Fire Safety Survey Report - Short Form, Form CMS-2786S

2476 - Fire Safety Survey Report - Short Form, Form CMS-2786S (Rev. 1, 05-21-04) 2476A - Background (Rev. 1, 05-21-04) The Fire Safety Survey Report - Short Form (Form CMS-2786C), (see Exhibit 71), was designed as a screening tool for LSC compliance, since it may not be necessary to conduct a complete survey of all facilities annually. Some features of a building do not change from year to year, e.g., an 8-foot corridor remains eight feet wide. Other items require periodic testing and maintenance, e.g., sprinkler systems and fire extinguishers. Such testing is easily verified by a check of service records. Verification does not require the level of expertise of a fire protection engineer or fire marshal, and can be capably performed by the SA surveyor. 2476B - When to Use Short Form (Rev. 1, 05-21-04) Except as outlined in subsection C, the SA uses Form CMS-2786S to survey non-JCAHO hospitals, SNFs, and NFs for compliance with the LSC. 2476C - When NOT to Use Short Form (Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) Instead of the SA using the short form in the following situations, the SA should have the State fire authority perform the survey using the regular Fire Safety Survey Report (Form CMS-2786R*): • Initial survey; • Survey of facilities with any construction or renovation since their last survey (facilities must report any construction or renovation to you); • Facilities with uncompleted PoCs (including facilities with waivers to complete construction activities; • ICFs/IID; • ASCs; • Surveys preceded by two successive certification surveys in which the Short Form was used; or • When conducting the first LSC survey under the 2000 Edition of the LSC. 2476D - Results of LSC Screening Process - SA Review of Completed Form CMS-2786S (Rev. 1, 05-21-04) 1 - All Items Met - No deficiencies. 2 - Some Items Not Met - If any item is not met the SA forwards the form to the State fire authority who will determine whether a complete survey is necessary. 3 - Complete Survey Recommended - The SA checks this block if there are many deficiencies or if it finds recent construction or renovation. The SA forwards the form to the State fire authority who takes appropriate action. 4 - Submission of Completed Package - When the Short Form is completed, the SA forwards it to the RO as part of the complete certification kit. (Note that OSCAR includes a special field on the crucial data extract (CDE) sheet for use of the Short Form.) 2476F - Waivers (Rev. 91, Issued: 09-27-13, Effective: 09-27-13, Implementation: 09-27-13) Items that have been waived in the past can continue to be waived even if a Short Form is used. If the health surveyor marks an item not met and the provider requests a waiver, the SA should have the waiver reviewed by the fire authority. The fire authority must decide whether to recommend waivers in the case of SNFs, NFs, or ICFs/IID, however, CMS must grant the waiver, not the State. There are no waivers for ICFs/IID under the Board and Care provisions. In no case is the health surveyor to recommend, grant, or review a waiver.