The Centers for Medicare & Medicaid Services (“CMS”) just released a revision to their August Survey and Certification letter concerning the August 13, 2013 deadline for the installation of automatic sprinkler systems in nursing facilities. Originally, facilities that did not meet the deadline were subject to deficiencies at scope and severity (“S&S”) levels of D, E or F. Recognizing that some facilities are still in the process of compliance, CMS has enumerated 10 protections that, if in place, may permit the deficiency citation to be reduced to an S&S level of C.
Facilities that have already received citations at the higher S&S levels may request a revisit with the possibility of a reduction in the S&S level of any citations related to sprinkler compliance.
The 10 protection measures that must all be implemented for the reduction in S&S are:
- A 24/7 fire watch;
- Posted fire watch staffing information;
- The building is constructed entirely of materials with at least a two-hour fire rating;
- The facility is in full compliance with CMS smoke alarm requirements and has free-standing fire extinguishers in common areas;
- The facility conducts fire drills in the unsprinklered areas at least monthly;
- The facility conducts monthly staff training on fire safety issues;
- The facility increases resident direct care staffing levels in all unsprinklered areas;
- The facility contracts or arranges with the local fire marshal’s office, or other approved inspectors, for monthly inspections of all unsprinklered areas;
- On-site monitoring by the State Survey Agency; and
- Minimization of the risk duration.
Alternatively, the facility can entirely remove residents from the unsprinklered portion of the building until sprinkler compliance is achieved.
Should you have any questions, please contact:
- Todd Selby at 317-977-1440 or tselby@wp.hallrender.com;
- Brian Jent at 317-977-1402 or bjent@wp.hallrender.com;
- David Bufford at 502-568-9368 or dbufford@wp.hallrender.com; or
- Your regular Hall Render attorney.
