CMS LTC Facility Survey Process Related to Sprinkler Extension

On May 16 2014, CMS issued an S&C letter, “Information on Applications to Extend the Due Date for the Installation of Automatic Sprinkler Systems in Existing Nursing Homes” (Ref: S&C: 14-29-LSC). This letter serves as a follow up to a final rule issued in the May 12, 2014 Federal Register on this Life Safety Code (LSC) requirement. A rule published in 2008 had required all long term care facilities to be equipped with automatic sprinkler systems by August 13, 2013. Very limited extensions will be given based on the specific criteria for the regulation, including replacement/major modification, financial commitments, plans filed and additional interim protections.

Survey Process Related to the Sprinkler Extension

In November 2013, CMS issued a memo regarding enforcement actions related to the sprinkler requirement. The memo outlined specific, integrated actions that long term care facilities could take to reduce fire risks while the sprinkler systems were being installed. The new May 16 memo provides information on three possible scenarios that LTC facilities may find themselves in regarding their fully sprinklered status:

  • If the extension has been approved before the survey, then surveyors will document the details of the extension based on the facility-provided copy of the extension approval that is provided when surveyors arrive onsite. No survey for compliance will be required.
  • If the facility was surveyed and cited at K-56 for not having a full and automatic sprinkler system in place before having its extension removed, then surveyors will follow the enforcement criteria outlined in the November 13 memo.
  • If the facility does not qualify for an extension and is surveyed and cited for not being fully sprinklered, then the facility will be cited at K-56. If, based on the criteria from the November 13 memo, the facility had been cited at a lower scope/severity of “C,” but still does not qualify for an extension, then a survey would take place (usually offsite) and a deficiency would be re-issued at a S/S of “F.” The enforcement cycle would start over then and all available enforcement actions could be put into place.

This is effective May 12, 2014. Read the full S&C letter on the CMS website.

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