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Form Cms-2786w - Fire Safety Survey Report - Icf-Iid (Large Facilities) 2012 Life Safety Code Page 2

PART I – INSTRUCTIONS FOR COMPLETING THE FORM (CMS-2786W)

(LARGE FACILITIES — 17 BEDS OR MORE)

EXISTING OCCUPANCIES

1. Complete a “Worksheet for Rating Residents” (CMS-2786M) for each resident in the facility.

Note: Completing this worksheet is the ONLY method permitted to determine Level of Evacuation Difficulty.

2. Transfer the calculated E-Score obtained in Worksheet 6.8.10 to the E-SCORE block (Page 1 of this form).

3. Determine the Level of Evacuation Capability, obtained in Worksheet 6.8.11 (i.e., Prompt, Slow or Impractical).

4. Complete a survey using Part II – Existing Residential Board & Care Occupancies of this form for compliance with the NFPA 101,

Chapter 33.

If Level of Evacuation Capability is:

1. PROMPT OR SLOW - Complete Part II PROMPT OR SLOW EVACUATION section ONLY.

2. IMPRACTICAL - Complete both sections, Part II PROMPT OR SLOW and IMPRACTICAL.

5. Complete the Part IV – Building Services section.

6. Complete Part V – Operating Features section.

NEW OCCUPANCIES

1. New Residential Board & Care Occupancies of this form for compliance with the NFPA 101, Chapter 32.

2. Complete the Part IV – Building Services section

3. Complete the Part V – Operating Features section.

OPTIONAL FIRE SAFETY EVALUATION SYSTEM

1. Reference 2013 edition NFPA 101A – Fire Safety Evaluation System for Board and Care Occupancies (Chapter 7)

Form CMS-2786W (10/2016)

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Form Cms-2786w - Fire Safety Survey Report - Icf-Iid (Large Facilities) 2012 Life Safety Code Page 2