Application of Fire Safety Evaluation System (FSES)

2478 - Application of Fire Safety Evaluation System (FSES) (Rev. 1, 05-21-04) 2478A - General (Rev. 1, 05-21-04) The National Bureau of Standards developed the FSES at the request of DHHS. It is an alternative method of determining compliance with the provisions of the LSC. Facilities that pass the FSES may be certified for participation in the program even though they have repeated deficiencies reflected on Form CMS-2786. 2478B - Application of System (Rev. 1, 05-21-04) The State fire authority uses the FSES in conjunction with Form CMS-2786 in facilities where the surveyor or the provider feels that the application of the system is beneficial to the facility. The state may complete the FSES for the facility at the State’s option. The State Fire Authority will review and approve any FSES’s submitted by the provider. 2478C - Survey Completion (Rev. 1, 05-21-04) Whenever an FSES evaluation is conducted by the fire authority, the following is completed: • Fire Safety Survey Report (Form CMS-2786); • FSES zone evaluation worksheet for each fire/smoke zone evaluated; • Copy of FSES table 8 (facility fire safety requirements worksheet); and • Statement of deficiencies (Form CMS-2567) for LSC and FSES items. The SA includes all FSES worksheets with the certification kit, even if certification is based on the findings of Form CMS-2786. The SA marks item 7A of the cover sheet of Form CMS-2786 “FSES.” FSES files are forwarded by the RO to a specialist for a thorough technical review. 2478D - Certification of Compliance with FSES (Rev. 1, 05-21-04) When the fire authority performs an FSES evaluation, a facility may elect to be certified with deficiencies as well as an acceptable PoC in either of two ways: • If the provider elects to be certified based upon the findings of the Form CMS-2786, it must indicate its proposed correction in the space adjacent to each deficiency recorded on Form CMS-2567; or • If the provider elects to be certified based on the FSES, it may not be necessary to correct all of the deficiencies found. In this case, the provider is to write: “Not Necessary to Correct - FSES” in the space next to such deficiencies under “Plan of Correction.” A facility that achieves a passing score on the FSES or which submits an acceptable PoC under the FSES may be certified based upon the FSES. Once a facility has been certified based upon the FSES, it may continue to be certified on that basis in subsequent certification surveys after completion of the Form CMS-2786. The SA refers any questions regarding application of the FSES, completion of the zone evaluation worksheet, appropriate documentation of PoCs, or requests for technical assistance to the LSC contact person in the RO.