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Compliance Reminder: CMS Mandatory Sprinkler Requirement Effective August 13, 2013

CMS issued a letter regarding the adoption of new fire safety requirements in long term care facilities in October of 2008 that mandated the installation of sprinklers throughout the facility by August 13, 2013. Well, 2013 has arrived, and hopefully your facility is nearing the end of its installation if it has not been completed yet. We expect that a strong focus in the latter half of 2013 will include inspecting for compliance with this new requirement, as CMS has explicitly stated that it will not issue extensions to any facilities that have not completed the work by August 13. In its letter, it states that if a facility is found to be not in compliance with this new rule, the full scale of remedies will be available for enforcement, including temporary management, denial of payment, civil monetary penalties, State monitoring, transfer of residents and closure of the facility.

This regulation also requires that your facility inspects, tests and maintains all sprinkler systems in accordance with the 1998 edition of NFPA 25, “Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.” This standard includes information on the broad range of sprinkler systems that facilities may install, including any extra equipment that may be required for installation, as well as the information on testing and maintaining them. The full listing of NFPA Codes and Standards can be found here.

In addition to checking to ensure your facility has implemented the sprinkler system and is testing and maintaining it, CMS has also discussed the impact of staffing levels on fire safety. Proper staffing levels for ensuring resident health and safety, CMS notes, are tied into requirements in:

  • § 483.15 – Quality of Life
  • § 483.30 – Nursing Services
  • § 483.70 – Physical environment

Remember, CMS has noted that the Federal regulations for LTC facilities are considered “minimum standards” and that each state or local area may have different/additional requirements. Ensure your facility is in compliance with these areas where staffing issues related to fire safety could potentially be cited as well the new rule for fully sprinklered buildings to help ensure better survey outcomes.

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9 Responses

  1. CMSCG

    via LeadingAge New York: http://www.leadingageny.org/providers/nursing-homes/regulations-and-operations/cms-update-on-sprinkler-waiver/

    The requirement that all nursing homes be fully sprinklered becomes effective 8/13/13. A waiver of the requirement had been proposed, but will not be in place by 8/13/13. The waiver would apply in very limited situations, such as a building replacement or significant renovation, and would generally be granted for a period of two years with an extension possible in unique circumstances. In the absence of a waiver, CMS has no authority to grant extensions to the requirement and must enforce the current statutory deadlines. In other words, facilities not in compliance with the requirement may face imposition of a Denial of Payment for New Admissions (DOPNA) at the 90th day after survey, and termination from the Medicare and Medicaid program if not in compliance by 180th day after survey. In addition, a Civil Money Penalty (CMP) is possible in some situations. CMS is currently working on a Survey and Certification (S&C) letter, expected within the next two weeks, that will address the potential impact to facilities when they are not in compliance and a waiver is not available. In the meantime, CMS plans to determine compliance with the sprinkler requirements as part of facilities’ next standard survey.

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