Fire Smoke Zone Evaluation Worksheet For Health Care Facilites {CMS-2786T}

DEPARTMENT OF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES2012 LIFE SAFETY CODEForm Approved OMB ExemptFIRE SAFETY EVALUATION SYSTEMHEALTH CARE FACILITIES 002 (NFPA 101A, 223Guide on Alternative Approaches to Life Safety224 2013 Edition)Complete the following worksheets for each fire/smoke zone*.Where conditions are the same in several zones, one set of worksheets can be used for those zones.* Fire/smoke zone is a space separated from all other spaces by floors, horizontal exits, or smoke barriersStep 1 227 Complete Cover Sheet using Worksheet 4.7.1. WORKSHEET 4.7.1 226 COVER SHEETZONEOFZONESNAME OF FACILITYADDRESS OF FACILITYZONE(S) EVALUATEDPROVIDER/VENDOR NO.DATE OF SURVEYSURVEYOR SIGNATURESURVEYOR IDTITLEOFFICEDATEFIRE AUTHORITY SIGNATURETITLEOFFICEDATEADDITIONAL COMMENTS:CMS FORMS SHALL BE COMPLETED AND RETAINED AS PART OF THE SURVEY RECORD.Page 1 American LegalNet, Inc. www.FormsWorkFlow.com DEPARTMENT OF HEALTH ANDHUMAN SERVICES 2012 LIFE SAFETY CODE CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB Exempt Step 2 227 Determine Occupancy Risk Parameter Factors using Worksheet 4.7.2. For each Risk Parameter in Worksheet 7.2, select and circle the appropriate risk factor value. Choose only one for each of the five Risk Parameters. WORKSHEET 4.7.2 226 OCCUPANCY RISK PARAMETER FACTORS Risk Parameters Risk Factor 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 12265 622610 1122630 >30 Risk Factor 1.0 1.2 1.5 2.0 3.Zone Location (L) Floor 1st 2nd or 3rd 4th to 6th 7th and Above Basements Risk Factor 1.1 1.2 1.4 1.6 1.6 4.Ratio of Patients to Attendants (T) Patients Attendant 12262 1 32265 1 622610 1 >10 1 One or More None Risk Factor 1.0 1.1 1.2 1.5 4.0* 5. Patient Average Age (A) Age Under 65 Years and Over 1 Year 65 Years and Over or 1 Year and Younger Risk Factor 1.0 1.2 *A risk factor of 4.0 is charged to any zone that houses patients without any staff in immediate attendance. Step 3 227 Compute Occupancy Risk Factor (F) using Worksheet 4.7.3. (1) Transfer the circled risk factor values from Worksheet 4.7.2 to the corresponding blocks in Worksheet 4.7.3. (2) Compute F by multiplying the risk factor values as indicated in Worksheet 4.7.3. WORKSHEET 4.7.3 - OCCUPANCY RISK FACTOR CALCULATION OCCUPANCY RISKMxDx Lx Tx A =F Step 4 227 Compute Adjusted Building Status (R) - Use Worksheets 4.7.4 or 4.7.5. WORKSHEET 4.7.4 ADJUSTED OCCUPANCY RISK FACTOR (NEW(1) If building is classified as 223NEW224 use Worksheet 4.7.4. If building is classified as 223Existing224 use Worksheet 4.7.5. (2) Transfer the value of F from Worksheet 4.7.3 to Worksheets 4.7.4 or 4.7.5, as appropriate. Calculate R. (3) Transfer R to the block labeled R in Worksheet 4.7.9. (4) In Worksheets 4.7.4 and 4.7.5, results are always rounded up (i.e., 3.2 is rounded to 4.0). ) F R F R WORKSHEET 4.7.5 ADJUSTED OCCUPANCY RISK FACTOR (EXISTING)0.6 x = Page 2 x = American LegalNet, Inc. www.FormsWorkFlow.com Step 5 227 Determine Safety Parameter Values using Worksheet 4.7.6. (1) Select and circle the safety value for each safety parameter that best describes the conditions in the zone. (2) Choose only one value for each of the 13 parameters. (3) If two or more appear to apply, choose the one with the lowest point value. WORKSHEET 4.7.6 226 SAFETY PARAMETER VALUES Safety Parameters Parameters Values 1. ConstructionCombustible Non-Combustible Types III, IV, and V Types I and II Floor or Zone 000 111 200 211, 2HH 000 111 222, 322, 442 First -2 0 -2 0 0 2 2 Second -7 -2 -4 -2 -2 2 4 Third -9 -7 -9 -7 -7 2 4 4th and Above -13 -7 -13 -7 -9 -7 4 2.Interior Finish Class C Class B Class A (Corridors and Exits) -5(0)f 0(3)f 3 3.Interior Finish Class C Class B Class A (Rooms) -3(1)f 1(3)f 3 4.Corridor None or Incomplete <1/2 hour >1/2 to <1 hour 1 hour Partitions/Walls-10(0)a 0 1(0)a 2(0)a 5.Doors to Corridor 20 min FPR and No Door <20 min FPR 20 min FPR Auto Closure -10 0 1(0)d 2(0)d 6.Zone Dimensions Dead End No Dead Ends >30 ft. and Zone Length Is >100 ft. >50 ft. to 100 ft. 30 ft. to 50 ft. >150 ft. 100 ft. to 150 ft. <100 ft. -6(0)b -4(0)b -2(0)b -2(0)c (0)h 0(0)h 1 7.Vertical OpeningsOpen 4 or More Open 2 or 3 Enclosed with Indicated Fire Resistance Floors Floors <1 hr. 1 hr. to <2 hr. 2 hr. -14 -10 0 2(0)e 3(0)e 8.Hazardous Areas Double Deficiency Single Deficiency No Deficiencies In Zone Outside Zone In Zone In Adjacent Zone -11 -5 -6 -2 0 9.Smoke Control No Control Smoke Barrier Mechanically Assisted Systems Serves Zone by Zone -5(0)c 0 3 10. Emergency <2 Routes Multiple Routes Direct Exit(s) Movement W/O Horizontal Horizontal Deficient Routes -8Exit(s) Exit(s) -2 0 1 5 11.Manual Fire Alarm No Manual Fire Alarm Manual Fire Alarm W/O F.D. Conn. W/F.D. Conn. -4 1 2 12. Smoke DetectionCorridor and Total Spaces None Corridor Only Rooms Only and Alarm Habit. Spaces in Zone 0(3)g 2(3)g 3(3)g 4 5 Corridor and Entire 13. Automatic None Habit. Space Building Sprinklers 0 8 10 DEPARTMENT OF HEALTH ANDHUMAN SERVICES 2012 LIFE SAFETY CODE CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB Exempt a 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. e Use (0) where Parameter 1 is based on first floor zone or on an unprotected type of construction (columns002 002 marked 223000224 or 223200224). 002 002 For SI Units: 1 ft.262 = 0.3048 m262 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 w ith quick-response automatic sprinklers. h Use (0) where zone area 22,500 ft.2 and distance from any point to reach a door Page 3 American LegalNet, Inc. www.FormsWorkFlow.com Step 6 227 Compute Individual Safety Evaluations using Worksheet 4.7.7. (1) Transfer each of the 13 circled Safety Parameter Values from Worksheet 4.7.6 to every unshaded block inthe line with the corresponding Safety Parameter in Worksheet 4.7.7. For Safety Parameter 13 (Sprinklers) the value entered in the People Movement Safety column is recorded in Worksheet 4.7.7 as 1/2 thecorresponding value circled in Worksheet 4.7.6. (2) Add the four columns, keeping in mind that any negative numbers deduct. (3)003 Transfer the resulting total values for S1, S2, S3, S4 to blocks labeled S1, S2, S3, S4 in Worksheet 4.7.9 onpage 4 of this sheet. WORKSHEET 4.7.7 - INDIVIDUAL SAFETY EVALUATIONS Safety ParametersContainmentSafety (S1)ExtinguishmentSafety (S2) PeopleMovementSafety (S3)GeneralSafety (S4) 1. Construction 2. Interior Finish (Corr. and Exit) 3. Interior Finish (Rooms)4. Corridor Partitions and Walls5. Doors to Corridor6. Zone Dimensions7. Vertical Openings8. Hazardous Areas9. Smoke Control10. Emergency Movement Routes11. Manual Fire Alarm 12. Smoke Detection and Alarm13. Automatic Sprinklers 367 2 =Total ValueS1=S2=S3=S4= 003 DEPARTMENT OF HEALTH ANDHUMAN SERVICES 2012 LIFE SAFETY CODE CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB Exempt 002002 Page 4 American LegalNet, Inc. www.FormsWorkFlow.com 002 002 002 002 DEPARTMENT OF HEALTH ANDHUMAN SERVICES 2012 LIFE SAFETY CODE CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB Exempt Step 7 227 Determine Mandatory Safety Requirement values using Worksheet 4.7.8A, 4.7.8B, or 4.7.8C. (1)Using the facility type (i.e., Hospital or Nursing Home), classification (i.e., New, Existing or Rehabilitated)and the floor where the zone is located, circle the appropriate value in each of the three columns found inWorksheet 4.7.8A, 4.7.8B, or 4.7.8C.(2) Transfer the three circled values to the blocks marked Sa, Sb, and Sc in Worksheet 4.7.9. (3)The Mandatory Safety Requirement value for basements are based on the distance of the basement levelfrom the closest level of discharge (See 4.6.