Form CMS-2786U "Fire Safety Survey Report - 2012 Life Safety Code Ambulatory Health Care"

What Is Form CMS-2786U?

This is a legal form that was released by the U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services on July 1, 2018 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

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  • The latest available edition released by the U.S. Department of Health and Human Services - Centers for Medicare and Medicaid Services;
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Download Form CMS-2786U "Fire Safety Survey Report - 2012 Life Safety Code Ambulatory Health Care"

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
2012 LIFE SAFETY CODE
CENTERS FOR MEDICARE & MEDICAID SERVICE
Form Approved OMB Exempt
FIRE SAFETY SURVEY REPORT –
2012 LIFE SAFETY CODE
1. (A) PROVIDER NUMBER
1. (B) MEDICAID I.D. NO.
AMBULATORY HEALTH CARE
K1
K2
PART I — Life Safety Code, New and Existing
PART II — Health Care Facilities Code, New and Existing
PART III — Recommendation for Waiver
PART IV – Crucial Data Extract
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 (STATE, CITY, ZIP
A.
Fully Sprinklered
CODE)
(All required areas are sprinklered)
A.
BUILDING
__
_______________
B.
Partially Sprinklered
B.
WING
__
_______________
(Not all required areas are
C.
FLOOR
_
________________
sprinklered)
C.
None (No sprinkler system)
K3
K0180
Date of Survey
Initial Survey
Resurvey
New
Existing
Number of Stations in ESRD
K4
CHECK ONE
DATE OF BLDG. PERMIT OR PLAN APPROVAL
DATE FIRST OCCUPIED AS AMBULATORY SURGICAL
Facility is:
CTR.
Physically located in a hospital
K6
Free-standing: only occupancy in building
If facility is located in a hospital or hospital owned/operated, was facility surveyed as part of Hospital LSC Survey?
Located in an Office Occupancy
Located in a Mercantile/Business Occupancy
Yes
No
Indicate Occupancy
____________________
Other (specify)
________________________
A
The facility MEETS based upon:
B
The facility DOES NOT MEET THE STANDARD
Accredited by _
________________________
_
1.
Compliance with all provisions
2.
Acceptance of a Plan of Correction
Non Accredited
3.
Recommended waivers
4.
Performance Based D esign
K9
SURVEYOR (Signature)
TITLE
OFFICE
DATE
SURVEYOR ID
K10
REVIEW AUTHORITY OFFICIAL (Signature)
TITLE
OFFICE
DATE
CMS FORMS SHALL BE COMPLETED AND RETAINED AS PART OF THE SURVEY RECORD.
Form CMS-2786U (07/2018)
Page 1
DEPARTMENT OF HEALTH AND HUMAN SERVICES
2012 LIFE SAFETY CODE
CENTERS FOR MEDICARE & MEDICAID SERVICE
Form Approved OMB Exempt
FIRE SAFETY SURVEY REPORT –
2012 LIFE SAFETY CODE
1. (A) PROVIDER NUMBER
1. (B) MEDICAID I.D. NO.
AMBULATORY HEALTH CARE
K1
K2
PART I — Life Safety Code, New and Existing
PART II — Health Care Facilities Code, New and Existing
PART III — Recommendation for Waiver
PART IV – Crucial Data Extract
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 (STATE, CITY, ZIP
A.
Fully Sprinklered
CODE)
(All required areas are sprinklered)
A.
BUILDING
__
_______________
B.
Partially Sprinklered
B.
WING
__
_______________
(Not all required areas are
C.
FLOOR
_
________________
sprinklered)
C.
None (No sprinkler system)
K3
K0180
Date of Survey
Initial Survey
Resurvey
New
Existing
Number of Stations in ESRD
K4
CHECK ONE
DATE OF BLDG. PERMIT OR PLAN APPROVAL
DATE FIRST OCCUPIED AS AMBULATORY SURGICAL
Facility is:
CTR.
Physically located in a hospital
K6
Free-standing: only occupancy in building
If facility is located in a hospital or hospital owned/operated, was facility surveyed as part of Hospital LSC Survey?
Located in an Office Occupancy
Located in a Mercantile/Business Occupancy
Yes
No
Indicate Occupancy
____________________
Other (specify)
________________________
A
The facility MEETS based upon:
B
The facility DOES NOT MEET THE STANDARD
Accredited by _
________________________
_
1.
Compliance with all provisions
2.
Acceptance of a Plan of Correction
Non Accredited
3.
Recommended waivers
4.
Performance Based D esign
K9
SURVEYOR (Signature)
TITLE
OFFICE
DATE
SURVEYOR ID
K10
REVIEW AUTHORITY OFFICIAL (Signature)
TITLE
OFFICE
DATE
CMS FORMS SHALL BE COMPLETED AND RETAINED AS PART OF THE SURVEY RECORD.
Form CMS-2786U (07/2018)
Page 1
Name of Facility
2012 LIFE SAFE TY CODE
ID
NOT
MET
N/A
REMARKS
PREFIX
MET
PART I – NFPA 101 LSC REQUIREMENTS
(Items in italics relate to the FSES)
SECTION 1 – GENERAL REQUIREMENTS
General Requirements – Other
K100
List in the REMARKS section any LSC Section 20.1 and 20.1 General
Requirements that are not addressed by the provided K-tags, but are
deficient. This information, along with the applicable Life Safety Code or
NFPA standard citation, should be included on Form CMS-2567.
Building Rehabilitation
K111
Repair, Renovation, Modification, or Reconstruction
Any building undergoing repair, renovation, modification, or reconstruction
complies with both of the following:
Requirements of Chapter 21
Requirements of the applicable Sections 43.3, 43.4, 43.5, and 43.6
20.1.1.4.3, 21.1.1.4.3, 4.6.7, 43.1.2.1
Change of Use or Change of Occupancy
Any building undergoing change of use or change of occupancy
classification complies with the requirements of Section 43.7, unless
permitted by 20.1.1.4.2 or 21.1.1.4.2
20.1.1.4.2, 21.1.1.4.2, 43.1.2.2 (43.7)
Additions
Any building undergoing an addition shall comply with the requirements of
Section 43.8. If the building has a common wall with a nonconforming
building, the common wall is a fire barrier having at least a 2 hour fire
resistance rating constructed of materials as required for the addition.
20.1.1.4.1, 21.1.1.4.1, 4.6.5, 4.6.7, 43.1.2.3 (43.8)
Form CMS-2786U (07/2018)
Page 2
Name of Facility
2012 LIFE SAFE TY CODE
ID
NOT
MET
N/A
REMARKS
PREFIX
MET
Multiple Occupancies – Sections of Ambulatory Health Care Facilities
K131
Multiple occupancies shall be in accordance with 6.1.14.
Sections of ambulatory health care facilities shall be permitted to be
classified as other occupancies, provided they meet both of the following:
The occupancy is not intended to serve ambulatory health care
occupants for treatment or customary access
They are separated from the ambulatory health care occupancy by a 1
hour fire resistance rating
Ambulatory health care facilities shall be separated from other tenants and
occupancies and shall meet all of the following:
Walls have not less than 1 hour fire resistance rating and extend from
floor slab to roof slab
Doors are constructed of not less than 1-3/4 inches thick, solid-bonded
wood core or equivalent and is equipped with positive latches.
Doors are self-closing and are kept in the closed position, except when
in use.
Windows in the barriers are of fixed fire window assemblies per 8.3.
Per regulation, ASCs are classified as Ambulatory Health Care
Occupancies, regardless of the number of patients served.
20.1.3.2, 21.1.3.3, 20.3.7.1, 21.3.7.1,42 CFR 416.44
Form CMS-2786U (07/2018)
Page 3
Name of Facility
2012 LIFE SAFETY CODE
ID
NOT
MET
N/A
REMARKS
PREFIX
MET
Building Construction Type and Height
K161
Building construction type and stories meet Table 20.1.6.1 or Table
21.1.6.1, respectively.
Construction Type
I (442), I (332), II (222),
Any number of stories
1
II (111), III (211), IV (2HH),
non-sprinklered or sprinklered
V (111)
One story non-sprinklered
2
II (000), III (200), V (000)
Any number of stories sprinklered
Any level below the level of exit discharge shall be separated by Type II
(111), Type III (211), or Type V (111) construction unless both of the
following are met:
1. Such levels are under the control of the ambulatory health care
occupancy.
2. Hazardous spaces are protected per section 8.7.
Sprinklered stories must be sprinklered throughout by an approved,
supervised automatic system in accordance with section 9.7. (See 20.3.5 or
21.3.5, respectively)
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.
20.1.6.1, 20.1.6.2, 21.1.6.1, 21.1.6.2
Interior Nonbearing Wall Construction
K163
Interior nonbearing walls in Type I or II construction are constructed of
noncombustible or limited-combustible materials.
Interior nonbearing walls required to have a minimum 2 hour fire resistance
rating are permitted to be fire-retardant-treated wood enclosed within
noncombustible or limited-combustible materials, provided they are not
used as shaft enclosures.
20.1.6.3, 20.1.6.4, 21.1.6.3, 21.1.6.4
Form CMS-2786U (07/2018)
Page 4
Name of Facility
2012 LIFE SAFETY CODE
ID
NOT
MET
N/A
REMARKS
PREFIX
MET
SECTION 2 – MEANS OF EGRESS REQUIREMENTS
Means of Egress Requirements – Other
K200
List in the REMARKS section any LSC Section 20.2 and 21.2 Means of
Egress Requirements that are not addressed by the provided K-tags, but
are deficient. This information, along with the applicable Life Safety Code or
NFPA standard citation, should be included on Form CMS-2567.
20.2, 21.2
Means of Egress – General
K211
Aisles, passageways, corridors, exit discharges, exit locations, and
accesses are in accordance with Chapter 7, and the means of egress is
continuously maintained free of all obstructions to full instant use in case of
emergency, unless modified by 20/21.2.2 through 20/21.2.11.
20.2.1, 21.2.1, 7.1.10.1
Egress Doors
K222
Special locking arrangements are in accordance with section 7.2.1.6
DELAYED-EGRESS LOCKING ARRANGEMENTS
Approved, listed delayed-egress locking systems installed in accordance
with 7.2.1.6.1 shall be permitted on door assemblies serving low and
ordinary hazard contents in buildings protected throughout by an approved,
supervised automatic fire detection system or an approved, supervised
automatic sprinkler system.
ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS
Access-Controlled Egress Door assemblies installed in accordance with
7.2.1.6.2 shall be permitted.
ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS
Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall
be permitted on door assemblies in buildings protected throughout by an
approved, supervised automatic fire detection system and an approved,
supervised automatic sprinkler system.
20.2.2.2, 21.2.2.2, 7.2.1.6.1 through 7.2.1.6.3
Form CMS-2786U (07/2018)
Page 5