Most skilled nursing facilities are not correctly complying with life safety requirements or emergency preparedness requirements, according to three recent reports by the Office of the Inspector General (“OIG”) of the U.S. Department of Health and Human Services.
OIG recently issued three reports on its audits of life safety requirements or emergency preparedness requirements: (1) Life Safety and Emergency Preparedness Deficiencies Found at 18 of 20 Texas Nursing Homes (“Texas Report”); (2) New York Should Improve Its Oversight Of Selected Nursing Homes’ Compliance With Federal Requirements For Life Safety And Emergency Preparedness (“New York Report“); and (3) California Should Improve Its Oversight Of Selected Nursing Homes’ Compliance With Federal Requirements For Life Safety And Emergency Preparedness (“California Report“).
Detailed Analysis
In 2016, the Centers for Medicare & Medicaid Services (“CMS”) updated its life safety and emergency preparedness regulations to improve protections for all Medicare and Medicaid beneficiaries, including those residing in skilled nursing facilities (“facilities”). 42 CFR § 483.73 requires that facilities comply with all applicable federal, state and local emergency preparedness requirements. These requirements call for facilities to have expanded sprinkler systems and smoke detector coverage. Under these rules, facilities are required to have an emergency preparedness plan that is reviewed, trained on, tested and updated at least annually and provisions for sheltering in place and evacuation.
Federal regulations on life safety (42 CFR § 483.90) require facilities to comply with standards set forth in the Life Safety Code (National Fire Protection Association (NFPA) 101) and Health Care Facilities Code (NFPA 99).
OIG Review – Texas
OIG reviewed a nonstatistical sample of 20 Texas facilities for the OIG audit based on proximity to the Gulf of Mexico and the highest number of deficiencies previously in those nursing homes identified by Texas surveyors. OIG then conducted unannounced site visits to check for life safety violations and review the facilities’ emergency preparedness plans.
OIG identified deficiencies in life safety or emergency preparedness areas at 18 of the 20 facilities. OIG found 235 deficiencies with life safety requirements related to building exits and smoke partitions, fire detection and suppression systems, hazardous storage areas, fire drills and smoking policies, and electrical equipment and elevator inspection and testing. OIG also found 55 deficiencies with emergency preparedness requirements related to written emergency plans, emergency supplies and power, emergency communications plans and emergency plan training.
OIG’s Texas Report concluded that these deficiencies occurred because management oversight at facilities was inadequate, and facilities had high maintenance and administrative staff turnover. In addition, maintenance personnel at some of the facilities indicated that building maintenance is challenging because of the advanced age of some buildings.
OIG Review – New York
OIG reviewed a sample of a nonstatistical sample of 20 New York facilities based on the highest number of deficiencies in those facilities. OIG then conducted unannounced site visits to check for life safety violations and review the facilities’ emergency preparedness plans.
OIG identified deficiencies in life safety or emergency preparedness areas at all 20 facilities. OIG found 205 areas of noncompliance with life safety requirements related to building exits and fire barriers, fire detection and suppression systems, carbon monoxide detectors, hazardous storage, smoking policies and fire drills, and elevator and electrical equipment testing and maintenance. OIG also found 219 areas of noncompliance with emergency preparedness requirements related to written emergency plans; emergency supplies and power; plans for evacuation, sheltering in place and tracking residents and staff; emergency communications; and emergency plan training.
OIG’s New York Report concluded that these deficiencies occurred because management oversight was inadequate, and facilities had high staff turnover. In addition, the state agency did not have a standard life safety training program for all facility staff, generally performed comprehensive life safety surveys no more frequently than once every 9 to 15 months and did not check to see whether carbon monoxide detectors were installed.
OIG Review – California
OIG reviewed a nonstatistical sample of 20 California facilities based on the highest number of deficiencies in those facilities. OIG then conducted unannounced site visits to check for life safety violations and review the facilities’ emergency preparedness plans. The California Report includes results for only 19 facilities because one of the 20 facilities selected was destroyed by a wildfire after the OIG site visit.
OIG identified deficiencies in life safety or emergency preparedness areas at all 19 facilities. OIG found 137 instances of noncompliance with life safety requirements related to building exits, smoke barriers and smoke partitions; 10 fire detection and suppression systems; hazardous storage areas; smoking policies and fire drills; and electrical equipment testing and maintenance. OIG also found 188 areas of noncompliance with written emergency plans; emergency power; plans for evacuation, sheltering in place and tracking residents and staff during and after an emergency; emergency communications plans; and emergency plan training and testing.
OIG’s California Report concluded that these deficiencies occurred because facilities lacked adequate management oversight and had high staff turnover. In addition, the state agency did not adequately follow up on deficiencies previously cited, ensure that surveyors were consistently enforcing CMS requirements or have a standard life safety training program for all facility staff.
OIG Recommendations
OIG recommended that each state take specific actions to:
- Follow up with the facilities to verify that corrective actions have been taken regarding the life safety and emergency preparedness deficiencies identified in this report;
- Conduct more frequent surveys at facilities with a history of multiple high-risk deficiencies;
- Ensure that all surveyors consistently enforce CMS requirements; and
- Work with CMS and other states’ survey agencies to develop standardized life safety training for facility staff.
Next Actions: Policy, Practices and Training Reviews Needed
- Skilled nursing facilities should expect that state survey agencies will pay increased attention and take actions to confirm that life safety and emergency preparedness practices exist and are followed.
- Facilities should carefully review and revise their life safety and emergency preparedness practices.
- Skilled nursing facilities should review and update training for staff on how to life safety and emergency preparedness areas.
Should you have any questions about this or how to update your policies, practices and staff training, please contact:
- Sean Fahey at (317) 977-1472 or sfahey@wp.hallrender.com;
- Todd Selby at (317) 977-1440 or tselby@wp.hallrender.com;
- Brian Jent at (317) 977-1402 or bjent@wp.hallrender.com; or
- Your regular Hall Render attorney.
More information about Hall Render’s Post-Acute and Long-Term Care services can be found here.
