12 Associations from 6 States Gather Data Regarding Life Safety Code Survey Costs
By Doug Beardsley
Earlier this week, nursing facility administrators in six states (Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin) representing states that are located within CMS Region V, received communications from their state association asking for costs associated with certain Life Safety Code deficiencies. It has become obvious that many nursing facilities have been subjected to erroneous but rigidly enforced Centers for Medicare and Medicaid Services (CMS) Region V interpretations of Life Safety Code (LSC) requirements. It is our understanding that CMS Region V's interpretation and enforcement directives are often irreconcilable with LSC survey and enforcement expectations outside of Region V's six-state jurisdiction. The legitimacy of Region V's LSC interpretations have been questioned by your Association, national experts, the National Fire Protection Association's Health Care Interpretation Task Force, state agencies, and formally challenged by an increasing number of facilities within our region. Our State Fire Marshals, who conduct the "routine" Life Safety Code surveys in our state, are required to comply with the interpretations provided by CMS Region V, as CMS Region V is the "Authority Having Jurisdiction" (AHJ) for our region.
Many of Region V's controversial interpretations and enforcement mandates to state survey agencies were subsequently rescinded, "clarified" or stopped after intervention by CMS Central Office in Baltimore, but only after considerable financial resources were expended by facilities to "correct" situations that should never have been cited in the first place.
Representatives from all 6 Region V controlled states feel that we are at a point now in our advocacy where we need to quantify the financial impact of these adverse actions.
The link below directs you to a brief LSC survey being presented to all nursing facilities by the AAHSA and AHCA affiliates in Illinois, Indiana, Michigan, Minnesota, Ohio, and Wisconsin. The survey aims to identify and quantify the degree to which incorrect interpretation and enforcement of Life Safety Code requirements has diverted scarce financial resources to fund facility "corrective" action with respect to LSC cites that should never have been issued. We are collaborating and supporting this undertaking to address past, present and future CMS Region V policy and enforcement directives that are incompatible with the content, intent, and integrity of the Life Safety Code. We have requested that each nursing facility in our membership go to the electronic survey and provide the information requested (please – only one response per facility).
If your facility has not already completed the LSC survey, please go to the following link:
We ask that you please submit your responses no later than July 24, 2009.
Should you have any questions on the LSC survey, please contact Doug Beardsley at 952-851-2489 or firstname.lastname@example.org.
The following are the most recent Region V Life Safety Code interpretations that were strictly enforced but later "clarified" or rescinded:
1. K17: CMS Region V required several facilities to install roll down fire shutters on reception office openings. Stopped citing.
2. K18: Door Gaps. CMS Region V declared a 1/8" max. Rescinded. The current CMS interpretation is up to ½" in sprinklered buildings and ¼" for non-sprinklered buildings.
3. K20: CMS reversed its position on vertical shafts by prohibiting the use of FSES – Fire Safety Evaluation System – on buildings of 4 stories or more. In the past, CMS also has required facilities to install dampers (including floor dampers) to bring K20 and K64 tags into compliance. Currently being challenged.
4. K32/K38: CMS Region V declared the FSES process could not be applied to unpaved exit discharge paths. Rescinded.
5. K32: CMS Region V disallowed magnetic locks to be mounted on the head of door frames. Stopped citing.
6. K47: CMS Region V required lit exit signs on outdoor gates. Stopped citing.
7. K56: CMS Region V declared FSES could not be applied to non-sprinklered canopies and overhangs. Rescinded.
8. K67: Resurrected the corridor air plenum issue disallowing resident room toilet exhaust to get make up from corridor. Rescinded.
9. K69: CMS Region V directed citing of older range hood extinguishing systems for not having automatic fuel shutdown. Rescinded, once it was noted this was not required in sprinklered buildings until upgraded.
10. K72: CMS Region V disallowed touchscreen computer monitors to be installed on a corridor wall. Rescinded. Still requires existing water coolers in corridors to be removed if they protrude into corridor more than 3 ½ inches.
11. K76: CMS Region V disallowed and directed citing of facilities for having a C2 container (larger size) of liquid oxygen in the resident's room. Subsequently, CMS permitted larger size containers if the resident was using the oxygen. However, CMS required the container be removed and stored while the resident went to dining on a portable. Region V later rescinded this storage requirement.
12. K108: Insisted that emergency battery lighting be provided for not only the generator but all associated equipment such as in rooms with the transfer switch. Rescinded. Now CMS only requires that the generator has this lighting. (According to K108 this is not applicable to existing buildings.)
13. K144: CMS Region V's position is that the LSC requirement that emergency generators must be "on premises" applies to both the generator and its back-up fuel source. This position has been rejected in Wisconsin IDR decisions; however, CMS Region V has not yet retracted its interpretation which is being challenged on numerous fronts. Being challenged.
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