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Task 1 – Offsite Survey Preparation. The surveyor or survey team will review the facility file for: • Recent licensure and/or certification surveys, ...
Typology: Summaries
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(Rev. 159, 09-09-16)
I. Introduction
II. The Survey Tasks
Task 1 – Offsite Survey Preparation Task 2 - Entrance Conference/Onsite Preparatory Activities Task 3 - Orientation Tour Task 4 - Information Gathering Task 5 - Information Analysis and Decision Making Task 6 - Exit Conference
III. Complaint Investigations
IV. Post Survey Revisits
(Rev.101, Issued: 02-14-14, Effective: 02-14-14, Implementation: 02-14-14)
Use the survey procedures in this appendix section for all Life Safety Code (LSC) surveys (initial and recertification) of facilities subject to Survey and Certification inspections for Medicare/Medicaid certification. This includes, but is not limited to, Skilled Nursing Facilities (SNFs), Nursing Facilities (NFs) whether freestanding, distinct parts, or dually certified, Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IID), Ambulatory Surgical Centers (ASC), inpatient Hospice facilities, Program for All inclusive Care for the Elderly (PACE) facilities, Critical Access Hospitals (CAH), Psychiatric and General Hospitals, including validation surveys of accredited facilities. These procedures also apply to complaint investigations. When conducting LSC complaint investigations, focus your review on those requirements relevant to the complaint.
All SNF/NF and ICFs/IID surveys must be unannounced. The LSC survey of a SNF/NF may precede the survey of resident care requirements and can be done independent of a health survey. LSC surveys must be conducted and completed on consecutive days. Survey team members need not be onsite for the entire survey. For example special consultants participating in the survey (such as, a fire protection engineer, or fire alarm technician) have the option of being onsite only during that portion of the survey that require their area of expertise; however, they must conduct that portion while the rest of the LSC survey team is present. The special consultant(s) should present their findings to the team or team leader before departing the facility. If any deficiencies are to be cited, supporting documentation should be left with the team. The consultant should be available during the exit conference to supply any additional information required. This can be in-person or by telephone.
The surveyor or survey team will review the facility file for:
there is two-hour fire wall between the hospital and the SNF, then a LSC survey of the SNF section alone is allowed. A floor-ceiling assembly does not meet the separation requirements of a two-hour fire wall. If there is no fire wall, then a LSC survey of the complete building, hospital and SNF, is to be conducted. When there is no two-hour separation, then the complete building must be surveyed regardless of whether the hospital is accredited. All deficiencies found will be reported whether they were found in the deemed hospital portion or in the distinct part SNF.
Validation surveys of deemed hospitals must use the appropriate chapters, NEW or EXISTING, of the 2000 LSC.
CMS, in its regulations adopting the 2000 edition of the LSC, did not adopt the paragraph 19.3.6.3.2 exception No.2 dealing with existing roller latches. The use of roller latches is no longer acceptable as a corridor door-latching device in existing health care facilities. This includes facilities that are both non-sprinklered and sprinklered. Facilities have until March 13, 2006 to remove roller latches from use. Emergency lighting lasting at least 1- 1/2 hours is required by the LSC; facilities have until March 13, 2006 to meet this requirement. CMS also adopted by regulation the requirement that any facility certified as an ASC is to meet the requirements of the LSC for ambulatory health care, without regard to the number of patients served by the ASC at any one time.
Hospital and critical access hospital anesthetizing locations in which clinical procedures are performed are required to maintain relative humidity. According to NFPA 99, anesthetizing locations are defined as “Any area of a facility that has been designated to be used for the administration of nonflammable inhalation anesthetic agents in the course of examination or treatment, including the use of such agents for relative analgesia.” NFPA 99 defines relative analgesia as “A state of sedation and partial block of pain perception produced in a patient by the inhalation of concentrations of nitrous oxide insufficient to produce loss of consciousness (conscious sedation).” (Note that this definition is applicable only for LSC purposes and does not supercede other guidance we have issued for other purposes concerning anesthesia and analgesia.)
Hospitals and critical access hospitals must maintain relative humidity (RH) at levels of 35 percent or greater in all anesthetizing locations, unless the hospital or CAH has elected to implement the CMS categorical waiver, which permits new and existing ventilation systems to operate at a RH level of 20 percent or greater. This categorical waiver does not apply where more stringent RH levels are required under State or local laws and regulations, or where the reduction in RH would negatively affect ventilation system performance. Hospitals and CAHs that choose to maintain a RH level of 20 percent or greater must elect to use this categorical waiver, document their decision, and notify the survey team of its decision at the entrance conference, in advance of being cited for a RH deficiency. The hospital or CAH must also monitor RH levels, and be able to provide evidence that RH levels are maintained, and effective corrective actions are taken in a timely manner if monitoring determines RH is less than the required percentage. Although not required, CMS recommends that hospitals and CAHs maintain the upper
range of relative humidity at less than or equal to 60 percent, as excessive humidity is conducive to microbial growth and may increase the risk of infections.
Determine whether or not a Fire Safety Evaluation Survey (FSES), has previously been conducted at the facility. The use of the FSES may be applicable when a facility has multiple deficiencies that may be cost prohibitive to correct. The facility should be informed that the use of the FSES is a certification option at the exit conference. It is up to the facility to decide if the FSES is to be used to achieve certification.
The State Agency, at its option, may complete the FSES for the facility or may act as a reviewer of an FSES submitted by the facility as part of the facility’s Plan of Correction (POC).
NFPA 101A, Guide on Alternative Approaches to Life Safety, 2001 Edition, is to be used to complete all FSES’s. An FSES evaluation is to be done in conjunction with the completion of the regular Fire Safety Survey form (CMS Form 2786). If the building is certified in compliance with the LSC on the basis of an FSES evaluation, an FSES evaluation must be completed each time a LSC survey is completed. To recertify the building using the FSES, a regular Fire Safety Survey form is completed before completing the FSES, this evaluation will take into account any changes in the facilities life safety features.
The FSES is only available for buildings surveyed using the Health Care Occupancies and Residential Board and Care Occupancies chapters. There is no FSES available for use when surveying ASCs, which are surveyed using the prescriptive requirements of the Ambulatory Health Care Occupancies chapter (20/21) of the LSC.
(Rev.101, Issued: 02-14-14, Effective: 02-14-14, Implementation: 02-14-14)
Entrance Conference:
Upon arrival at the facility, proceed to the Administrator’s office and identify yourself and state the purpose of your visit: to perform a fire safety survey under the regulations of Medicare/Medicaid. The team coordinator or individual surveyor conducts the Entrance Conference, informing the facility’s administrator about the survey and introducing any team members. The team coordinator then explains the survey process and answers any questions from facility staff.
While the team coordinator conducts the Entrance Conference, other LSC team members, may begin Task 3 - Orientation Tour.
Ask the Administrator to describe any special features of the facility’s physical plant. For example, was the facility constructed at different times and were different types of
Since there are no survey report forms for these chapters of the LSC, the chapters and their references serve as the source documents, and, if deficiencies are found, they are to be reported on the CMS Form-2567 and identified using the appropriate code reference number in the applicable chapter(s) of the code.
To determine which LSC chapters are applicable to ICFs/IID, the type and extent of services provided need to be determined. The New Residential Board and Care Occupancy Chapter (Chapter 32) or the Existing Residential Board and Care Occupancy Chapter (Chapter 33) of the 2000 edition of the LSC is applicable to a ICF/IID in the Medicaid program which provide “personal care services.” The LSC defines personal care as “protective care of a resident who does not require chronic or convalescent medical or nursing care.” Generally, protective oversight and personal care is defined as assistance in meeting daily needs (e.g., being aware of residents’ whereabouts, reminding them of appointments). This may include “transient medical care,” such as the kind of care provided in the home by one family member to another when he/she is sick. In an ICFs/IID this means supervising client’s movements and daily living skills. An RN or LPN on staff at the board and care home solely to dispense medication is not an indication of chronic medical or nursing care.
If a resident receives skilled/acute nursing or medical care such as is provided in a hospital, nursing home or an inpatient hospice, Chapter 18/19 (Health Care Occupancies) must be applied.
If the LSC surveyor determines that an ICFs/IID will be surveyed under the Residential Board and Care Occupancy of chapters 32 and 33, it must be further broken down into one of two categories based on size and evacuation capability before the survey can continue.
Small facilities are those with sleeping accommodations for not more than 16 residents (section 32.2 or 33.2). Large facilities are facilities with sleeping accommodations for more than 16 residents (section 32.3 or 33.3). This means that an apartment building containing several ICFs/IID in separate apartments must meet Section 32.2 or 33.2 for the individual units, and the apartment building must meet the requirements of Chapter 30/ Apartment Buildings which are listed in section 32.4 or 33.4.
Most large facilities tend to fall into the category of health care, while smaller facilities tend to be residential board and care occupancies.
An orientation tour may be in order to provide an overview of the facility, and serve as an introduction of the surveyors to the staff. This may be helpful if the facility is a very large single building or has multiple buildings that may have to be surveyed.
(Rev. 159, Issued: 09-09-16, Effective: 09-09-16, Implementation: 09-09-16)
Upon completion of the review of the documentation provided by the facility, the more detailed inspection begins. Using the layout of the building as a guide, begin an observation tour that includes the outside of the building as well as the inside.
At this time determine the type of building construction. This can be accomplished by review of the construction drawings, if available, and must be confirmed by direct observation of the structure and building materials used in constructing the building (exposed areas above the ceilings or vertical pipe shafts may provide insight).
Check floor-to-floor separations, corridor wall construction, smoke barrier locations, construction and condition, and any vertical opening construction including access doors. If multiple buildings or wings are involved, any fire barriers present should be inspected for construction materials used, the protection of penetrations through the barriers and the type and arrangement of any doors thru the barriers. Buildings separated by a vertical two-hour fire barrier can be considered separate buildings for the purposes of a Life Safety survey. (Note: If the two-hour fire barrier has been so severely compromised by penetrations or other construction defects that it may not provide the required fire protection, it may be necessary to ignore this feature and consider combining the two buildings together. If this is done, the two buildings will be surveyed as if there were only one building. The facility may elect to repair the two-hour separation and have the buildings surveyed as two separate buildings.)
When separate buildings are surveyed, each building requires the use of an individual set of reporting forms.
Proceed next to a complete room-by-room, floor-by-floor, walk through of the facility. This includes a representative sample of bedrooms (Table 1). At a minimum, inspect: one smoke barrier, including doors, on each floor or wing; all fire barriers; all hazardous areas including doors into the area; all exit stairs, doors, signs; resident room doors for condition, latching and fit in the door frame; the fire alarm system; the sprinkler system; the emergency power generator set; corridor walls; emergency lighting; and medical gas storage, if applicable.
Inspect the smoke and fire barriers for construction materials and continuity, completeness from outside wall to outside wall and from the floor to the bottom of the floor above where applicable. Inspect any penetrations to determine if they are sealed properly. Where ductwork penetrates the barrier, inspect any dampers, fire or smoke that have been installed in the ductwork.
For each room inspected, check the corridor door for latching, operation and fit into the doorframe. The fire rating of the door should also be inspected if applicable. The interior of the room should then be inspected for hazards such as electrical outlets,
demonstration of the emergency power system should not be requested due to the large amount of computerization and the use of life support equipment that may be affected.
Inspect laboratories for proper sprinklering, fire separation construction, door type, emergency eye wash equipment, storage of flammable liquids and gases, and fume hood ventilation.
Inspect medical gas storage areas for proper construction, ventilation, gas system controls/alarms and proper restraint of cylinders.
Review the facility fire plan including fire drill records and staff interviews to determine staff actions and responsibilities during a fire or emergency. The surveyor may request an actual fire drill demonstration based on a review of the facility fire drill records and interviews with the staff to verify the adequacy of staff response. This should be done only if there is a question of the adequacy of staff response found in the documentation of the monthly fire drills.
Determining the ICFs/IID “E” Score
The technique for surveying and determining compliance with the LSC of ICFs/IID is very similar to previous parts of this protocol with several additional requirements. After determining the type and size of the ICF/IID, determine the level of evacuation difficulty if the facility chooses to comply with the requirements for residential board and care. This is done for each of the types of facilities; small, large, and a Board and Care facility in an apartment house. The three levels of evacuation difficulty are known as Prompt (level A), Slow (level B) and Impractical (level C). CMS regulations require the use of NFPA 101A, Guide on Alternative Approaches to Life Safety, 2001 Edition, Chapter 6, Evacuation Capability Determination for Board and Care Occupancies to determine the evacuation difficulty index (EDI).
Large buildings previously meeting health care requirements such as a facility with 17 beds or more, which currently meets the health care provisions of the LSC, can continue to be surveyed either under the Health Care Chapter or the FSES/Health Care. If the large facility qualifies as Residential Board and Care occupancy, it may elect to be surveyed under Health Care.
If the facility is to be certified based upon achieving a passing score on the FSES/BC, complete a Statement of Deficiencies, Form CMS-2567, for both the regular Survey Report and the FSES/BC for any deficiencies found. The provider will indicate whether it chooses to correct the deficiencies on the Form CMS-2786, or the deficiencies on the FSES/BC.
There are no provisions for the granting of waivers when using the prescriptive requirements under the Residential Board and Care Occupancies Chapters 32/33. Providers may elect to be surveyed under the Health Care chapters to take advantage of the ability to obtain waivers.
Only surveyors that have completed CMS’s basic Life Safety Code and the FSES/HC and if appropriate the FSES/BC training courses may apply the FSES in Medicare/Medicaid facilities.
The table below gives the sample size (number of patient/resident rooms to be checked) needed.
Number of Bedrooms in the Facility
Bedrooms to be Checked
General Objective
The general objective is to review and analyze all observations and findings in order to determine whether the facility has a deficiency in one or more of the regulatory requirements. A deficiency is defined as observed problems of sufficient severity and/or frequency so as to identify the facility as responsible, and which require some form of corrective action by the facility.
Frequency means the incidence or extent of the occurrence of an observed problem in the facility.
Severity means the seriousness of the observed problem, e.g., the degree to which the problem compromises the residents’ health and safety.
A deficiency may be cited when a deficient practice occurs once, or when it occurs frequently.
Procedures
The fire safety survey report forms, worksheets and procedures are designed to assist in the gathering information about the level of fire safety provided by the facility. The K- tags refer to the data tags on the Fire Safety Survey Report form. For each item on the report form page indicate “Met” or “Not Met” or “Not Applicable.” For each item marked “Not Met,” enter the appropriate documentation in the Explanatory Remarks section explaining the nature of the deficiency and the degree of hazard it presents. Use additional sheets of paper for additional comments. Throughout the survey, discuss your observations with any other LSC team members and the facility staff. This interaction will assist you in identifying facility problems and will permit the facility the opportunity to provide additional information that may alleviate your concerns.
At the end of the survey, meet with any other LSC team members to draw conclusions about the level of fire safety provided by the facility, and the facility’s compliance with the life safety code.
Deliberately review the negative findings and documentation from each task, and decide whether any further information or documentation is required. Consider your findings and observations in terms of credibility and reliability. Also, consider whether there are any rival or competing explanations related to particular negative findings. If necessary, ask the facility for additional information for clarification about particular findings and carefully weigh any countervailing explanations before making a deficiency determination.
There is no provision in the regulations for the granting of waivers of the LSC requirements under Chapter 32/33 (Residential Board and Care Occupancies). A facility may use the FSES survey or request to be surveyed under the requirements of Chapter 18/19 (Health Care Occupancies). There also cannot be a waiver of the requirement for a generator in a facility with life support equipment.
When recommending a waiver of a specific LSC requirement on the basis of correction of another deficiency, the waiver should not be granted until the corrective action on the other item is completed. For example, if a facility is requesting a waiver of the installation of return air ducts where corridors are being used as return air plenums on the condition that the facility install smoke detectors tied into an alarm system and the automatic shutdown of ventilation fans, do not waive the return air plenums until you verify that the facility has actually installed the detectors and that are appropriately connected to the fire alarm and air circulation systems. In the above cases, the first page of the Form CMS-2786 should be marked “Meets, Based Upon, 2. Acceptance of a Plan of Correction” and then upon completion of the corrective action it can be marked “Meets, Based Upon, 3. Recommended Waivers.”
Waivers of specific LSC criteria can be recommended for an extended length of time if correction of the deficiency is not possible.
When a waiver is recommended, both the surveyor and concurring fire authority official must sign the form at the bottom of Part IV, Recommendation for Waiver of Specific Life Safety Code Provisions, after the facility has responded to the Statement of Deficiencies.
In instances where CMS has issued policy which allows for a categorical waiver of specific life safety code provisions, facilities must document their election to use a categorical waiver and notify the survey team of their decision in advance of being cited for a deficiency. The surveyor must review the facility’s documented decision, confirm that the facility is meeting all of the categorical waiver requirements, and reference the use of the categorical waiver to achieve compliance under Tag K000 and in Part IV on the CMS-2786. Categorical waivers do not require a prior deficiency citation or Regional Office approval, therefore the first page of the Form CMS-2786 should be marked “The Facility Meets, Based Upon, 3. Recommended Waivers.”
Writing Deficiency Statements
Following the Principles of Documentation, (appendix P) write the deficiency statement in terms specific enough to allow a reasonably knowledgeable person to understand the aspect(s) of the requirement(s) that is (are) not met. Indicate the data prefix tag and regulatory citation, followed by a summary of the deficiency and supporting findings using resident identifiers, not resident names. List the data tags in numerical order, whenever possible.
The statement of deficiencies should:
Decision Making for Compliance with the LSC
The final part of the fire safety survey is sometimes considered the most difficult, and that is making a compliance decision on whether or not the facility meets the LSC. There is no number of deficiencies, that if exceeded makes the facility out of compliance with the LSC. It is possible to have one or two deficiencies are significant enough to be considered an immediate and serious threat to the residents/patients or a large number of less serious deficiencies that do not have the same impact. In the final analysis a decision has to be made, one that is based on the facts and can be objectively defended if questioned.
The decision making process for health care facilities is very similar across all provider groups with the exception of accredited hospitals.
If a facility has no deficiencies or non-consequential deficiencies the decision making process is very simple; the facility is in compliance and no deficiencies are cited. The survey report form is marked “The Facility Meets, Based Upon 1. Compliance With All Provisions.” No further action by the facility is expected regarding this survey. The facility is to be notified and the results posted and available to the residents and the public.
If the facility has deficiencies and they are not at the level that would constitute an immediate and serious jeopardy or threat to the health and safety of the residents/patients (see Appendix Q for criteria) then a compliance decision will have to be made based on the results of the survey. This decision needs to be based on the facts at hand and not biased one way or the other due to outside forces.
Deficiencies may be considered corrected by the approval of a waiver of a specific requirement of the Life Safety Code.
administrator is notified that immediate and serious threat termination procedures are being invoked. The surveyor should explain to the administrator the nature of the threat. The surveyor should complete the remainder of the survey to determine the extent of deficiency.
The Form CMS-2786 should be marked as 7. B. “THE FACILITY DOES NOT MEET THE STANDARD” if the facility is found to have an immediate and serious threat. If the form is marked “MEETS WITH ACCEPTANCE OF A PLAN OF CORRECTION,” the State Agency cannot make a finding of immediate and serious jeopardy at the facility.
See Appendix Q for guidance regarding the determination of immediate and serious threat, and §3010 of the State Operations Manual (SOM) for procedures to follow if the immediate and serious threat termination procedures are invoked.
(Rev. 159, Issued: 09-09-16, Effective: 09-09-16, Implementation: 09-09-16)
General Objective
The purpose of the exit conference is to inform the facility of the survey team’s observations and findings.
Conduct of Exit Conference
Conduct the exit conference with the facility administrator or anyone designated by the administrator. Also, invite an Officer of the organized residents group, if one exists, or a representative of the residents of the facility to the exit conference.
Provide the facility with specific information necessary for POC, if there is a need for a POC. Do not provide the facility worksheets that contain surveyor notes.
For life safety code surveys, the survey team may follow the procedures for either non- LTC or LTC described in Chapter 2, Section 2724C - Presentation of Findings. This would be determined depending on the degree to which, in the judgment of the team, the tag codes are important in helping the provider/supplier to understand the nature and location of the deficiency, and the corrective actions that would be necessary. Facility representatives are typically invited to accompany life safety code surveyors during building tours, to improve familiarity with preliminary findings and exit conference proceedings.
Under no circumstances should you make general statements about the facility such as, “Overall the facility is very good.” Stick to the facts. Do not rank regulatory requirements, but treat requirements as equally as possible. Cite problems that clearly violate regulatory requirements. The surveyors must not make statements such as, “The condition was not met,” or “The standard was not met.”
Provide the facility with the opportunity to discuss and supply additional information, if necessary, and attempt to resolve differences regarding deficiencies.
Review with the facility alternatives to compliance with the prescriptive requirements of the LSC if appropriate, such as, waivers of specific life safety code requirements or the suitability of the facility to achieve compliance using the FSES.
If the provider asks for the specific regulatory basis or the specific tag code, the surveyors should generally provide this information (except as noted in Chapter 2, Presentation of Findings), but must always caution the facility that such coding classifications are preliminary and are provided only to help the provider gain more insight into the issues through the information provided in the interpretive guidance. If the facility does not specifically ask for the regulatory basis or tag, the survey team may use its own judgment in determining whether this information would provide additional insight for the facility.
The level of scope and severity will be determined in accordance with procedures found in SOM, Chapter 7, §7400. The level of scope and severity will depend on the extent of the deficient practice and its impact on the health and safety of the residents. This can occur on-site or presented to the facility on the Form CMS-2567.
In accordance with your Agency’s policy, present the Form CMS-2567, on site or after supervisory review, no later than 10 calendar days following the survey.
If a complaint alleges a deficient practice in fire safety, and the complaint is of a specific nature, use your discretion to investigate the complaint independent of the standard fire safety survey (a special survey) or incorporate the investigation of the complaint into that specific task that covers that issue in the standard fire safety survey.
The scope, duration and conduct of a complaint investigation are at the discretion of the State survey team. The investigation should be widespread enough to resolve the complaint. Base any citation of deficiencies upon observations at the time of the survey. If it can be determined that the facility was out of compliance at the time of the complaint but, is no longer out of compliance, this should be noted.
A Form CMS-2567 should be completed and forwarded to the facility in accordance with Agency policy if deficiencies are found.
