score = 10
Response
Not Probable
score = 0
(Check only one)
score = 20
score = 6
score = 1
(Check only one)
VI. Waking
Response to
Alarm
score = 20
Totally Impaired
Needs Limited
Assistance from
2 Staff
score = 0
Needs Full
Assistance or
Very Slow
score = 6
score = 3
Partially Impaired
score = 0
Needs at Most
One Staff
score = 6
VII. Response to Fire Drills
Initiates and Completes
Evacuation Promptly
Yes
(Without guidance
or advice from staff)
Chooses and Completes
Back-up Strategy
Yes
No
score = 0
score = 8
No
score = 0
Yes
Remains at Designated
Location
Appendix 2-F
score = 4
No
score = 0
Form CMS-2786W (06/07) EF 06/2007
Score
Boxes
score = 20
Needs Limited
Assistance
score = 0
(Check only one)
V. Response to
Instructions
Slow
Self-Starting
(Check only one)
Risk of Strong
Resistance
score = 6
score = 0
(Check only one)
III. Impaired
Consciousness
Risk of Mild
Resistance
score = 6
Sum of
These
Three
Scores
Page 4
Worksheet 6.8.3 Determining the Resident’s Overall Need for Assistance
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.
Evacuation
Assistance Score
Notes:
Worksheet 6.8.4 Resident Scores
Evac.
Assist.
Score
Resident’s Name
Evacuation
Assistance Score
Form CMS-2786W (06/07) EF 06/2007
Total
Evac.
Assist.
Score
Resident’s Name
Evacuation
Assistance Score
Appendix 2-F
Total
Page 5
Worksheet 6.8.5 Cover Sheet
Staff Shift Score
Facility ________________________________________
Zone __________________________________________
Evaluator ______________________________________
Date ___________________________________________
Staff Shift: From_________________________________
To_____________________________________________
Worksheet 6.8.6 Staff Response and Training
YES
NO
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)
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)
Every staff member considered in this rating can meaningfully participate in the evacuation of each resident. (See 6.5.2.3)
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)
At least 12 fire drills were conducted during the previous year.
(See 6.5.2.5 and Exception)
All items must score “Yes” before proceeding.
Worksheet 6.8.7 Promptness of Response Scores
Alarm Effectiveness
Staff Availability
Standby or asleep
Immediately available
Immediately available and close by
Assured
16
20
20
Not Assured
2
2
10
Worksheet 6.8.8 Staff Scores
Promptness
of Response
Score
Resident’s Name
Staff Shift Score
Form CMS-2786W (06/07) EF 06/2007
Total
Promptness
of Response
Score
Resident’s Name
Staff Shift Score
Appendix 2-F
Total
Page 6
Worksheet 6.8.9 Rating the Facility
Vertical Distance from Sleeping Rooms to Exits
All SR on Floors with
Direct Exit
Small Facility
Any SR One Floor
from Exit
Score 0.8
Any SR Two or More
Floors from Exit
Score 1.0
Large Facility or Apartment
Score 1.2
Score 1.0
NOTE: Small facilities have 16 or fewer residents. See 6.6.6 for apartments.
Worksheet 6.8.10 Calculation of Evacuation Capability Score
Total Resident Evacuation
Assistance Score (Worksheet 6.8.4)
Vertical Distance from Sleeping Room
to Exit (Worksheet 6.8.9)
X
=
Evacuation
Capability Score
(Go to Worksheet 6.8.11)
Staff Shift Score
(Worksheet 6.8.8)
Worksheet 6.8.11 Evacuation Capability Score
Evacuation
Capability Score
Level of
Evacuation Capability
<1.5
Prompt
>1. to <5.0
Slow
>5.0
Impractical
Form CMS-2786W (06/07) EF 06/2007
Appendix 2-F
Evacuation Capability for
this Facility or Zone
Page 7
ID
PREFIX
MET NOT N/A
MET
LARGE FACILITY
PROMPT AND SLOW EVACUATION CAPABILITIES
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
Form CMS-2786W (06/07) EF 06/2007
Page 8
Appendix 2-F
ID
PREFIX
MET NOT N/A
MET
LARGE FACILITY
PROMPT AND SLOW EVACUATION CAPABILITIES
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
Form CMS-2786W (06/07) EF 06/2007
Page 9
Appendix 2-F
ID
PREFIX
K211
MET NOT N/A
MET
LARGE FACILITY
PROMPT AND SLOW EVACUATION CAPABILITIES
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.
Form CMS-2786W (06/07) EF 06/2007
Page 10
Appendix 2-F
ID
PREFIX
MET NOT N/A
MET
LARGE FACILITY
PROMPT AND SLOW EVACUATION CAPABILITIES
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
Form CMS-2786W (06/07) EF 06/2007
Page 11
Appendix 2-F
ID
PREFIX
MET NOT N/A
MET
LARGE FACILITY
PROMPT AND SLOW EVACUATION CAPABILITIES
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
Form CMS-2786W (06/07) EF 06/2007
Page 12
Appendix 2-F
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
Form CMS-2786W (06/07) EF 06/2007
Page 13
Appendix 2-F
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.
Form CMS-2786W (06/07) EF 06/2007
Page 14
Appendix 2-F
ID
PREFIX
MET NOT N/A
MET
LARGE FACILITY
PROMPT AND SLOW EVACUATION CAPABILITIES
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.
Form CMS-2786W (06/07) EF 06/2007
Page 15
Appendix 2-F
ID
PREFIX
MET NOT N/A
MET
LARGE FACILITY
PROMPT AND SLOW EVACUATION CAPABILITIES
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 (06/07) EF 06/2007
Page 16
Appendix 2-F
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
Form CMS-2786W (06/07) EF 06/2007
Page 17
Appendix 2-F
ID
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
Form CMS-2786W (06/07) EF 06/2007
Page 18
Appendix 2-F
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 (06/07) EF 06/2007
Page 19
Appendix 2-F
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 (06/07) EF 06/2007
Page 20
Appendix 2-F
ID
PREFIX
LARGE FACILITY
IMPRACTICAL EVACUATION
MET
NOT
N/A
MET
REMARKS
LARGE
IMPRACTICAL
2000 NEW
Interior finish shall be in accordance with 10.2.
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
Form CMS-2786W (06/07) EF 06/2007
Page 21
Appendix 2-F
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 (06/07) EF 06/2007
Page 22
Appendix 2-F
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 (06/07) EF 06/2007
Page 23
Appendix 2-F
FIRE SAFETY SURVEY REPORT
CRUCIAL DATA EXTRACT
(TO BE USED WITH CMS-2786 FORMS)
PROVIDER NUMBER
FACILITY NAME
SURVEY DATE
K1
K6
* K4
K3
DATE OF PLAN
APPROVAL
MULTIPLE CONSTRUCTION
TOTAL NUMBER OF BUILDINGS ____________
NUMBER OF THIS BUILDING
LSC FORM INDICATOR
____________
12
13
14
15
ASC Form
2000 EXISTING
2000 NEW
SMALL
(16 BEDS OR LESS)
K8:
1 PROMPT
2 SLOW
3 IMPRACTICAL
LARGE
K8:
ICF/MR Form
2786V, W, X
2000 EXISTING
2786V, W, X
2000 NEW
16
17
SELECT NUMBER OF FORM USED FROM ABOVE
*K9:
7 PROMPT
8 SLOW
9 IMPRACTICAL
ENTER E – SCORE HERE
(Check if K29 or K56 are marked as not applicable
in the 2786 M, R, T, U, V, W, X and Y.)
K29:
4 PROMPT
5 SLOW
6 IMPRACTICAL
APARTMENT HOUSE
K8:
* K7
BUILDING
WING
FLOOR
APARTMENT UNIT
COMPLETE IF ICF/MR IS SURVEYED UNDER CHAPTER 21
Health Care Form
2786R
2000 EXISTING
2786R
2000 NEW
2786U
2786U
A
B
C
D
K5:
K56:
e.g. 2.5
FACILITY MEETS LSC BASED ON (Check all that apply)
A1.
(COMP. WITH
ALL PROVISIONS)
A2.
(ACCEPTABLE POC)
FACILITY DOES NOT MEET LSC
B.
A3.
A4.
(WAIVERS)
A5.
(FSES)
(PERFORMANCE
BASED DESIGN)
K0180
A.
FULLY SPRINKLERED
B.
PARTIALLY SPRINKLERED
(All required areas are sprinklered) (Not all required areas are sprinklered)
C.
NONE
(No sprinkler system)
* MANDATORY
Form CMS-2786W (06/07) EF 06/2007
Page 24
Appendix 2-F