State Operations Manual (Pub. 100-07), Ch. 2 § 2474
Fire Safety Survey Report Forms (Form CMS-2786 Series)
2474 - Fire Safety Survey Report Forms (Form CMS-2786 Series)
(Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13)
The Form CMS-2786 series contains the forms to be used for determining compliance
with the LSC. There are currently 13 in this series:
1.
Form CMS-2786M, Fire Safety Survey Rating Residents; 2000Code.
2.
Form CMS-2786R, Fire Safety Survey Report 2000 Code-Health Care -
Medicare/Medicaid.
3.
Form CMS-2786S, Fire Safety Survey Report - Short Form; 2000 Code.
Form CMS-2786T, Fire/Smoke Zone Evaluation Worksheet For Health
Facilities; 2000 Code.
Form CMS-2786U, Fire Safety Survey Report Ambulatory Surgical Centers;
2000 Code.
Form CMS-2786V, Fire Safety Survey Report ICF/IID -Small Facilities;
2000Code.
Form CMS-2786W, Fire Safety Survey Report ICF/IID-Large Facilities; 2000
Code.
Form CMS-2786X, Fire Safety Survey Report ICF/IID Apartment House; 2000
Code.
4.
Form CMS-2786Y, Fire Safety Survey Report ICF/IID- Small FSES; 2000 Code.
They each contain four parts:
I. LSC requirements - New and Existing;
II. Other Federal requirements; and
III. Waiver recommendation form.