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Form CMS-2786Y, 07 2018 Form CMS-2786Y, 07 2018

Form CMS-2786Y, 07 2018 Form CMS-2786Y, 07 2018-2025

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The document outlines the 2012 Life Safety Code for small residential board and care facilities, specifically focusing on fire safety evaluation procedures. It includes worksheets for assessing safety parameters, determining mandatory safety requirements, and evaluating equivalency to ensure compliance with fire safety standards as prescribed by NFPA 101. The process involves completing various worksheets to evaluate construction, fire alarms, smoke detection, means of escape, and overall fire safety measures for facilities housing 16 or fewer residents.

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Click ‘Get Form’ to open it in the editor.
Begin by completing the Cover Sheet using Worksheet 7.3.1. Fill in the facility name, address, provider/vendor number, date of survey, and signatures as required.
Proceed to Worksheet 7.3.2 and select a Safety Parameter Value for each parameter. Circle only one value for each of the eight parameters based on your facility's conditions.
Transfer the circled values from Worksheet 7.3.2 to Worksheet 7.3.3 for Individual Safety Evaluations, ensuring you halve any values marked ‘÷ 2 =’.
Determine Mandatory Safety Requirements using either Worksheet 7.3.4A or 7.3.4B based on your facility type and transfer those values to Worksheet 7.3.5.
Complete the Equivalency Evaluation in Worksheet 7.3.5 by performing necessary subtractions and checking if values are zero or greater.
Evaluate Operating Features Requirements with Worksheet 7.3.6 and conclude if safety levels meet NFPA standards using Worksheet 7.3.7.

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