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SKILLED NURSING FACILITY FIRE SPRINKLER RETROFITS: A GUIDE TO CMS REQUIREMENTS

As many of you may already know, as of the notice sent out on August 13, 2008, all nursing homes must be fully sprinklered as of August 13, 2013 in order to participate in Medicare or Medicaid. Below are a few quick facts about this requirement, excerpted from a CMS memo that was recently released. Please click here to the full document to learn more about the specific requirements for your facility.


Survey and Enforcement Process:

While CMS is not requiring any special surveys focused on the sprinkler requirement, a life-safety code (LSC) inspection is part of each facility’s recertification survey. As these surveys occur during the year, facilities that are not fully sprinklered on or after August 13, 2013 will be cited for a deficiency.


LSC surveys will continue to occur as part of a normally-scheduled annual survey, or as part of a complaint visit in which LSC deficiencies are noted or referred. On or after the August 13, 2013 deadline, LSC surveys finding a facility without a complete automatic sprinkler system will be cited on the CMS Form 2567 at deficiency tag K056 as not in compliance with CMS requirements.


Facilities that are cited for not meeting the sprinkler requirement will be required to submit a plan of correction (POC) to correct the deficiency.


Penalties and Consequences:

CMS will generally not impose a civil monetary penalty (CMP) for a facility that is newly subject to the requirement to have an automatic sprinkler system installed throughout the building if the plan of correction ensures, by means of appropriate and timely investment, contracts in place, and completed plans for installation, that full sprinkler status will be achieved within three months of the completed survey. However, this does not preclude CMPs from being imposed immediately where the noncompliance is serious, particularly if at the time of the survey the necessary plans have not been completed.


When an LSC citation is made, the facility will be placed on the normal enforcement track. As indicated previously, a CMP will generally not be imposed if contracts are in place, plans are completed, and the plan of correction ensures that full sprinkler status will be achieved within three months of the completed survey. Denial of payment for new admissions going into effect at three months if compliance has not been achieved by then, and termination from the program at six months, if noncompliance continues. The CMS Regional Office may issue other remedies and earlier enforcement effective dates based on its judgment regarding all the circumstances at the facility (including non-LSC factors). The absence of a clear commitment to, and reasonable time frame for, sprinklering the facility will likely be cause for strong enforcement action, including CMPs.


What’s Next?:

Many of our clients have taken the steps necessary to add sprinklers to their facilities, and projects range from those still in governing jurisdiction plan review to those that are now fully sprinklered. If your facility does not have a clear plan regarding sprinklers moving forward, we can assist in guiding you down the path toward compliance!