CMS: Enforcement Actions – Installation of Sprinkler Systems in Nursing Homes

In a revision to its existing memo on nursing home automatic sprinkler system requirements, on November 15th, CMS issued an updated memo, “Enforcement Actions – Installation of Automatic Sprinkler Systems in Nursing Homes – August 13, 2013 Deadline” (Ref: S&C-13-55-LSC Revised 11.15.13). As we had mentioned in a previous post, CMS maintained its August 13, 2013 deadline for the installation of these sprinkler systems in nursing facilities. The agency continues to maintain its position that it does not have the authority to allow any extensions to this timeframe, and while they issued a proposed rule earlier this year to grant some extensions, a final rule has not yet been promulgated. This current memo includes specific “integrated” actions a nursing home may take to reduce its fire risks while a sprinkler system is being installed.

CMS notes that there are unique circumstances that facilities that are in the process of installing a sprinkler system may be in, including financial requirements, the need to relocated affected residents in a safe manner during construction, or dependence on local agencies that are required for granting permits or completing the work. For these groups, CMS has developed a set of “extraordinary protective actions that a facility may implement while it is still in the process of installing sprinkler systems or building a replacement facility.” In special circumstances, CMS states, if a facility has reduced the fire injury risk and there is only a short exposure period before the facility is fully sprinklered, then citations given during a Life Safety Code Survey (LSC) may be cited at a “C” level – no more than potential for minimum harm. However, this list of “extraordinary protections” is definitely that, and can be taxing on the facility to complete comprehensively. All of the elements of either of the two sections below must be met in order to have the citation lowered to a “C” if they are met and confirmed by a revisit survey.

1.       Immediate, Extraordinary, and Sustained Risk Mitigation During Sprinkler Installation

  1. Fire Watch 24/7 – a 24 hour fire watch is in place by one (or more) staff who are dedicated to fire watch without any other responsibilities and make hourly rounds of all non-sprinklered areas of the building 24×7
  2. Posting of Fire Watch Staffing Information – Facility must post information regarding the addition of a fire watch on each shift
  3. Construction – The building is constructed entirely of material with a fire resistance rating of not less than 2 hours and does not rely on the use of Fire Safety Evaluation system to comply with any construction-type deficiencies
  4. Smoke Alarms and Fire Extinguishers – Facility must be in full compliance with CMS requirements for smoke alarms
  5. Fire Drills – Facility conducts fire drills in unsprinklered areas on at least a monthly basis for each shift
  6. Staff Training – Facility conducts monthly training of all staff who are employed in unsprinklered areas regarding: fire safety awareness, fire prevention, mitigation, protection of residents from hazards during a fire and supervision of activities that may present fire risk
  7. Staffing – Facility has increased resident direct care staff levels on each floor in all unsprinklered areas, based on resident acuity and is sufficient to ensure increased evacuation readiness and resident care. The facility needs to provide monthly staffing reports for unsprinklered areas to CMS and the State Agency documenting the increased staff levels
  8. Fire Inspections – Facility contracts/arranges with local Fire Marshall’s office or other qualified inspection service approved by SA to have monthly fire inspection of all unsprinklered areas. Reports should be submitted monthly to SA and CMS RO
  9. State Monitoring – SA maintains onsite monitoring, unless CMS RO determines that this is not required
  10. Minimization of Risk Duration – CMS notes, “we will not consider risk to be reduced to no more than potential for minimum harm unless the facility limits the duration of time in which the unsprinklered areas will remain without an installed system of automatic sprinklers, including evidence that:”
    i.      Installation construction had started, or all necessary permits have been filed to begin installation and these permits have been approved, AND
    ii.      Installation will be completed within 6 months, or the remaining portion of the facility that does not have the sprinklers is vacated from resident use


2.       Removal of Use by Residents – The Second Option if Full Sprinkler Status is Not Yet Achieved

Under this option, the non-sprinklered area of the facility is entirely vacated from any use by residents. CMS may lower the scope and severity rating of the deficiency as long as the vacated section of the facility does not pose a significant fire hazard to any area that the residents resident in, and at a minimum, the facility has ensured a smoke barrier between the unoccupied and occupied areas is in place.


Review the attachments provided by CMS for specific information on this enforcement action update.

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