DEPARTMENT OF HEALTH AND HUMAN SERVICES 2012 Life Safety Code

CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB Exempt

FIRE SAFETY EVALUATION SYSTEM

Intermediate Care Facilities for Individuals with Intellectual Disabilities
SMALL FACILITIES
(NFPA 101A, “Guide on Alternative Approaches to Life Safety” 2013 Edition)

Complete these worksheets for each individual resident or apartment used as a small residential board and care facility*.
* A small residential board and care facility with a capacity of 16 or fewer residents.

Step 1 — Complete Cover Sheet using Worksheet 7.3.1.

WORKSHEET 7.3.1 – COVER SHEET

ZONE OF ZONES

FACILITY NAME ADDRESS OF FACILITY

ZONE(S) EVALUATED

PROVIDER/VENDOR NO. DATE OF SURVEY

SURVEYOR SIGNATURE TITLE OFFICE DATE

SURVEYOR ID

FIRE AUTHORITY SIGNATURE TITLE OFFICE DATE

ADDITIONAL COMMENTS:

CMS FORMS SHALL BE COMPLETED AND RETAINED AS PART OF THE SURVEY RECORD.

Form CMS-2786Y (07/2018) Page 1

 DEPARTMENT OF HEALTH AND HUMAN SERVICES 2012 Life Safety Code
CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB Exempt

Step 2 — Select and circle the Safety Parameter Value for each safety parameter in Worksheet 7.3.2 that best describes
the conditions in the facility. Choose only one value for each of the eight parameters. If two or more values
appear to apply, choose the one with the lowest point value.
WORKSHEET 7.3.2 SAFETY PARAMETER VALUES
Safety Parameters Parameter Values
Exposed Structural Protected Protected
1. Construction/ Members 15 min 1 hr.
Fire Resistance
0 1 3
Double Deficiency Single Deficiency None or No Deficiency
2. Hazardous Areas
-7 -4 0
None or Incomplete w/o F.D. Notification w/ F.D. Notification
3. Manual Fire Alarm
0 1 2
Warning to All Bedrooms
None or Single Lev. Det./ Total Coverage
4. Smoke Detection Incomplete Limited Warning Every Lev. Plus System
Every Lev. Det.e
and Alarm Det. in Each Bdrm.
-4 0 2 3(4)f 4
Quick-Response or
Nonsprinklered Standard Sprinklers
5. Automatic Sprinklers Residential Sprinklers
0 8 10
Flame-Spread Ratings
6. Interior Finish >75 to ≤200 >25 to ≤75 ≤25
-3 -1 0
Unprotected Vertical
Protected Vertical Openingsd
Openings
7. Separation of
Sleeping Rooms Smoke Smoke Smoke
1/2 hr. 1/2 hr. w/
(from other levels None or Resisting Resisting None or Smoke Res. w/
1/2 hr. Auto- Door
Incomp. w/o w/ Incomp. Resisting Door
and from corridors) Closing Closer
Closers Closers Closer
-6 -4 0(0)c -2 0 1(0)a 2(0)a 1 2(1)a
<2 Remote Routes
Means of 2 Remote
2 Remote Routes Direct Exit from
Escape on w/o Alt. Means Routes
w/ Alt. Means Separated Each Bdrm.
All Sleeping Unseparated
Levels
8. Means -1 0 1(0)b 2(0)b 3(0)b
of Escape Primary Route Not Protected Primary Route Protected
Means of
Escape <2 Remote Routes < 2 Remote Routes
Not on All 2 Remote 2 Remote
W/O Alt. W/ Alt. Routes W/O Alt W/ Alt. Routes
Sleeping Means Means Means Means
Levels -4 -3 0 -1 0 2(0)b
NOTES:
a Use ( ) if Parameter 1 is 0 and Parameter 5 is 0.
b Use (0) if Parameter 7 is based on a “none or incomplete” situation.
c Use (0) if door is 20-minute and has automatic closer.
d Consider a single-level building as having protected vertical openings.
e Every level detection is permitted to be omitted with a quick-response automatic sprinklers throughout;
however, detection in each bedroom is required.
f Use (4) in existing buildings if detection in each bedroom and quick-response automatic sprinklers
throughout.

Form CMS-2786Y (07/2018) Page 2

 DEPARTMENT OF HEALTH AND HUMAN SERVICES 2012 Life Safety Code
CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB Exempt

Step 3 — Complete Individual Safety Evaluations using Worksheet 7.3.3.

(1) Transfer each of the eight circled safety parameter values from Worksheet 7.3.2 to every available block in
the line with the corresponding safety parameter in Worksheet 7.3.3. Where the block is marked “÷ 2 =,” enter
one-half the value from Worksheet 7.3.2.
(2) Add each of the four columns, keeping in mind that any negative numbers need to be deducted.
(3) Transfer the resulting values for S1, S2, S3, and S4 to the corresponding blocks in Worksheet 7.3.5.

WORKSHEET 7.3.3 INDIVIDUAL SAFETY EVALUATIONS

General Fire
Safety Parameters Fire Control (S1) Egress (S2) Refuge (S3)
Safety (S4)

1. Construction

2. Hazardous Areas –: 2 =

3. Manual Fire Alarm –: 2 = (See note)

4. Smoke Detection and Alarm –: 2 = –: 2 =

5. Automatic Sprinklers –: 2 =

6. Interior Finish –: 2 =
7. Separation of
Sleeping Rooms
8. Means of Escape
Total S 1= S 2= S3= S 4=
NOTE: Maximum value of manual fire alarm for means of escape is 1.

Step 4 — Determine Mandatory Safety Requirements using Worksheet 7.3.4A or 7.3.4B, as appropriate.
(1) Select the level of requirements from Worksheet 7.3.4A or 7.3.4B as appropriate. Circle the appropriate
values.
(2) Transfer the circled values from Worksheet 7.3.4A or 7.3.4B to the corresponding blocks for Sa, Sb, Sc, and
Sd in Worksheet 7.3.5.

WORKSHEET 7.3.4A MANDATORY SAFETY REQUIREMENTS – NEW FACILITIES

Control Egress Refuge General Fire Safety
Requirement Requirement Requirement Requirement
(Sa) (Sb) (Sc) (Sd)
10.5 5 11.5 7

WORKSHEET 7.3.4B MANDATORY SAFETY REQUIREMENTS – EXISTING FACILITIES

Level of Evacuation Control Egress Requirement Refuge Requirement General Fire Safety
Difficulty Requirement (Sa) (Sb) (Sc) Requirement (Sd)

Prompt 0 4 2 1
Slow 2 7 4 7
Slow* 1 6 2 5
Impractical 8 9 9 10
* Use these mandatory safety requirements if the evacuation capability score is 3 or less as determined by Chapter 6, NFPA 101A.

Form CMS-2786Y (07/2018) Page 3

 DEPARTMENT OF HEALTH AND HUMAN SERVICES 2012 Life Safety Code
CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB Exempt

Step 5 — Determine the Equivalency Evaluation using Worksheet 7.3.5.

(1) Perform subtractions indicated in Worksheet 7.3.5. Enter the differences in the appropriate answer blocks.
(2) For each row, check “yes” if the value in the answer block is zero (0) or greater. Check “no” if the value in
the answer block is a negative number.
WORKSHEET 7.3.5 EQUIVALENCY EVALUATION

Yes No

Control
S1 Sa
Required
Provided minus
Control (Sa) > 0
(S1) - =

Egress S2 Sb
Required
Provided minus
Egress (Sb) > 0
(S2) - =
S3 Sc
Refuge
Required
Provided minus
Refuge (Sc) > 0
(S3) - =

Required S4 Sd
General
General
Fire Safety minus
Fire > 0
(S4)
Safety (Sd)
- =

Step 6 — Evaluate Operating Features Requirements using Worksheet 7.3.6.

Complete one copy of this separate worksheet for each facility.

WORKSHEET 7.3.6 FACILITY FIRE SAFETY REQUIREMENTS WORKSHEET CONSIDERATIONS

NOT
MET
MET
Complies with the applicable requirements of Section 32.7 and 33.7 (NFPA 101).

Step 7 — Determine equivalency Conclusion to determine if the level of life safety is at least equivalent to that prescribed
by the Life Safety Code using Worksheet 7.3.7.
WORKSHEET 7.3.7 CONCLUSIONS

1. All of the checks in Worksheet 7.3.5 are in the “Yes” column and all applicable considerations in
Worksheet 7.3.6 are identified as “Met”. The level of fire safety is at least equivalent to that prescribed by
NFPA 101, Life Safety Code, for small residential board and care occupancies.
2. All of the checks in Worksheet 7.3.5 are in the “Yes” column and all considerations identified in
Worksheet 7.3.6 as “Not Met” have been evaluated and mitigated to the satisfaction of the AHJ. The
level of fire safety is at least equivalent to that prescribed by NFPA 101, Life Safety Code, for small
residential board and care occupancies.
3. One or more of the checks in Worksheet 7.3.5 are in the “No” column or any consideration identified in
Worksheet 7.3.6 as “Not Met” has NOT been evaluated and mitigated to the satisfaction of the AHJ. The
level of fire safety is not shown by this system to be equivalent to that prescribed by NFPA 101, Life
Safety Code, for small residential board and care occupancies.

Form CMS-2786Y (07/2018) Page 4