Nursing Home Fire Safety
Recent Fires Highlight Weaknesses in Federal Standards and Oversight
Gao ID: GAO-04-660 July 16, 2004
In 2003, 31 residents died in nursing home fires in Hartford, Connecticut, and Nashville, Tennessee. Federal fire safety standards enforced by the Centers for Medicare & Medicaid Services (CMS) did not require either home to have automatic sprinklers even though they have proven very effective in reducing the number of multiple deaths from fires. GAO was asked to report on (1) the rationale for not requiring all homes to be sprinklered, (2) the adequacy of federal fire safety standards for nursing homes that lack automatic sprinklers, and (3) the effectiveness of state and federal oversight of nursing home fire safety.
Cost has been a barrier to CMS requiring sprinklers for all older nursing homes even though sprinklers are considered to be the single most effective fire protection feature. There has never been a multiple-death fire in a fully sprinklered nursing home and sprinklers are now required in all new facilities. The decision to allow older, existing facilities to operate without sprinklers is now being reevaluated in light of the 2003 nursing home fires. Although the amount is uncertain, sprinkler retrofit costs remain a concern, and the nursing home industry endorses a transition period for homes to come into compliance with any new requirement. If retrofitting is eventually required, it is likely to be several years before implementation begins. The nursing home fires in Hartford and Nashville revealed weaknesses in federal nursing home fire safety standards for unsprinklered facilities. For example, federal standards did not require either home to have smoke detectors in resident rooms where the fires originated, and the fire department investigations suggested that their absence may have delayed the notification of staff and activation of the buildings' fire alarms. In light of inadequate staff response to the Hartford fire, the degree to which the standards rely on staff to protect and evacuate residents may be unrealistic. Moreover, many unsprinklered homes are not required to meet all federal fire safety standards if they obtain a waiver or are able to demonstrate that compensating features offer an equivalent level of fire safety. However, some of these exemptions raise a concern about whether resident safety was adequately considered. For example, a large number of unsprinklered homes in at least two states have waivers of standards designed to prevent the spread of smoke during a fire. State and federal oversight of nursing home fire safety is inadequate. Postfire investigations by Connecticut and Tennessee revealed deficiencies that existed, but were not cited, during prior surveys. For example, a survey conducted of the Hartford home 1 month prior to the fire did not uncover the lack of fire drills on the night shift and, on the night the fire occurred, the staff failed to implement the home's fire plan. The survey was conducted during the daytime and relied on inaccurate documentation that all shifts were conducting fire drills. On the other hand, Tennessee's postfire investigation failed to explore staff response, a deficiency cited on the home's four prior surveys. The limited number of federal fire safety assessments, though inconsistent with the statutory requirement for federal oversight surveys, nonetheless demonstrate that state surveyors either miss or fail to cite all fire safety deficiencies. CMS provides limited oversight of state survey activities to address these fire safety survey concerns. In general, CMS (1) lacks basic data to assess the appropriateness of uncorrected deficiencies, (2) infrequently reviews state trends in citing fire safety deficiencies, and (3) provides insufficient oversight of deficiencies that are waived or that homes do not correct because of asserted compensating fire safety features.
Recommendations
Our recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
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GAO-04-660, Nursing Home Fire Safety: Recent Fires Highlight Weaknesses in Federal Standards and Oversight
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Report to Congressional Requesters:
United States Government Accountability Office:
GAO:
July 2004:
Nursing Home Fire Safety:
Recent Fires Highlight Weaknesses in Federal Standards and Oversight:
GAO-04-660:
GAO Highlights:
Highlights of GAO-04-660, a report to congressional requesters
Why GAO Did This Study:
In 2003, 31 residents died in nursing home fires in Hartford,
Connecticut, and Nashville, Tennessee. Federal fire safety standards
enforced by the Centers for Medicare & Medicaid Services (CMS) did not
require either home to have automatic sprinklers even though they have
proven very effective in reducing the number of multiple deaths from
fires. GAO was asked to report on (1) the rationale for not requiring
all homes to be sprinklered, (2) the adequacy of federal fire safety
standards for nursing homes that lack automatic sprinklers, and (3) the
effectiveness of state and federal oversight of nursing home fire
safety.
What GAO Found:
Cost has been a barrier to CMS requiring sprinklers for all older
nursing homes even though sprinklers are considered to be the single
most effective fire protection feature. There has never been a
multiple-death fire in a fully sprinklered nursing home and sprinklers
are now required in all new facilities. The decision to allow older,
existing facilities to operate without sprinklers is now being
reevaluated in light of the 2003 nursing home fires. Although the
amount is uncertain, sprinkler retrofit costs remain a concern, and the
nursing home industry endorses a transition period for homes to come
into compliance with any new requirement. If retrofitting is
eventually required, it is likely to be several years before
implementation begins.
The nursing home fires in Hartford and Nashville revealed weaknesses in
federal nursing home fire safety standards for unsprinklered
facilities. For example, federal standards did not require either home
to have smoke detectors in resident rooms where the fires originated,
and the fire department investigations suggested that their absence
may have delayed the notification of staff and activation of the
buildings‘ fire alarms. In light of inadequate staff response to the
Hartford fire, the degree to which the standards rely on staff to
protect and evacuate residents may be unrealistic. Moreover, many
unsprinklered homes are not required to meet all federal fire safety
standards if they obtain a waiver or are able to demonstrate that
compensating features offer an equivalent level of fire safety.
However, some of these exemptions raise a concern about whether
resident safety was adequately considered. For example, a large number
of unsprinklered homes in at least two states have waivers of standards
designed to prevent the spread of smoke during a fire.
State and federal oversight of nursing home fire safety is inadequate.
Postfire investigations by Connecticut and Tennessee revealed
deficiencies that existed, but were not cited, during prior surveys.
For example, a survey conducted of the Hartford home 1 month prior to
the fire did not uncover the lack of fire drills on the night shift
and, on the night the fire occurred, the staff failed to implement the
home‘s fire plan. The survey was conducted during the daytime and
relied on inaccurate documentation that all shifts were conducting
fire drills. On the other hand, Tennessee‘s postfire investigation
failed to explore staff response, a deficiency cited on the home‘s four
prior surveys. The limited number of federal fire safety assessments,
though inconsistent with the statutory requirement for federal
oversight surveys, nonetheless demonstrate that state surveyors either
miss or fail to cite all fire safety deficiencies. CMS provides limited
oversight of state survey activities to address these fire safety
survey concerns. In general, CMS (1) lacks basic data to assess the
appropriateness of uncorrected deficiencies, (2) infrequently reviews
state trends in citing fire safety deficiencies, and (3) provides
insufficient oversight of deficiencies that are waived or that homes
do not correct because of asserted compensating fire safety features.
What GAO Recommends:
GAO is making several recommendations to the Administrator of CMS to
(1)improve oversight of nursing home fire safety, such as reviewing the
appropriateness of exemptions to federal standards granted to
unsprinklered facilities and (2) strengthen the fire safety standards
and ensure thorough investigations of any future multiple-death nursing
home fires in order to reevaluate the adequacy of fire safety
standards. CMS concurred with GAO‘s recommendations.
www.gao.gov/cgi-bin/getrpt?GAO-04-660.
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Kathryn G. Allen at
(202) 512-7118.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Despite Effectiveness, Cost Has Been a Barrier to Requiring Sprinklers
for All Older Nursing Homes:
Federal Fire Safety Requirements for Unsprinklered Nursing Homes Are
Weak:
State and Federal Oversight of Nursing Home Fire Safety Is Inadequate:
Conclusions:
Recommendations for Executive Action:
Agency, State, and NFPA Comments and Our Evaluation:
Appendix I: Percentage of Surveyed Nursing Homes Cited with Fire Safety
Deficiencies on Their Most Recent Surveys, by State:
Appendix II: Federal Comparative Survey Results for Fiscal Year 2003--
Examples of Fire Safety Deficiencies Missed or Not Cited:
Appendix III: Comments from the Centers for Medicare & Medicaid
Services:
Tables:
Table 1: Scope and Severity of Deficiencies Identified during Nursing
Home Surveys:
Table 2: Key Facts about the Hartford and Nashville Nursing Home Fires:
Table 3: Sprinkler Requirements for Existing Nursing Homes, by
Construction Type:
Table 4: Potential Weaknesses in Federal Standards Contributing to
Multiple-deaths in Hartford and Nashville Nursing Home Fires:
Table 5: Violations of Federal Standards in Hartford and Nashville
Nursing Home Fires Not Identified during Prior Surveys:
Table 6: States with Large Proportions of Current Fire Safety Surveys
Conducted in 2 hours or Less:
Table 7: Comparison of the Number and Type of Federal Monitoring
Surveys Including Quality-of-Care and Fire Safety Standards, Fiscal
Year 2003:
Figures:
Figure 1: How Nursing Homes May Address Fire Safety Deficiencies:
Figure 2: Percentage of Nursing Homes Reported to Have Fire Safety
Deficiencies on Their Most Recent Surveys in States with at Least 100
Homes:
Abbreviations:
AHCA: American Health Care Association:
CMS: Centers for Medicare & Medicaid Services:
FSES: Fire Safety Evaluation System:
HVAC: heating, ventilating, and air-conditioning system:
NFPA: National Fire Protection Association:
OSCAR: On-Line Survey, Certification, and Reporting system:
United States Government Accountability Office:
Washington, DC 20548:
July 16, 2004:
The Honorable Charles E. Grassley:
Chairman:
Committee on Finance:
United States Senate:
The Honorable Bill Frist, MD:
United State Senate:
Two deadly nursing home fires in 2003 focused considerable attention on
the safety of the nation's 1.5 million nursing home residents, a highly
vulnerable population of elderly and disabled individuals. The
development and enforcement of fire safety standards for nursing homes
is critical because many residents have restricted mobility that may be
accompanied by cognitive impairments, conditions that can limit their
ability to escape if a fire should occur. To ensure the health and
safety of nursing home residents, the federal government adopts and
enforces standards that all homes serving Medicare or Medicaid
beneficiaries must meet, and state survey agencies conduct periodic
inspections, known as surveys, to determine whether the standards are
being met.[Footnote 1] The most recent data show that an average of
about 2,300 of the nation's approximately 16,300 nursing homes reported
a structural fire each year from 1994 through 1999 and that annually,
the average number of fire-related nursing home deaths nationwide was
about five.[Footnote 2] Over this same time frame, one multiple-death
nursing home fire resulted in three fatalities.[Footnote 3] In
contrast, the fire-related death toll in 2003 was considerably higher-
-a total of 31 residents died in the nursing home fires in Hartford,
Connecticut (16 deaths), and Nashville, Tennessee (15 deaths). Neither
home was required to have an automatic sprinkler system even though
such systems have proven very effective in reducing the number of
multiple deaths from fires. Federal fire safety standards do not
require sprinklers in existing nursing homes of certain noncombustible
construction, and it is estimated that 20 to 30 percent of nursing
homes nationwide lack full automatic sprinkler protection.
The large number of resident deaths in the Hartford and Nashville fires
raised serious questions about nursing home fire safety. You asked us
to report on (1) the rationale for not requiring all nursing homes to
have sprinklers and the status of any initiatives to change that
requirement; (2) the adequacy of federal fire safety standards for, and
their application to, nursing homes that lack automatic sprinkler
systems; and (3) the effectiveness of state and federal oversight of
nursing home fire safety. To do so, we used information related to the
Hartford and Nashville fires as a context for addressing these broader
issues. In responding to the first two questions, we reviewed federal
fire safety standards with a focus on why some homes are not required
to install sprinklers and on features in such homes that compensate for
the lack of sprinklers. We discussed the process for developing the
standards and their evolution over time with officials from the Centers
for Medicare & Medicaid Services (CMS), the federal agency responsible
for managing Medicare and Medicaid and overseeing compliance with
federal nursing home standards, including those related to fire safety;
the National Fire Protection Association (NFPA), a nonprofit membership
organization that develops and advocates scientifically based consensus
standards regarding fire, building, and electrical safety;[Footnote 4]
associations representing nursing homes, state fire marshals, and the
sprinkler industry; and officials in selected states that exceed
federal requirements because nursing homes were required to install
automatic sprinkler systems. CMS and the associations we contacted are
either NFPA members or are represented on one of its technical
committees that develops criteria for the standards. NFPA shared with
us data it collects on significant structural fires, including those in
nursing homes. We also reviewed multiple investigative reports on the
Hartford and Nashville fires conducted by state and local fire marshals
and state survey agencies to determine if they identified any
weaknesses in the standards for unsprinklered homes. Because nursing
homes are allowed to operate in some circumstances without correcting
all deficiencies identified during state surveys, we worked with CMS to
identify states having both a high proportion of unsprinklered nursing
homes and certain uncorrected deficiencies that could contribute to the
spread of smoke--a factor that often results in multiple fire
fatalities. We then examined the rationale for exemptions from federal
standards for a sample of uncorrected deficiencies in unsprinklered
homes in four states.
To assess state and federal oversight of nursing home fire safety, we
reviewed the investigations of the Hartford and Nashville fires
conducted by the respective state survey agencies; examined the fire
safety records of the two homes, including the most recent surveys
prior to the fires; and discussed oversight issues with officials in
both states and their respective CMS regional offices. In addition, we
analyzed data in CMS's On-Line Survey, Certification, and Reporting
(OSCAR) system on the results of periodic state nursing home surveys
for compliance with federal fire safety requirements. We discussed
state fire safety compliance with officials at CMS headquarters and in
each of CMS's 10 regional offices and collected data on CMS oversight
activities, such as the results of federal monitoring surveys, which
are conducted to assess the adequacy of state survey activities. We
conducted electronic testing of the OSCAR data for completeness and to
identify obvious errors. CMS officials generally recognize OSCAR data
to be reliable, and throughout the course of our work, we shared our
analysis of OSCAR data with CMS officials at both headquarters and the
regions to ensure that the data accurately reflected state fire safety
activities. Based on these reliability checks, we judged OSCAR to be
appropriate for our work. We conducted our review from November 2003
through July 2004 in accordance with generally accepted government
auditing standards.
Results in Brief:
Although the substantial loss of life in the Hartford and Nashville
fires could have been reduced or eliminated by the presence of properly
functioning automatic sprinkler systems, the potential retrofit cost
has been a barrier to CMS requiring them for all homes nationwide.
Older homes, such as the Hartford and Nashville facilities (built in
1970 and 1967, respectively), are generally allowed to operate without
sprinklers if they are constructed with noncombustible materials that
have a certain minimum ability to resist fire. According to CMS, the
decline in multiple-death fires after the adoption of NFPA fire safety
standards in 1971 and their subsequent enforcement suggested that the
estimated cost to retrofit all older nursing homes nationwide
outweighed the benefit. This position is being reevaluated, however,
because of the 2003 nursing homes fires, and the nursing home industry
has indicated its support for requiring older homes to install
sprinklers. Industry officials believe that there must be a discussion
about how to pay for the cost of installing sprinklers and a transition
period for homes to come into compliance. It is likely to be several
years before all older homes would be required to install sprinklers
because of the process and time required for affected stakeholders--
including NFPA, CMS, and the nursing home industry--to develop a
consensus on and implement such a standard.
The recent nursing home fires in Hartford and Nashville revealed
weaknesses in federal fire safety standards and their application in
unsprinklered facilities. For example, even in the absence of
sprinklers, the standards do not require smoke detectors in most
nursing homes, yet investigations of the Hartford and Nashville fires
suggested that the lack of smoke detectors in resident rooms where the
fires started may have delayed staff response and activation of the
buildings' fire alarms. Moreover, walls between resident rooms are not
required to resist the passage of smoke, yet residents in rooms
adjacent to where the fires originated died from smoke inhalation. In
addition, inadequate staff response contributed to the loss of life in
the Hartford fire, suggesting that the standards' reliance on staff
response as a key component of fire protection may not always be
realistic, particularly in an unsprinklered facility. CMS did not
conduct its own independent review of the two fires, thus forgoing an
opportunity to obtain critical information on which to evaluate the
adequacy of the standards. While the surveys of the Hartford and
Nashville facilities conducted shortly before the fires found that the
facilities met all applicable federal standards, many other
unsprinklered nursing homes are not required to meet all standards if
they obtain a waiver from CMS or demonstrate a level of fire protection
equivalent to the standards. However, we found that the exemption of
some unsprinklered facilities from certain standards may jeopardize
resident safety. For example, unsprinklered facilities in some states
have received CMS waivers of certain ventilation system requirements
for preventing the spread of smoke, yet fire safety experts consider
such waivers to present an unacceptable hazard. Furthermore, while
facilities that demonstrate equivalency are not required to meet all
federal standards, in some cases facilities are exempt from important
standards, such as that the fire alarm be either monitored or linked
directly to the local fire department. We also identified assessments
of equivalency in unsprinklered facilities that were not evaluated
correctly or not updated as facility conditions changed, placing
residents at unnecessary risk.
State and federal oversight of nursing home compliance with fire safety
standards is inadequate. Postfire investigations by Connecticut and
Tennessee revealed deficiencies that existed, but were not cited,
during prior surveys. The Hartford facility was surveyed less than 1
month before the fire, and no violations of federal standards were
identified. However, the survey agency's postfire investigation found
that the home was not conducting required fire drills during the night
shift, and that on the night of the fire the staff failed to follow the
facility's fire plan. The agency did not interview night shift staff
during its prefire survey and was provided inaccurate documentation of
fire drills by the nursing home. During routine fire safety surveys,
Tennessee surveyors repeatedly failed to detect a deficiency that would
allow smoke to travel between floors--a problem that may have
contributed to the spread of smoke to upper floors where one-third of
residents who died succumbed to smoke inhalation. Tennessee's postfire
investigation did not cite the home for any deficiencies and did not
pursue potential deficiencies that may have been present at the time of
the fire. For example, surveyors did not determine if the nursing home
staff appropriately implemented the home's fire plan during the fire,
even though the home had been cited repeatedly for this deficiency on
prior surveys. The results of CMS's federal fire safety monitoring
surveys conducted during fiscal year 2003 found that state surveyors
either missed or failed to cite an average of more than two
deficiencies per home surveyed, such as inadequate construction to
contain fire and smoke or missing or improperly maintained sprinkler
systems. CMS provides insufficient oversight of state survey activities
to address these and other fire safety concerns. CMS did not fully
comply with the statutory requirement to conduct federal monitoring
surveys in at least 5 percent of surveyed nursing homes in each state-
-a total of over 800 federal surveys annually; only 40 federal surveys
conducted in fiscal year 2003 covered fire safety, a required element
of both state and federal surveys. No federal assessments of fire
safety were conducted in 27 states. Four of CMS's 10 regions did not
require states to request waiver renewals or states in those regions
did not submit waiver renewals, and 8 of 10 regional offices did not
routinely review the accuracy of fire safety equivalency assessments,
as CMS requires. Furthermore, CMS lacks data to identify the extent to
which facilities have sprinklers, data that would be useful in
reviewing the appropriateness of waivers or equivalency assessments.
We are making several recommendations to the Administrator of CMS to
(1) improve oversight of federal fire safety standards, such as
ensuring that the fire safety component is included in federal
monitoring surveys and reviewing the appropriateness of exemptions to
federal standards granted to unsprinklered facilities and (2)
strengthen fire safety standards by working with NFPA to reexamine
standards for unsprinklered homes and by ensuring thorough
investigations of multiple-death nursing home fires in order to
reevaluate the adequacy of fire safety standards. In commenting on a
draft of this report, CMS concurred with our recommendations and
provided examples of steps it is already taking to implement those
recommendations. We also provided a draft of this report to the
Connecticut and Tennessee state survey agencies and NFPA for comments.
CMS, Connecticut, and NFPA provided technical and clarifying comments,
which we incorporated as appropriate. Tennessee did not provide
comments.
Background:
Combined Medicare and Medicaid payments to nursing homes for care
provided to vulnerable elderly and disabled beneficiaries totaled about
$64 billion in 2002, with a federal share of approximately $45.5
billion. Oversight of nursing home fire safety is a shared federal-
state responsibility. Based on statutory requirements, CMS defines
standards that nursing homes must meet to participate in the Medicare
and Medicaid programs and contracts with states to assess whether homes
meet these standards through annual surveys and complaint
investigations. CMS is also responsible for monitoring the adequacy of
state survey activities.
Fire Safety Standards:
Under federal law, CMS does not develop fire safety standards itself
but instead adopts standards developed through a consensus process by
NFPA, of which CMS is a member. NFPA generally updates the standards
every 3 years, but CMS has updated federal standards less frequently.
The NFPA standards were first applied by CMS to health care facilities
such as hospitals and nursing homes in 1971 when CMS adopted the 1967
NFPA code. The federal standards for nursing homes were subsequently
updated when CMS adopted the 1973, 1981, 1985, and 2000 editions of the
NFPA code.[Footnote 5] The agency has the authority to modify or make
exceptions to the NFPA standards but has rarely done so.[Footnote 6]
States are free to adopt and apply stricter standards under their state
licensure authority.
Nursing home fire safety standards are built on several principles that
combine certain construction and operational features along with an
acceptable staff response. These principles are a reflection of the
mobility and cognitive limitations of many elderly and disabled
residents who cannot be easily evacuated in the event of a fire. The
principles include (1) appropriate design and construction of the
facility, particularly compartmentation to contain both fire and smoke;
(2) provision for fire detection, alarm, and extinguishment, such as
smoke detectors and sprinkler systems; and (3) fire prevention policies
and the testing of plans for staff response, such as steps to isolate
the fire and transfer occupants to areas of refuge.
The fire safety standards for nursing homes cover 18 categories ranging
from building construction to furnishings. Examples of specific
requirements include (1) the use of fire or smoke resistant
construction materials for interior walls and doors; (2) installation
and testing of fire alarms and smoke detectors; (3) protection of
hazardous areas, such as laundry rooms; (4) regulation of smoking by
residents; and (5) development and routine testing of a fire emergency
plan. The standards differentiate between "existing" and "new"
facilities. In the past, whenever a new edition of the NFPA code was
adopted by CMS, nursing homes had the option of complying with the new
standards or with an earlier edition of the standards. Thus, a nursing
home that began serving Medicare and Medicaid residents under the 1967
edition of the standards could have continued to be surveyed under
those standards up until 2003. With the implementation of the 2000
edition of the NFPA standards in 2003, however, CMS eliminated the
option for facilities to be "grandfathered" under earlier editions. All
nursing homes participating in Medicare and Medicaid as of March 2003
must comply with the 2000 standards for existing facilities.
State Oversight of Fire Safety:
Every nursing home receiving Medicare or Medicaid payment must undergo
a standard survey not less than once every 15 months, and the statewide
average interval for these surveys must not exceed 12 months.[Footnote
7] A standard survey is conducted by state survey agency personnel and
entails an assessment of both federal quality of care and fire safety
requirements.[Footnote 8] Most states use fire safety specialists
within the same department as the state survey agency to conduct fire
safety inspections, but 16 states contract with their state fire
marshal's offices. The fire safety portion of a standard survey is not
always conducted concurrently with the quality of care review,
particularly in states that contract with the state fire marshal. All
personnel conducting the inspections are required to complete a self-
paced, computer-based course before registering for and completing 5
days of classroom training on fire safety standards.
Fire safety inspections focus on the home's compliance with federal
requirements for health care facilities. When a deficiency is found, it
is assigned to 1 of 12 categories according to its scope (the number of
residents potentially or actually affected) and its severity. An A-
level deficiency is the least serious and is isolated in scope, while
an L-level deficiency is the most serious and is considered to be a
widespread problem involving immediate jeopardy (see table 1).[Footnote
9] States are required to enter information about surveys and complaint
investigations, including the scope and severity of deficiencies
identified, in CMS's OSCAR database.
Table 1: Scope and Severity of Deficiencies Identified during Nursing
Home Surveys:
Severity: Immediate jeopardy[B];
Scope[A]: Isolated: J;
Scope[A]: Pattern: K;
Scope[A]: Widespread: L.
Severity: Actual harm;
Scope[A]: Isolated: G;
Scope[A]: Pattern: H;
Scope[A]: Widespread: I.
Severity: Potential for more than minimal harm;
Scope[A]: Isolated: D;
Scope[A]: Pattern: E;
Scope[A]: Widespread: F.
Severity: Potential for minimal harm[C];
Scope[A]: Isolated: A;
Scope[A]: Pattern: B;
Scope[A]: Widespread: C.
Source: CMS.
[A] CMS defines the scope levels as follows: isolated--affecting a
single or a very limited number of residents; pattern--affecting more
than a very limited number of residents; and widespread--affecting or
having the potential to affect a large portion of or all residents.
[B] Actual or potential for death/serious injury.
[C] Nursing home is considered to be in "substantial compliance."
[End of table]
If a deficiency is cited, a nursing home may have three alternatives
(see fig. 1). First, a home may be required to prepare a plan of
correction that eliminates an identified fire safety deficiency, a fact
that may be verified on a subsequent revisit. Second, a home may
request a waiver from compliance with the requirement through the state
survey agency if the cost of correcting the deficiency would place a
financial or other undue hardship on the facility and the health and
safety of the residents would not be at risk if the deficiency remains
uncorrected. In general, waivers are limited to deficiencies cited at
less than actual harm. Waivers must be reviewed and approved by one of
CMS's regional offices. Waivers may be temporary--to allow a home to
develop and obtain approval of a construction plan--or longer term in
nature.
Third, as an alternative to correcting or receiving a waiver for
deficiencies identified on a standard survey, a home may undergo an
assessment using the Fire Safety Evaluation System (FSES). FSES was
developed by the Department of Commerce's National Institute of
Standards and Technology to provide a means for providers who
participate in the Medicare and Medicaid programs to meet the fire
safety objectives of the standards without necessarily being in full
compliance with every standard.[Footnote 10] FSES uses a grading system
to compare the overall level of fire safety in a specific facility to a
hypothetical facility that exactly matches each requirement of the fire
safety standards.[Footnote 11] FSES may be conducted by either the
state or the facility, but CMS requires both the state survey agency
and the regional office to review the results. Once a facility has been
certified using FSES, it can continue to be certified on that basis in
subsequent years provided there are no significant changes that might
alter the FSES score. However, an annual survey must still be
conducted.
Figure 1: How Nursing Homes May Address Fire Safety Deficiencies:
[See PDF for image]
[End of figure]
Federal Oversight of State Survey Agencies:
CMS is responsible for assessing the adequacy of state survey
activities to ensure nursing home compliance with federal fire safety
requirements. To assess the adequacy of state surveys, CMS is required
by statute to conduct federal monitoring surveys annually in at least 5
percent of the Medicare and Medicaid nursing homes surveyed by each
state with a minimum of five facilities per state.[Footnote 12] The
federal monitoring surveys are required to include an assessment of the
fire safety component of states' standard surveys.[Footnote 13] Federal
monitoring surveys can be either comparative or observational.
Comparative surveys involve a federal survey team conducting a
complete, independent survey of a home within 2 months of the
completion of the state's survey in order to compare and contrast the
findings. In an observational survey, one or more federal surveyors
accompany a state survey team to a nursing home to observe the team's
performance. CMS also analyzes the results of state surveys to identify
trends or anomalies, such as a failure to cite certain types of
deficiencies or citation of deficiencies at an inappropriate scope and
severity level. As noted earlier, regional office staff are required to
review and approve state requests to waive fire safety standards and to
review the results of FSES assessments.
Hartford and Nashville Nursing Home Fires:
Table 2 provides key facts about the circumstances of the 2003 Hartford
and Nashville fires in which 31 residents lost their lives. As with
earlier multiple-death fires (1) the homes were constructed of
noncombustible materials and therefore were not required to be
sprinklered; (2) the fires occurred at night, when staffing is at the
lowest level; and (3) each fire broke out in a resident's room. The
cause of the fire in Nashville remains undetermined, while the Hartford
investigations concluded that a 23-year-old cognitively impaired
resident set the fire.[Footnote 14] As shown in table 2, both nursing
homes had undergone their annual safety survey within 1 to 4 months of
the fires. Most of the deaths in the Hartford and Nashville fires were
due to smoke inhalation rather than burns. According to CMS officials,
state survey agencies are required to treat a fire-related death in a
nursing home as a complaint and must conduct a complaint investigation.
In the case of a multiple-death fire, CMS staff from a regional office
or from central office may also be involved in the
investigation.[Footnote 15]
Table 2: Key Facts about the Hartford and Nashville Nursing Home Fires:
Key facts: Date and time of fire;
Hartford: February 26, 2003; alarm received by fire department at
2:38 a.m;
Nashville: September 25, 2003; alarm received by fire department at
10:18 p.m.
Key facts: Date of last fire safety inspection;
Hartford: January 29, 2003;
Nashville: May 27, 2003.
Key facts: Number of residents;
Hartford: 148;
Nashville: 118.
Key facts: Fire department response;
Hartford: 6 minutes after notification;
Nashville: 9 minutes after notification.
Key facts: Origin of fire;
Hartford: Resident's room;
Nashville: Resident's room.
Key facts: Nursing home staff on duty;
Hartford: 12;
Nashville: 12.
Key facts: Construction type;
Hartford: Noncombustible with 1-hour fire-rated exterior walls and
structural frame. Unsprinklered;
Nashville: Noncombustible with 2-hour fire-rated exterior walls and
structural frame. Unsprinklered.
Key facts: Year(s) of construction;
Hartford: 1970 and 1974;
Nashville: 1967.
Key facts: Number of floors in facility;
Hartford: 1;
Nashville: 4.
Key facts: Number of deaths;
Hartford: 16, primarily in vicinity of room where fire broke out;
Nashville: 15; 10 residents died on 2nd floor where fire originated.
Five residents died on 3rd and 4th floors.
Key facts: Cause of fire;
Hartford: Arson by cognitively impaired resident with a history of
self-inflicted cigarette burns;
Nashville: Undetermined.
Sources: Hartford and Nashville Fire Departments and Connecticut and
Tennessee State Fire Marshals.
[End of table]
Despite Effectiveness, Cost Has Been a Barrier to Requiring Sprinklers
for All Older Nursing Homes:
Although there has never been a multiple-death fire in a fully
sprinklered nursing home, cost has been an impediment to requiring all
homes to install automatic sprinklers. Newly constructed homes must
incorporate sprinkler systems; however, older homes that meet certain
construction standards are not required to install sprinklers in part
because of the cost of retrofitting such structures. The decline in
multiple-death fires with the introduction and enforcement of fire
safety standards was also a rationale for not requiring sprinklers for
older structures. The Hartford and Nashville fires, however, have
reopened the debate about the need to retrofit older nursing homes.
As the fire safety code evolved over time, a properly functioning,
automatic sprinkler system came to be regarded as the single most
effective fire protection feature. From 1994 through 1998, NFPA data
show an 82 percent reduction in the chances of death occurring in a
sprinklered nursing home: 1.9 deaths per 1,000 fires in sprinklered
facilities versus 10.8 deaths per 1,000 fires in unsprinklered homes.
In general, if a facility is fully sprinklered, the standards allow a
less stringent set of requirements to apply for building construction,
smoke and fire containment, and protection of hazardous areas. In 1991,
the NFPA code began requiring full sprinkler coverage for newly
constructed nursing homes or for any portion of a home that underwent a
substantial renovation. CMS adopted this requirement for new
construction when it began using the 2000 edition of the NFPA fire
safety code in 2003. Although CMS has the authority to require
sprinklers for any facility that serves Medicare and Medicaid
beneficiaries, it generally follows the NFPA fire safety code.
CMS does not require certain older nursing homes of noncombustible
construction to install sprinklers (see table 3). While combustible
facilities are typically built of wood, the materials used in
noncombustible nursing homes include concrete, steel, or brick. Whether
a noncombustible nursing home requires sprinklers depends on a
combination of factors: (1) the ability of exterior walls, the
structural frame, and flooring to resist fire, known as fire resistance
rating, and (2) the number of floors. A facility is referred to as
"protected" if the construction materials are rated to withstand a fire
for a minimum of 1 hour, while a home with less than 1-hour fire-rated
construction is considered to be "unprotected." For example, a
noncombustible nursing home with one story and a fire resistance rating
of 1 hour, such as the Hartford facility, need not be sprinklered.
Because of the difficulty of evacuating nursing home residents, a
comparable structure that is more than one story requires sprinklers.
The four-story Nashville facility, however, had 2-hour fire-rated walls
and flooring and thus did not require sprinklers.
Table 3: Sprinkler Requirements for Existing Nursing Homes, by
Construction Type:
Construction type: Sprinklers required: Noncombustible;
Fire resistance rating of exterior walls, the structural frame, and
flooring (in hours): 0-1;
Number of floors (maximum): 2-3.
Construction type: Sprinklers required: Mixed combustible/
noncombustible;
Fire resistance rating of exterior walls, the structural frame, and
flooring (in hours): 2;
Number of floors (maximum): 1-2.
Construction type: Sprinklers required: Combustible (heavy timber);
Fire resistance rating of exterior walls, the structural frame, and
flooring (in hours): 2[A];
Number of floors (maximum): 2.
Construction type: Sprinklers required: Combustible;
Fire resistance rating of exterior walls, the structural frame, and
flooring (in hours): 0-1;
Number of floors (maximum): 1-2.
Construction type: Sprinklers not required: Noncombustible;
Fire resistance rating of exterior walls, the structural frame, and
flooring (in hours): 2-4[B];
Number of floors (maximum): No limit.
Construction type: Sprinklers not required: Noncombustible;
Fire resistance rating of exterior walls, the structural frame, and
flooring (in hours): 1;
Number of floors (maximum): 1.
Sources: CMS and NFPA.
Note: These requirements are based on the current federal fire safety
standards that were updated in 2003.
[A] The 2-hour fire resistance rating applies to exterior walls only.
Heavy timber is permitted for the construction of the structural frame
and flooring.
[B] For buildings with 3 to 4 hour fire-rated walls, the fire
resistance rating for flooring is 2 to 3 hours.
[End of table]
NFPA considered requiring sprinklers for all existing nursing homes on
several occasions in the past. Improvements in the fire safety record
of nursing homes, however, suggested that such a requirement was not
cost effective. When the federal government first adopted the NFPA fire
safety standards in 1971, the number of multiple-death fires in nursing
homes was about 15 to 18 per year. With the adoption and enforcement of
these standards, including the requirement for sprinklers in homes that
were not highly fire resistant, the number of fire-related nursing home
fatalities dropped dramatically. Though infrequent, multiple-death
nursing home fires have led some states to require nursing homes to be
retrofitted with sprinklers, such as Virginia after 12 residents died
in a 1989 fire.[Footnote 16] From 1990 through 2002, there were no
major nursing home fires with such a high number of
fatalities.[Footnote 17]
The Hartford and Nashville fires reopened the issue of requiring the
retrofitting of existing nursing homes with sprinklers. In the
aftermath of these fires, both Connecticut and Tennessee passed laws
requiring all nursing homes to install sprinkler systems.[Footnote 18]
In addition, the International Fire Marshals' Association proposed
amending the 2003 NFPA code on an emergency basis. According to an NFPA
official, this proposal was not adopted because committee members had
not seen the results of the Hartford and Nashville fire investigations
and because it lacked a transition period for homes to come into
compliance. However, the NFPA technical committee responsible for
health care facilities voted in February 2004 to revise the code to
require existing homes to be retrofitted with sprinklers.[Footnote 19]
If the technical committee's recommendation is upheld, the change would
be effective with the 2006 NFPA code update, but would not be
incorporated into federal nursing home fire safety standards until
formally adopted by CMS.[Footnote 20] The American Health Care
Association (AHCA), the association representing primarily for-profit
nursing homes, has also endorsed requiring all homes to be sprinklered.
AHCA, however, believes that there must be (1) some discussion about
how to pay for sprinklers and (2) a transition period of from 3 years
to 5 years for homes to come into compliance.[Footnote 21]
Although concerns about cost have been a barrier to requiring all homes
to install sprinklers, CMS has not developed its own cost estimate for
retrofitting older nursing homes. An October 2003 estimate developed
for AHCA by a fire-safety consulting firm suggested that the cost of
installing sprinklers in all nursing homes would be about $1 billion.
However, there is considerable uncertainty about the assumptions on
which the estimate is based. For example, the estimate assumed that
about 25 percent of nursing homes are unsprinklered, treating partially
sprinklered facilities as unsprinklered. We found that the term
"partially sprinklered" covers homes that have very few sprinklers as
well as homes that are almost completely sprinklered.[Footnote 22]
Furthermore, CMS as well as states lack complete and reliable data on
the extent to which homes are partially sprinklered.[Footnote 23] Other
uncertainties in the AHCA cost estimate involve the square footage
requiring sprinkler coverage and the cost per square foot. AHCA assumed
that the average unsprinklered home is 40,000 square feet and that the
cost of retrofitting sprinklers in such homes was approximately $7 per
square foot. A 2004 survey by the Tennessee state survey agency found
that the average unsprinklered square footage of state nursing homes
was about half that of the AHCA estimate. In addition, the $7 per
square foot estimate could be higher or lower depending on
circumstances, such as whether asbestos abatement is required or
whether a home has to install storage tanks or pumps to compensate for
inadequate municipal water supplies. Moreover, a Connecticut state
survey agency official identified other costs that may be associated
with sprinkler installation, such as potential lost revenue if
admissions need to be suspended or residents need to be moved to a
different facility during the construction.
Federal Fire Safety Requirements for Unsprinklered Nursing Homes Are
Weak:
The nursing home fires in Hartford and Nashville during 2003 as well as
our review of waivers and FSES results revealed weaknesses in federal
fire safety standards and their application to unsprinklered nursing
homes. Neither home was required to have automatic sprinklers because
of their noncombustible type of construction. Federal standards,
however, allowed these homes to operate without several basic fire
safety features, such as smoke detectors in resident rooms that could
have helped to compensate for the lack of sprinklers. While the surveys
of the Hartford and Nashville facilities conducted shortly before the
fires either found compliance with federal standards or required
corrective action, many other unsprinklered homes, including some
constructed of combustible materials, are not required to meet all
federal standards if they obtain a waiver from CMS or demonstrate an
equivalent level of fire protection using FSES. Our review of selected
waivers and FSES results, however, found that resident safety was
sometimes jeopardized by inappropriate use of these alternatives to
actual compliance.
2003 Fires Revealed Weaknesses in Federal Nursing Home Fire Safety
Standards:
State and local fire investigators looking into the causes and origins
of the Hartford and Nashville fires identified a variety of factors
that may have contributed to the substantial loss of life, including
some that reflect potential weaknesses in federal fire safety standards
(see table 4). Because both nursing homes were constructed of
noncombustible material with the minimum fire ratings required by their
height (number of floors), neither was required to have automatic
sprinklers in order to meet federal fire safety standards. In the
absence of sprinklers, however, they were highly dependent on a variety
of other building features and systems, as well as staff response, for
fire detection and containment. Contrary to actions taken in previous
multiple-death nursing home fires, neither CMS nor NFPA investigated
the Hartford or Nashville fires to assess the adequacy of the current
fire safety standards.[Footnote 24] Consequently, they lack the
firsthand information needed to determine the degree to which the
multiple-deaths were due to weaknesses in federal fire safety standards
and to make recommendations for future revisions to the standards.
Table 4: Potential Weaknesses in Federal Standards Contributing to
Multiple Deaths in Hartford and Nashville Nursing Home Fires:
Smoke detectors;
Federal standard: Depending on date of construction, smoke detectors
may be required in corridors or resident rooms.[A];
Potential weaknesses: Hartford nursing home: Smoke detectors not
required. No smoke detectors in resident rooms;
Potential weaknesses: Nashville nursing home: Smoke detectors not
required. No smoke detectors in resident rooms.
Fire and smoke barriers;
Federal standard: Complete fire and smoke barriers required between
corridor and resident rooms;
not required between resident rooms;
Potential weaknesses: Hartford nursing home: Residents in room adjacent
to room of origin died from smoke inhalation. Smoke and fire spread
through space above false ceiling;
Potential weaknesses: Nashville nursing home: Residents in room
adjacent to room of origin died from smoke inhalation. Investigative
reports do not indicate if fire spread through space above false
ceilings.
Heating, ventilating, and air-conditioning (HVAC) system;
Federal standard: Depending on date of construction, dampers may be
required in ductwork to prevent the spread of fire and smoke;
Potential weaknesses: Hartford nursing home: Not applicable.[B];
Potential weaknesses: Nashville nursing home: Under the 1967 standards,
the home was not required to have dampers in ductwork. Ductwork did not
have dampers, allowing smoke to spread to upper floors of building.
Staff response;
Federal standard: The staff is expected to implement the written plan
for the protection of all residents, such as taking steps to contain
the fire and evacuate residents;
Potential weaknesses: Hartford nursing home: Staff may have failed to
close all resident room doors, and all designated staff did not respond
to assist in containment and evacuation of residents as called for in
fire plan;
Potential weaknesses: Nashville nursing home: Not clear from available
investigations.
Sources: GAO analysis of information provided by state and local fire
investigations in Hartford and Nashville, and by CMS and NFPA.
[A] Although both homes had corridor smoke detectors, they were not
required. The requirement for smoke detectors in either corridors or
resident rooms was added to federal standards in 1981 and only for new
facilities constructed after that date. Older, existing facilities,
such as the Hartford and Nashville nursing homes, were exempt from this
requirement.
[B] The facility did not have a central heating and cooling system with
ductwork but rather relied on wall-mounted heat pumps in each
resident's room.
[End of table]
The fire safety standards applicable to these two nursing homes did not
require smoke detectors in resident rooms and neither home had them.
Although federal standards for most nursing homes do not require smoke
detectors, the two facilities did have smoke detectors in the
corridors. Only nursing homes surveyed under federal standards for new
construction since 1981 were required to have either corridor or in-
room smoke detectors. According to fire department investigators and
state officials, the lack of smoke detectors in resident rooms may have
contributed to a delay in both staff response and fire department
notification; earlier detection of these fires may have helped to limit
the number of fatalities.[Footnote 25] In the Nashville fire, the fire
alarm was activated by corridor smoke detectors. The Tennessee fire
marshal's office concluded that there was evidence of heavy smoke
production in the room where the fire originated prior to discovery of
the fire. The fire marshal's report indicated that a large gap between
the top of the doorway and the ceiling created a large airspace that
delayed smoke from entering the hallway and activating the smoke alarm
until the space was filled to capacity. In the Hartford fire, it is
unclear whether the alarm was first activated by the corridor smoke
detector or manually by the staff member who first attempted to
extinguish the fire. According to the Hartford fire department, the
absence of smoke detectors in resident rooms contributed to a delay of
up to 5 minutes or more. However, an NFPA official questioned the basis
for this estimate given the lack of a detailed timeline of the events
prior to activation of the home's fire alarm. In recognition of the
importance of smoke detectors, Tennessee is now requiring all newly
licensed nursing homes to have smoke detectors in resident rooms and
the Hartford facility is voluntarily installing smoke detectors in all
resident rooms.[Footnote 26]
Another potential weakness in federal standards, particularly in an
unsprinklered facility, is that resident rooms are not required to be
separated from each other by fire or smoke barriers. According to
Connecticut survey agency officials, the open doors rather than the
lack of a complete smoke barrier was the primary factor contributing to
the spread of smoke. Investigative reports from the Hartford fire
indicated that fire and smoke also spread from the room of origin to
the adjacent room through the space above the false ceiling. However,
even if all doors had been closed, as called for in the nursing home's
fire plan, smoke could still have spread to the adjacent room through
space above the false ceiling. In addition, the 1967 standards applied
to the Nashville facility did not require smoke dampers in the
ventilation ductwork to prevent the spread of smoke, although
subsequent editions of the standards do require such dampers.[Footnote
27]
According to NFPA officials, the fire safety standards' heavy reliance
on appropriate staff response in a nursing home fire may not always be
realistic, suggesting the need to reevaluate the policy of allowing
some nursing homes to operate without automatic sprinkler
systems.[Footnote 28] The multiple deaths in these fires resulted most
directly from a failure to contain the spread of smoke. The primary
factor contributing to the spread of smoke in the Hartford fire was
human error. Staff may have failed to follow the facility fire plan and
close all resident room doors and all designated staff did not respond
with fire extinguishers as called for in the fire plan.
CMS's 2003 adoption of the 2000 NFPA standards is likely to have little
effect on fire detection or containment in existing nursing homes, such
as those in Hartford and Nashville. Only one of the potential
weaknesses discussed above is addressed by the new standards. Smoke
dampers will now be required where ductwork passes through a smoke
barrier, and older homes, such as the Nashville facility, will no
longer be "grandfathered" under earlier editions of the standards that
do not include such a requirement. However, a facility that lacks
dampers in ductwork as required by current federal standards could
still be certified for Medicare or Medicaid by obtaining a waiver of
this requirement from CMS. The new standards make no change to
requirements for existing facilities regarding smoke detectors or
separation of resident rooms. However, CMS guidance still requires
smoke detectors in resident rooms and fire-rated separation of resident
rooms as compensating features when considering waivers for some
unsprinklered one-story, wood-frame facilities.
In past cases of multiple-death nursing home fires, both CMS and NFPA
have conducted their own investigations and issued reports on the
fires, in addition to investigations conducted by state and local
authorities into fire cause and origin and by state survey agencies
that examine a facility's compliance with current fire safety
standards.[Footnote 29] According to a CMS official, fires are a test
of the standards designed to safeguard life and property, providing an
opportunity to identify strengths and weaknesses. The purpose of such a
postfire review is to determine whether modifications to the standards
or their implementation are needed to prevent similar occurrences in
the future. The findings of such reviews can then be taken into
consideration by NFPA as part of its code revision process. In the case
of the Hartford and Nashville fires, however, no such reviews were
conducted.[Footnote 30] An NFPA official told us that the Nashville
fire authorities turned down NFPA's request to investigate the fire. In
the absence of such reviews, both CMS and NFPA lack access to critical
firsthand information on which to judge the need for revisions to
federal fire safety standards.
Exemptions from Federal Fire Safety Standards Are a Concern in Some
Unsprinklered Nursing Homes:
Our review of waiver and FSES results found that resident safety may be
compromised in some unsprinklered nursing homes that were granted
exceptions to federal fire safety standards.[Footnote 31] While the
Hartford and Nashville facilities were determined to have met all
federal standards prior to the fires, many other unsprinklered nursing
homes are exempt from meeting certain provisions of the standards if
they obtain a waiver from CMS or demonstrate an equivalent level of
fire protection using FSES. Waivers and FSES allow homes to avoid
costly renovations, but homes are required to demonstrate that resident
safety would not be compromised. Approximately one in five nursing
homes nationwide (1) receives a waiver of one or more fire safety
standards, (2) obtains a passing score on FSES, or (3) uses a
combination of waivers and FSES.
Waivers of Federal Fire Safety Standards Pose a Serious Hazard in Some
Unsprinklered Nursing Homes:
Some waivers of federal fire safety standards, or combinations of
waivers, pose a significant risk to resident safety in some
unsprinklered facilities. In our view, CMS's ability to exempt
facilities from selected standards through waivers is equivalent to
exercising a standard-setting role.[Footnote 32] In some cases, waivers
of sprinkler requirements were granted for many years even though the
facilities lacked adequate compensating fire detection and containment
features. As of December 2003, 15 percent of nursing homes in 30 states
operated with waivers of certain federal fire standards. However, the
proportion of homes that have applied for and received waivers varies
widely, from less than 1 percent of homes in California, Florida, and
Maine to more than 57 percent in Ohio as of 2003.
The most frequently waived requirement that may pose a risk to
residents is that the HVAC system meets applicable codes and is
constructed to restrict the spread of smoke and fire within the
building. As of December 2003, 10 percent of all nursing homes
nationwide (1,556 of 16,334) were cited for deficiencies in this area
on their most recent surveys; half of these subsequently received
waivers of this standard and were not required to make corrections. In
Arkansas, however, 26 percent of nursing homes (64 of 242) operate with
waivers of this requirement. According to a CMS regional office
official, at least 50 of these nursing homes are unsprinklered and use
the corridor as part of the air return system. Similarly, 60 nursing
homes in Wisconsin have a waiver of this same standard, primarily for
using the corridor as part of the air return system; according to state
officials, some of these homes are not fully sprinklered. Federal fire
safety standards have always prohibited the use of facility corridors
as an air return in lieu of individual air return vents in resident
rooms because such an arrangement could accelerate the spread of smoke
during a fire, particularly in an unsprinklered facility. CMS guidance
permits a waiver of this requirement in an unsprinklered facility if it
has compensating features, such as a complete corridor smoke detection
system, and its air handling system is designed to shut down
automatically upon activation of the smoke detectors or fire alarm.
However, an NFPA official told us that these features were insufficient
and that there are no compensating features permitting a nursing home
to operate safely with such a deficiency, irrespective of the home's
sprinkler status. Such facilities, he indicated, should be required to
correct the deficiency and discontinue the use of the corridor as an
air return.
According to OSCAR data, standards for allowable construction type and
sprinkler installation are also frequently not met.[Footnote 33] As of
December 2003, approximately 15 percent of nursing homes nationwide
(2,440 of 16,334) were cited for failure to meet one or both of these
standards on their most recent surveys, and about one in six were not
required to correct the deficiency by virtue of a waiver. While only
about 2 percent of nursing homes nationally operate with construction-
type or sprinkler waivers, these percentages are much higher in some
states. In Iowa, for example, 15 percent of all nursing homes (68) have
waivers of construction-type and/or sprinkler standards. According to a
CMS official, many of these facilities are unsprinklered one-story
buildings of unprotected noncombustible or protected wood-frame
construction--homes that federal fire safety standards require to be
sprinklered.[Footnote 34] However, CMS guidelines allow a waiver of the
sprinkler requirement in such facilities if (1) all hazardous areas are
sprinklered; (2) an automatic fire detection system is provided
throughout the building, which is designed to activate an alarm and
close all doors in fire partitions; (3) resident rooms are separated
from each other by at least 1-hour fire-rated construction; and (4) the
response time and capability of the local fire department is adequate.
According to a CMS official, many of these Iowa facilities received
construction-type and sprinkler waivers for many years even though some
lacked the adequate fire detection and containment features required by
federal fires safety standards, posing a serious fire hazard for
residents:
* One protected wood-frame Iowa facility had waivers for construction
type and sprinklers even though it lacked smoke detectors throughout
and resident rooms were not adequately separated from each other as
called for in CMS guidelines. In addition, the facility was cited for a
deficiency and subsequently received a waiver for a lack of corridor
smoke detectors, which were required by the applicable edition of
federal standards. The facility currently has a temporary waiver to
complete installation of a sprinkler system.
* Another one-story wood frame facility had construction-type and
sprinkler waivers despite a lack of smoke detection in both corridors
and resident rooms.[Footnote 35] In addition, the facility received a
temporary waiver of HVAC requirements in order to consult with an
engineer about ventilation system modifications. The basement corridor
was used as part of the return air system, and exhaust fans in three of
four wings of the building were not properly ducted to the outside.
We also found that inappropriate combinations of waivers, which could
pose a serious risk for residents, are sometimes granted. For example,
the older unprotected section of a noncombustible facility in Wisconsin
was granted waivers for (1) a lack of sprinklers in a construction type
that required sprinklers, (2) use of the corridor as an air supply, (3)
corridor walls that did not extend to the roof deck, and (4) incomplete
smoke barrier walls. Such a combination of structural features could
greatly facilitate the spread of smoke in the event of fire. Waiver
application materials for this facility inaccurately indicated the
presence of complete smoke barrier walls, which was used as a partial
justification of waivers of construction type and corridor-wall
deficiencies.
Some FSES-Certified Nursing Homes Lack Adequate Compensating Features
for Sprinklers:
Some FSES-certified nursing homes lack adequate compensating features
for the absence of sprinklers, posing a significant risk to resident
safety in the event of a fire. As of December 2003, 7 percent of all
nursing homes nationwide (1,138) were certified using FSES. These homes
were located in 30 states. According to a CMS official, FSES is used by
many nursing homes as a means of demonstrating an equivalent level of
fire protection in order to avoid costly corrective measures, such as
the installation of sprinklers, which would otherwise be required for
the facility to meet all the prescriptive provisions of the code.
Compensating features that may allow an unsprinklered home to meet the
overall fire protection requirements include (1) higher-than-required
fire resistance rating of interior construction and finish, (2) smoke
detectors and alarms in individual resident rooms in addition to
corridors, (3) multiple routes of evacuation from resident rooms, or
(4) mechanically assisted smoke control systems.
We identified cases of FSES assessments in unsprinklered facilities
that were (1) not evaluated correctly by the state survey agency, (2)
not updated as facility conditions changed, and (3) used
inappropriately in combination with waivers. According to an NFPA
official, FSES should not be used in combination with waivers.
* An unsprinklered Pennsylvania facility was certified based on an FSES
assessment conducted in January of 2004, using the new 2000 federal
standards. The building was assessed on FSES as a one-story unprotected
noncombustible construction type. However, the facility is a two-story
structure that should not have received a passing score on FSES,
according to federal guidelines. The facility should have been required
to install sprinklers or seek a waiver from CMS.
* Another unsprinklered facility in Pennsylvania continued to be
certified for several years based on FSES even though uncorrected
deficiencies identified on state surveys should have caused the
facility to receive a failing score.[Footnote 36] The facility
originally failed FSES in 1995, but indicated fire-rated corridor doors
would be added in certain areas and the number of evacuation routes
would be increased in order to achieve a passing score. Although it was
subsequently cited for deficiencies in resident evacuation and corridor
openings that would have generated a failing score on FSES, the
facility continued to be certified based on this evaluation. According
to CMS guidelines, a new FSES is required when facility conditions
change.
* At one unsprinklered Iowa facility, state surveys identified multiple
deficiencies for nonallowable construction type; failure to maintain
fire rating of corridor walls; incomplete smoke barriers; and lack of
sprinklers that the facility attempted to address through a combination
of corrective action, temporary waivers, and FSES. Although the
facility failed FSES in 2003, the statement of deficiencies indicated
that certain deficiencies would not have to be corrected because the
home had achieved a passing score on FSES. Although the facility was
subsequently required to install a complete sprinkler system in 2004,
the combination of fire safety deficiencies had clearly posed a risk to
resident safety for many years.
State and Federal Oversight of Nursing Home Fire Safety Is Inadequate:
State and federal oversight of nursing home fire safety is inadequate.
Postfire investigations by Connecticut and Tennessee revealed
deficiencies that existed, but were not cited, during prior surveys.
Those deficiencies were cited during Connecticut's but not during
Tennessee's postfire investigation. Nationally, the wide variability
among states in reported fire safety deficiencies suggests that other
states may also be missing or failing to cite deficiencies, and the
results of federal comparative fire safety surveys demonstrate that
state surveyors either miss or fail to cite all fire safety
deficiencies. While CMS provides oversight information to the public on
its Nursing Home Compare Web site, the Web site currently lacks data on
fire safety deficiencies or the sprinkler status of homes. CMS provides
limited oversight of state survey activities to address the fire safety
survey inconsistencies we identified. CMS regional offices (1) do not
fully comply with the statutory requirement to conduct a minimum number
of federal monitoring surveys to assess state surveyors' performance on
the fire safety component of state surveys, (2) lack basic data to
assess the appropriateness of uncorrected deficiencies, (3)
infrequently review state trends in citing fire safety deficiencies,
and (4) provide insufficient oversight of deficiencies that are waived
or that homes need not correct because of claimed compensating fire
safety features.
Connecticut and Tennessee Surveyors Did Not Identify Deficiencies that
Existed Prior to Fires:
Postfire investigations by the Connecticut and Tennessee state survey
agencies revealed deficiencies that state surveyors did not identify on
prior surveys (see table 5). As part of its postfire investigation, the
Connecticut survey agency identified two fire safety deficiencies not
cited during a survey just 1 month before the fire that found the home
to be deficiency free. First, the home failed to control and monitor
smoking for 21 of the approximately 48 residents who were included in
the sample during the state's postfire investigation, including the
resident who allegedly started the fire. Although surveyors did not
review the records of this resident prior to the fire, they
subsequently determined that she was inappropriately classified as an
independent smoker even though she was cognitively impaired and had a
history of burning herself. In addition, of the 21 residents identified
with smoking-related deficiencies after the fire, 3 of these residents
were included in the resident sample during the prefire survey, but no
problems were identified at that time.[Footnote 37] During the prefire
survey, surveyors checked to determine if the facility had a policy in
place to conduct a smoking assessment of each resident but did not
systematically verify the accuracy of such assessments. Connecticut
officials told us that if surveyors happen to observe potential
problems, such as unsafe smoking during the course of a survey, they
ensure that the residents involved are accurately assessed for smoking
and that appropriate supervision is being provided. Otherwise,
surveyors assume that resident assessments have been conducted
accurately and that smoking supervision is adequate. Second, staff
interviews conducted after the fire to determine where each nursing
home staff person was when the fire began and how each responded
revealed that (1) the staff did not implement the home's fire plan on
the night of the fire, and (2) the home failed to conduct required
quarterly fire drills during the night shift, relying instead on a
review of written procedures.[Footnote 38] The prior survey was based
on inaccurate documentation provided by the nursing home and was
conducted during the daytime when night shift staff were not available
for interviews. The state survey agency concluded that these serious
deficiencies contributed to the deaths of 16 residents and cited the
Hartford nursing home with two actual harm fire safety deficiencies
after the fire. Connecticut officials stated that the investigation
following the fire was much more extensive than a routine fire safety
survey and focused on specific issues that surfaced soon after the
fire. In addition, while Connecticut surveyors spend on average about 5
hours on-site during a standard fire safety survey, the state agency
was on-site for 4 days following the fire and continued to interview
staff throughout its 3-month investigation.
Table 5: Violations of Federal Standards in Hartford and Nashville
Nursing Home Fires Not Identified during Prior Surveys:
Smoking policy;
Federal standard: Smoking by residents classified as not responsible
shall be prohibited except when under direct supervision;
Violations: Hartford nursing home: Facility failed to control and
monitor smoking for 21 residents--including 3 whose records were
reviewed during the prior survey, but no violations were identified at
that time;
Violations: Nashville nursing home: Not applicable.
Staff response;
Federal standard: Fire drills are conducted quarterly on all shifts,
and all staff are familiar with facility fire plan and appropriate
procedures;
Violations: Hartford nursing home: Staff may have failed to close all
resident room doors, and all designated staff did not respond with
fire extinguishers as called for in the fire plan;
Violations: Nashville nursing home: Not clear from available
investigations.
HVAC system;
Federal standard: Air handling system is required to shut down
automatically when fire alarm is triggered to prevent the spread of
smoke;
Violations: Hartford nursing home: Not applicable.[A];
Violations: Nashville nursing home: Air handling system may have failed
to shut down as required, contributing to spread of smoke.
Vertical openings;
Federal standard: Vertical openings or penetrations between floors are
required to be protected (fire rated and resistant to the passage of
smoke);
Violations: Hartford nursing home: Not applicable.[B];
Violations: Nashville nursing home: Unprotected vertical opening in
group shower room ceiling where penetrated by plumbing allowed smoke to
migrate to upper floors of the building.
Sources: GAO analysis of information provided by Connecticut and
Tennessee state survey agencies.
[A] The facility did not have a central heating and cooling system with
ductwork but rather relied on wall-mounted heat pumps in each
resident's room.
[B] The facility is only one-story.
[End of table]
In contrast to Connecticut's investigation, the Tennessee state survey
agency's investigation was less thorough and did not cite any
deficiencies following the fire. A Tennessee fire safety surveyor who
conducted a walk-through of the facility the day after the fire
identified, but did not follow up on, a number of potential
deficiencies that may have contributed to the loss of life.[Footnote
39] During his walk-through, the fire safety surveyor noted that the
fire had been largely contained to the second floor area where it
originated and that a large amount of smoke had traveled to the upper
two floors--where one-third of the residents died as a result of smoke
inhalation. He concluded, based on the smoke stains on the heating and
cooling registers and around other openings, that some of the smoke
traveled through the ventilation system to individual resident rooms
and through openings around shower room plumbing that ran between
floors. Although he suspected that the ventilation system might not
have shut down as required when the fire alarm was activated, he never
investigated to determine if a deficiency should have been cited, and
according to CMS fire safety specialists, the unprotected vertical
opening around the shower room pipes should have been cited by the
state on previous surveys and corrected years ago.[Footnote 40]
Although the Nashville home was cited for poor implementation of its
fire plan on each of its four most recent surveys, the state survey
agency never interviewed nursing home staff directly to determine if
this recurring problem contributed to the loss of life during the fire.
According to CMS and NFPA officials who have investigated serious
fires, one of the critical initial steps is to separately interview
staff who were present during the fire to determine whether they
followed the home's fire plan. Instead, a Tennessee state surveyor
obtained a description of how the staff responded from the nursing
home's administrator and a corporate vice president who were not inside
the building when the fire began. Thus, the state agency never
established a clear chronology of the staff's response, including
whether they closed resident room doors to contain the fire and
smoke.[Footnote 41] CMS officials were unaware of the limited nature of
the Tennessee state survey agency's fire investigation even though it
is CMS's responsibility to monitor state fire safety survey
performance.
Wide Interstate Variability in Reported Deficiencies as well as Results
of Federal Surveys Suggest that Fire Safety Deficiencies Are
Understated:
The wide interstate variability in reported fire safety deficiencies
and the results of federal monitoring surveys suggest that the
understatement of deficiencies during fire safety surveys may not be
limited to Connecticut and Tennessee. As shown in appendix I, about 59
percent of all nursing homes nationwide were cited for fire safety
deficiencies on their most recent surveys, but this proportion ranged
from about 10 percent in Kentucky to 99 percent in North
Dakota.[Footnote 42] Figure 2 shows the considerable variation that
exists in states with at least 100 nursing homes.[Footnote 43]
Figure 2: Percentage of Nursing Homes Reported to Have Fire Safety
Deficiencies on Their Most Recent Surveys in States with at Least 100
Homes:
[See PDF for image]
[End of figure]
We discussed this variability with officials in CMS's central office
and each of its 10 regions. A CMS central office fire safety specialist
told us that some states enforce the federal standards more rigorously
than other states and that the variability in survey deficiencies
suggests that some states do not cite all the deficiencies they find.
Officials in 6 of the 10 CMS regions confirmed that state surveyors do
not always cite the deficiencies identified during surveys. We were
told that state surveyors had (1) allowed nursing homes to correct
identified problems without documenting the deficiencies, (2) granted
unofficial waivers by not citing deficiencies and not requiring the
homes to correct the deficiencies, and (3) cited deficiencies under
state licensure authority but failed to cite them as federal
deficiencies. For example, for over 2 years, surveyors in one state
were whiting-out deficiencies on the survey forms and reporting that
the homes had no fire safety deficiencies. Some of the state's survey
forms read "per fire marshal, do not cite."[Footnote 44]
The results of federal comparative fire safety surveys also demonstrate
that state surveyors either miss or fail to cite all fire safety
deficiencies. A comparative survey involves a federal survey team
conducting a complete, independent survey of a home shortly after a
state's survey to compare and contrast the findings. Of the 40
comparative surveys that assessed fire safety standards in fiscal year
2003, federal surveyors identified on average more than two fire safety
deficiencies per home that were either missed or not cited by state
surveyors, but in one region the average number of such deficiencies
was about five.[Footnote 45] Some of the deficiencies found by federal
surveyors were potentially serious, including the absence of required
sprinkler systems, improper maintenance of sprinkler systems,
inadequate building construction to contain fire and smoke during a
fire, and failure to conduct routine fire drills.[Footnote 46] Some of
the same deficiencies not cited by Connecticut and Tennessee surveyors
prior to the fires likely contributed to the spread of smoke during the
two nursing home fires in 2003. Appendix II identifies examples of
deficiencies identified during fiscal year 2003 federal comparative
fire safety surveys that were either missed or not cited by state
surveyors on standard surveys. While several regional office officials
stated that comparative fire safety surveys could be used to reduce the
variability in how states conduct fire safety surveys, CMS central
office does not review comparative survey results nationally to
identify training and refresher topics for state surveyors.
In some cases, the deficiencies missed or not cited during state
surveys were so basic that they raise a question about the preparation
or training of state surveyors or the thoroughness of state surveys:
* State surveyors incorrectly classified nursing home construction
types, thus failing to identify buildings that were required to be
sprinklered under federal standards.
* State surveyors failed to identify the lack of a fire-rated ceiling
that would resist the spread of fire for 1 hour in a one-story wood-
frame nursing home.
* State surveyors failed to identify that approximately 80 percent of a
home's resident rooms had sidewall-mounted sprinkler heads that would
not work in the event of a fire because they were blocked by privacy
curtains hanging in the room.
* State surveyors incorrectly surveyed additions and major renovations
in facilities across the state by using less stringent federal
standards that applied to the original nursing home structures.
* State surveyors missed obvious fire safety deficiencies, such as the
use of plywood rather than drywall for corridor walls, unprotected
hazardous areas, hollow core doors that were required to be solid, and
facilities lacking fire alarms.[Footnote 47]
A CMS fire safety specialist who identified some of these missed
deficiencies told us that they were overlooked because of a lack of
rigor on the part of state surveyors.[Footnote 48] According to this
official, conducting a fire safety survey involves more than simply
walking through a nursing home. Because floors, walls, and ceilings
mask many building construction features, surveyors need to take
additional steps to verify that a home meets federal standards. Such
steps could include (1) removing electrical switch plates to verify the
thickness and type of material used for walls; (2) using a ladder to
look above a false ceiling to ensure that there are no hidden openings
in the corridor walls that would allow smoke to enter resident rooms;
and (3) checking attics to ensure that they contain sprinklers, as
required. Moreover, we were told it is important during each annual
survey to thoroughly examine a building's fire safety elements because
features do change over time due to routine maintenance and renovation.
For example, homes may replace their false ceilings with non-fire-rated
material, add new light fixtures that block sprinkler coverage, or
install ceiling fans that interfere with the operation of smoke
detectors. In addition, mechanical systems may not always work as
intended and should be checked routinely during state surveys.
OSCAR data on the duration of on-site fire safety surveys also raised
questions about the thoroughness of some state fire safety surveys. For
current surveys, the average amount of time spent on-site conducting a
fire safety survey is about 5 hours, nationally. In 16 states, 25
percent or more of homes' current surveys occurred in 2 hours or less
(see table 6).[Footnote 49] According to CMS officials, a survey of 2
hours or less may be adequate because of surveyor familiarity with a
facility, the small size of some facilities, or the existence of
sprinklers that mitigate certain deficiencies. However, regional office
officials identified concerns in at least five states where surveyors
may not be spending enough time in facilities to adequately assess
their compliance with federal standards.
Table 6: States with Large Proportions of Current Fire Safety Surveys
Conducted in 2 hours or Less:
Percentage of homes surveyed in 2 hours or less: From 25 to 50 percent;
States: Colorado, Indiana, Maine, Minnesota, Oklahoma, South Carolina,
and Virginia.
Percentage of homes surveyed in 2 hours or less: From 51 to 75 percent;
States: Georgia, Iowa, Kentucky, Nebraska, Vermont, and Washington.
Percentage of homes surveyed in 2 hours or less: More than 75 percent;
States: Maryland, Oregon, and Rhode Island.
Source: GAO analysis of OSCAR data as of January 22, 2004.
[End of table]
The CMS Web site that provides information on the results of nursing
home quality-of-care oversight lacks fire safety data. Since 1998, CMS
has shown a strong commitment to providing the public with information
on nursing homes through its Nursing Home Compare Web site.[Footnote
50] The Web site includes information on state quality-of-care surveys,
other measures of quality based on resident assessment data, complaint
investigations, and staffing levels for individual nursing homes.
Although fire safety deficiency data available to the public were
initially included on CMS's Web site, they were subsequently removed
because of concern over how to portray deficiencies that remain
uncorrected because of waivers or FSES. However, one state survey
agency (Pennsylvania) found a way to clearly indicate whether
deficiencies had to be corrected.[Footnote 51] In addition, the CMS Web
site contains no information on whether a nursing home has automatic
sprinklers or smoke detectors in resident rooms.
CMS Oversight of State Fire Safety Activities Is Insufficient:
CMS provides insufficient oversight of state survey activities to
address the fire safety survey inconsistencies we identified. In
general, CMS regional offices (1) do not fully comply with the
statutory requirement to conduct federal monitoring surveys; (2) lack
basic data to assess the appropriateness of waivers and FSES,
especially in unsprinklered facilities; (3) infrequently review state
trends in citing fire safety deficiencies; and (4) provide insufficient
oversight of deficiencies that are waived or that homes need not
correct because of compensating fire safety features.
Evaluation of State Surveyors' Performance Is Limited:
CMS's evaluation of state surveyors' performance has not routinely
included fire safety as part of the statutory requirement to annually
conduct federal monitoring surveys in at least 5 percent of surveyed
nursing homes in each state.[Footnote 52] Table 7 contrasts the number
and type of annual federal monitoring surveys that included quality-of-
care and fire safety standards. While 871 federal monitoring surveys
focused on quality-of-care standards in fiscal year 2003, only 40 such
surveys assessed fire safety--all of them comparative.[Footnote 53] Six
of the 10 CMS regional offices included fire safety as part of federal
monitoring surveys in fiscal year 2003, but the number of such fire
safety assessments varied from four per state to none. Overall, 27
states had no federal assessments of fire safety in this time period.
Officials in all 6 of the regional offices that assessed fire safety
told us that they lacked sufficient staff to increase the number of
surveys that included fire safety. While acknowledging that CMS
guidance does not specifically direct regions to assess compliance with
fire safety standards when conducting federal monitoring surveys, CMS
officials agreed that such assessments are mandatory and that they need
to clarify this matter with regional offices.
Table 7: Comparison of the Number and Type of Federal Monitoring
Surveys Including Quality-of-Care and Fire Safety Standards, Fiscal
Year 2003:
Total surveys;
Federal monitoring surveys: Quality-of-care: 871;
Federal monitoring surveys: Fire safety: 40[A].
Proportion of homes surveyed;
Federal monitoring surveys: Quality-of- care: More than 5 percent;
Federal monitoring surveys: Fire safety: About .2 percent.
Number of states in which federal monitoring surveys were conducted;
Federal monitoring surveys: Quality-of-care: All states plus the
District of Columbia;
Federal monitoring surveys: Fire safety: 23 states plus the District of
Columbia.
Proportion comparative[B];
Federal monitoring surveys: Quality-of- care: 20 percent;
Federal monitoring surveys: Fire safety: All.
Proportion observational;
Federal monitoring surveys: Quality-of-care: 80 percent;
Federal monitoring surveys: Fire safety: None.
Source: CMS.
[A] Our analysis excluded 15 surveys in four of the six regions that
were conducted either before the state survey or more than 60 days
after the state survey. We excluded these surveys because by statute a
federal survey must begin within 2 months of the state's survey to
ensure a valid comparison.
[B] We noted in 1999 that comparative surveys, though insufficient in
number, were the most effective technique for assessing state agencies'
abilities to identify deficiencies in nursing homes because they
constitute an independent evaluation of the state survey. See U.S.
General Accounting Office, Nursing Home Care: Enhanced HCFA Oversight
of State Programs Would Better Ensure Quality, GAO/HEHS-00-6
(Washington, D.C.: Nov. 4, 1999).
[End of table]
Data Limitations and Inconsistent Use of Available Information Hamper
CMS Oversight:
OSCAR data limitations and inconsistent use of available information by
CMS regions hamper CMS's efforts to oversee state fire safety
activities. While OSCAR identifies homes cited for deficiencies on fire
safety surveys, it is unable to distinguish between deficiencies cited
for sprinklered and unsprinklered homes.[Footnote 54] As previously
discussed, information on the extent of sprinkler coverage at a home is
important both when initially considering allowing uncorrected
deficiencies through waivers and FSES and when reevaluating the
appropriateness of uncorrected deficiencies--especially in
unsprinklered nursing homes. Such information is also needed to develop
a reliable estimate of the cost of retrofitting older homes with
sprinklers. During the course of our work, we shared our concern about
the lack of such data and, as a result, CMS officials told us that they
are in the process of developing a new data field on sprinkler coverage
for the form used by surveyors to collect data on a facility's
compliance with federal fire safety standards.
Despite the variability in fire safety deficiency patterns across
states, CMS makes limited use of OSCAR data to identify potential
problems in state adherence to federal requirements and the need for
training. CMS central office does not review fire safety deficiency
patterns, and only 3 of the 10 regions routinely review state-level
OSCAR data on fire safety deficiencies for the states in their regions.
During such reviews, 1 region discovered that surveyors in a particular
state had cited only five fire safety deficiencies at the 100 homes
surveyed. The region used the data as an opportunity to review federal
fire safety requirements with state surveyors and, as a result, the
state surveyors are now citing deficiencies that had previously been
missed or not cited. Another region noticed that state surveyors were
improperly citing potentially serious deficiencies at the lowest scope
and severity level. While facilities are expected to address fire
safety deficiencies at all levels, a regional office official stated
that homes with low scope and severity levels might receive less
scrutiny than facilities with higher levels. Since CMS discussed the
matter with the state, state surveyors cite deficiencies at levels that
more appropriately reflect the extent and seriousness of the problems
identified. The region also uses OSCAR data to identify specific state
surveyors who may need additional training.
Routinely reviewing OSCAR data would also help CMS ensure that state
surveys, including assessments of fire safety, are taking place within
the time frames required by statute. For example, we found that 31
percent of a state's surveys in one region and 9 percent of all surveys
in a different region were not conducted within 15 months of the prior
fire safety survey, as required by statute. Neither of the regions
overseeing these states nor CMS central office routinely examined OSCAR
data to determine if fire safety surveys occurred within statutory time
frames.
CMS Does Not Review All Waiver Renewal Requests and FSES Results:
CMS regional office staff are not reviewing and approving all renewal
requests for waivers of federal fire safety standards nor are they
reviewing the results of FSES, as required by CMS guidance. Moreover,
half of the 10 regions do not have fire safety specialists on staff and
some regions allow nonspecialists to conduct waiver reviews. Although a
regional office may waive certain requirements and allow deficiencies
to remain uncorrected, such deficiencies must be identified on
subsequent surveys and any waivers must be periodically renewed and
reviewed. We found that four regions either did not require states to
submit requests for waiver renewals or that states in those regions did
not submit waiver renewal requests.[Footnote 55] Since the
circumstances that led to the approval of a waiver may change, periodic
renewal of waivers is important. For example, based on the lessons of
the Tennessee nursing home fire in September 2003, the Atlanta regional
office raised a question about the renewal of waivers for at least 50
homes in Arkansas. For many years, these unsprinklered homes had
received a waiver for a ventilation system requirement that could allow
smoke to spread to resident rooms during a fire.
We also found considerable variability in the expertise of CMS regional
office staff tasked with reviewing waiver requests. Overall, 5 of the
10 regional offices currently have fire safety specialists who are
either civil or mechanical engineers or have a significant amount of
fire safety experience or training.[Footnote 56] NFPA commented that
civil or mechanical engineers are not necessarily qualified in fire
safety and that fire protection engineers would be a good addition to
CMS staff. In contrast, 2 regions have either public health or health
insurance specialists conduct waiver reviews, whereas a third region
has its waivers reviewed by a fire safety specialist in another CMS
regional office. In a fourth region, two of the three health insurance
specialists who conduct waiver reviews have not taken CMS's basic fire
safety training. According to the staff, they generally accept the
state's recommendation with little independent review. Until one
regional office decided to hire its own fire safety specialist in 2002,
waiver review was treated as a clerical function. According to CMS
officials, the decision not to have a full-time fire safety specialist
in each region was made in the early 1980s and was based on resource
constraints. They pointed out that regions lacking sufficient fire
safety expertise may obtain assistance from specialists either in CMS
central office or in other regions.
Eight of 10 regional offices do not adhere to CMS's policy that
requires regions to review FSES results as an alternative way for
nursing homes to comply with federal fire safety standards. Five
regions currently lack a fire safety specialist to conduct the reviews.
According to an NFPA technical expert, it is critical for the
individuals who review FSES results to have both an extensive knowledge
of the standards and the ability to distinguish among different
construction types and materials. We believe that this is particularly
important in homes that lack sprinkler protection but claim to have
compensating construction features. A regional office fire safety
specialist who does not routinely review FSES results told us that he
was aware of two unsprinklered homes where the passing scores
determined by the state were incorrect. After he discovered the errors,
one home agreed to install a sprinkler system, and the other moved
residents to a facility with sprinkler protection.
Conclusions:
Our examination of the lessons learned from the Hartford and Nashville
nursing home fires in which 31 residents died found systemic problems
with the adequacy and enforcement of federal fire safety standards that
go well beyond these two tragic events. As a result of these fires,
NFPA is now actively considering incorporating a sprinkler retrofit
requirement into its 2006 update of the standards, a move supported by
the nursing home industry. Given industry concerns about the cost and
the need for a transition period for homes to come into compliance,
older homes will likely continue to operate without sprinklers for
several years. Because of the uncertainty concerning whether or when
the fire safety standards will be revised and implemented, we believe
that certain actions are needed now to better protect residents in the
event of a fire in an unsprinklered nursing home.
Federal oversight of state fire safety activities is currently
inadequate to ensure that existing standards are being enforced. For
example, CMS does not routinely include the fire safety component as
part of its statutory mandate to conduct annual federal monitoring
surveys intended to assess state survey agency performance,
particularly in unsprinklered facilities. Moreover, CMS's review of
deficiencies that nursing homes do not correct because of waivers or
FSES is weak. Because it lacks data on the extent to which facilities
have sprinklers, it is currently unable to quickly focus its attention
on uncorrected deficiencies in unsprinklered facilities. Despite the
availability of information on oversight of nursing home quality
through CMS's Nursing Home Compare Web site, no comparable information
on fire safety is currently available. Thus, consumers lack a complete
picture of a home's compliance with federal health and safety
requirements when selecting a facility, including information on
whether the home has automatic sprinklers or smoke detectors in
resident rooms.
Action by CMS is required to ensure that an appropriate balance is
struck between resident safety and a concern about costs when updating
federal fire safety standards. For example, although commonsense
features such as smoke detectors in resident rooms have been shown to
be effective in alerting staff to a fire while it is still relatively
manageable, smoke detectors are not required in unsprinklered nursing
homes. Furthermore, CMS has not yet developed a reliable cost estimate
for retrofitting older homes with sprinklers, a critical issue as NFPA
considers requiring all homes to have sprinklers. Finally, CMS
acknowledges that fires are a test of the standards designed to
safeguard both life and property, providing an opportunity to identify
strengths and weaknesses. However, the agency missed an opportunity to
obtain critical information on which to base decisions regarding future
revisions to the standards when it did not conduct its own independent
investigations of the Hartford and Nashville fires, as it has done in
past multiple-death fires.
Recommendations for Executive Action:
To improve federal oversight of state fire safety activities, provide
the public with important information about the fire safety status of
nursing homes, and better ensure the adequacy of fire safety standards,
we recommend that the Administrator of CMS take the following seven
actions.
* Ensure that CMS regional offices fully comply with the statutory
requirement to conduct annual federal monitoring surveys by including
an assessment of the fire safety component of states' standard surveys,
with an emphasis on unsprinklered homes.
* Ensure that data on sprinkler coverage in nursing homes are
consistently obtained and reflected in the CMS database.
* Until sprinkler coverage data are routinely available in CMS's
database, work with state survey agencies to identify the extent to
which each nursing home is sprinklered or not sprinklered.
* On an expedited basis, review all waivers and FSES assessments for
homes that are not fully sprinklered to determine their
appropriateness.
* Make information on fire safety deficiencies available to the public
via the Nursing Home Compare Web site, including information on whether
a home has automatic sprinklers.
* Work with NFPA to strengthen fire safety standards for unsprinklered
nursing homes, such as requiring smoke detectors in resident rooms,
exploring the feasibility of requiring sprinklers in all nursing homes,
and developing a strategy for financing such requirements.
* Ensure that thorough investigations are conducted following multiple-
death nursing home fires so that fire safety standards can be
reevaluated and modified where appropriate.
Agency, State, and NFPA Comments and Our Evaluation:
We provided a draft of this report to CMS, the Connecticut and
Tennessee state survey agencies, and NFPA. CMS concurred with our
findings and recommendations, stating that it has undertaken several
initiatives to improve federal oversight of state fire safety surveys.
(CMS's comments are reproduced in app. III.)
CMS commented that because protecting nursing home residents from fire
hazards was an important goal, it conducted its own analysis of nursing
home fire risk at the same time our study was underway. As a result,
CMS has already taken steps to implement all seven of our
recommendations. For example, CMS stated that because it is important
for every resident room to have a smoke detector, it will pursue a
regulatory change requiring their installation. Similarly, CMS plans to
confirm the sprinkler status of each home during upcoming facility
surveys and to enter this information in CMS's database. CMS also plans
to make both the sprinkler status and fire safety survey results
available to the public on its Medicare Compare Web site by the summer
of 2005. Finally, to fulfill the statutory requirement for annual
federal monitoring surveys designed to assess the effectiveness of
state fire safety surveys, CMS has reprioritized resources for a five-
fold increase in comparative surveys to about 200 during fiscal year
2005, with a focus on unsprinklered nursing homes. Its goal is to
accomplish the remaining approximately 700 observational surveys by
redesigning regional office workplans. CMS also provided technical
comments which we incorporated as appropriate.
The Connecticut state survey agency provided technical comments, which
we incorporated as appropriate. In discussing the state's comments with
survey agency officials, we were told that the agency now (1) reminds
facilities that fire drills on all shifts must be more than a paper
review of a home's fire plan and (2) pays more attention to smoking-
related issues during fire safety surveys, including obtaining a list
of all smokers at the beginning of a survey. Based on our prior work,
we believe that Connecticut's, and likely other states', experience
underscores the risks of relying on documentation without
systematically verifying its accuracy through interviews and
observation.[Footnote 57]
NFPA provided technical comments, which we incorporated as appropriate.
The Tennessee state survey agency did not comment on our draft.
As arranged with your offices, unless you publicly announce its
contents earlier, we plan no further distribution of this report until
30 days after its issue date. At that time, we will send copies to the
Administrator of the Centers for Medicare & Medicaid Services and
appropriate congressional committees. We also will make copies
available to others upon request. In addition, the report will be
available at no charge on the GAO Web site at http://www.gao.gov.
Please contact me at (202) 512-7118 or Walter Ochinko, Assistant
Director, at (202) 512-7157 if you or your staffs have any questions.
GAO staff who contributed to this report include Eric Anderson, Dean
Mohs, and Paul M. Thomas.
Signed by:
Kathryn G. Allen:
Director, Health Care--Medicaid and Private Health Insurance Issues:
[End of section]
Appendix I: Percentage of Surveyed Nursing Homes Cited with Fire Safety
Deficiencies on Their Most Recent Surveys, by State:
State: North Dakota;
Number of homes surveyed: 84;
Percentage of surveyed homes with fire safety deficiencies: 98.8%.
State: Montana;
Number of homes surveyed: 101;
Percentage of surveyed homes with fire safety deficiencies: 97.0%.
State: Utah;
Number of homes surveyed: 90;
Percentage of surveyed homes with fire safety deficiencies: 96.7%.
State: Wyoming;
Number of homes surveyed: 39;
Percentage of surveyed homes with fire safety deficiencies: 94.9%.
State: Nevada;
Number of homes surveyed: 44;
Percentage of surveyed homes with fire safety deficiencies: 93.2%.
State: Michigan;
Number of homes surveyed: 431;
Percentage of surveyed homes with fire safety deficiencies: 92.1%.
State: South Dakota;
Number of homes surveyed: 113;
Percentage of surveyed homes with fire safety deficiencies: 88.5%.
State: Kansas;
Number of homes surveyed: 374;
Percentage of surveyed homes with fire safety deficiencies: 86.6%.
State: Texas;
Number of homes surveyed: 1,143;
Percentage of surveyed homes with fire safety deficiencies: 84.4%.
State: Pennsylvania;
Number of homes surveyed: 740;
Percentage of surveyed homes with fire safety deficiencies: 82.3%.
State: Iowa;
Number of homes surveyed: 454;
Percentage of surveyed homes with fire safety deficiencies: 79.7%.
State: Tennessee;
Number of homes surveyed: 337;
Percentage of surveyed homes with fire safety deficiencies: 78.6%.
State: New Mexico;
Number of homes surveyed: 81;
Percentage of surveyed homes with fire safety deficiencies: 76.5%.
State: Louisiana;
Number of homes surveyed: 314;
Percentage of surveyed homes with fire safety deficiencies: 74.5%.
State: Delaware;
Number of homes surveyed: 42;
Percentage of surveyed homes with fire safety deficiencies: 73.8%.
State: Arizona;
Number of homes surveyed: 135;
Percentage of surveyed homes with fire safety deficiencies: 73.3%.
State: Illinois;
Number of homes surveyed: 831;
Percentage of surveyed homes with fire safety deficiencies: 71.4%.
State: District of Columbia;
Number of homes surveyed: 21;
Percentage of surveyed homes with fire safety deficiencies: 71.4%.
State: Ohio;
Number of homes surveyed: 990;
Percentage of surveyed homes with fire safety deficiencies: 70.8%.
State: Georgia;
Number of homes surveyed: 360;
Percentage of surveyed homes with fire safety deficiencies: 70.8%.
State: Oregon;
Number of homes surveyed: 141;
Percentage of surveyed homes with fire safety deficiencies: 68.8%.
State: Alaska;
Number of homes surveyed: 14;
Percentage of surveyed homes with fire safety deficiencies: 64.3%.
State: Alabama;
Number of homes surveyed: 228;
Percentage of surveyed homes with fire safety deficiencies: 61.0%.
State: Florida;
Number of homes surveyed: 694;
Percentage of surveyed homes with fire safety deficiencies: 60.5%.
State: Nation;
Number of homes surveyed: 16,334;
Percentage of surveyed homes with fire safety deficiencies: 58.9%.
State: Wisconsin;
Number of homes surveyed: 408;
Percentage of surveyed homes with fire safety deficiencies: 56.4%.
State: North Carolina;
Number of homes surveyed: 423;
Percentage of surveyed homes with fire safety deficiencies: 56.3%.
State: Arkansas;
Number of homes surveyed: 242;
Percentage of surveyed homes with fire safety deficiencies: 56.2%.
State: Virginia;
Number of homes surveyed: 278;
Percentage of surveyed homes with fire safety deficiencies: 53.2%.
State: California;
Number of homes surveyed: 1,342;
Percentage of surveyed homes with fire safety deficiencies: 51.0%.
State: Mississippi;
Number of homes surveyed: 204;
Percentage of surveyed homes with fire safety deficiencies: 49.5%.
State: Colorado;
Number of homes surveyed: 216;
Percentage of surveyed homes with fire safety deficiencies: 48.2%.
State: New Jersey;
Number of homes surveyed: 356;
Percentage of surveyed homes with fire safety deficiencies: 48.0%.
State: Massachusetts;
Number of homes surveyed: 481;
Percentage of surveyed homes with fire safety deficiencies: 47.6%.
State: West Virginia;
Number of homes surveyed: 136;
Percentage of surveyed homes with fire safety deficiencies: 45.6%.
State: New York;
Number of homes surveyed: 671;
Percentage of surveyed homes with fire safety deficiencies: 45.6%.
State: Washington;
Number of homes surveyed: 260;
Percentage of surveyed homes with fire safety deficiencies: 45.0%.
State: Missouri;
Number of homes surveyed: 534;
Percentage of surveyed homes with fire safety deficiencies: 44.0%.
State: Indiana;
Number of homes surveyed: 527;
Percentage of surveyed homes with fire safety deficiencies: 43.5%.
State: Maryland;
Number of homes surveyed: 243;
Percentage of surveyed homes with fire safety deficiencies: 40.7%.
State: Oklahoma;
Number of homes surveyed: 370;
Percentage of surveyed homes with fire safety deficiencies: 30.5%.
State: Rhode Island;
Number of homes surveyed: 95;
Percentage of surveyed homes with fire safety deficiencies: 28.4%.
State: Connecticut;
Number of homes surveyed: 252;
Percentage of surveyed homes with fire safety deficiencies: 26.6%.
State: Minnesota;
Number of homes surveyed: 425;
Percentage of surveyed homes with fire safety deficiencies: 25.7%.
State: New Hampshire;
Number of homes surveyed: 81;
Percentage of surveyed homes with fire safety deficiencies: 23.5%.
State: Vermont;
Number of homes surveyed: 43;
Percentage of surveyed homes with fire safety deficiencies: 23.3%.
State: Hawaii;
Number of homes surveyed: 45;
Percentage of surveyed homes with fire safety deficiencies: 22.2%.
State: Maine;
Number of homes surveyed: 119;
Percentage of surveyed homes with fire safety deficiencies: 21.9%.
State: Nebraska;
Number of homes surveyed: 228;
Percentage of surveyed homes with fire safety deficiencies: 21.5%.
State: Idaho;
Number of homes surveyed: 80;
Percentage of surveyed homes with fire safety deficiencies: 20.0%.
State: South Carolina;
Number of homes surveyed: 178;
Percentage of surveyed homes with fire safety deficiencies: 14.0%.
State: Kentucky;
Number of homes surveyed: 296;
Percentage of surveyed homes with fire safety deficiencies: 9.8%.
Source: GAO analysis of most recent state surveys in OSCAR as of
December 1, 2003.
[End of table]
[End of section]
Appendix II: Federal Comparative Survey Results for Fiscal Year 2003--
Examples of Fire Safety Deficiencies Missed or Not Cited:
CMS regional office (state): Atlanta (Georgia);
Federal fire safety standard: Corridor walls must be fire-rated, extend
from the floor to the roof deck or floor above, and resist the passage
of smoke. In a fully sprinklered facility, corridor walls may terminate
at the underside of the ceiling, need not be fire-rated, and must only
resist the passage of smoke;
Fire safety deficiencies missed or not cited by state surveyors:
* Not all corridor walls extended to the roof deck to provide the
minimum fire resistance rating;
* Smoke walls extending from the corridor to the exterior walls were
incomplete, with openings in the wall that would allow smoke to move
from one side of the smoke wall to the other.
CMS regional office (state): Atlanta (Georgia);
Federal fire safety standard: Depending on construction type and number
of stories, sprinklers required throughout home;
Fire safety deficiencies missed or not cited by state surveyors:
* Approximately 95 percent of the building was not protected by an
automatic sprinkler system, even though the building construction type
required complete sprinkler protection.
CMS regional office (state): Boston (Connecticut, Massachusetts, and
New Hampshire);
Federal fire safety standard: Depending on construction type and number
of stories, sprinklers required throughout home;
Fire safety deficiencies missed or not cited by state surveyors:
* Wood roof overhang used as a screened porch was not protected by
sprinkler system;
* Home failed to provide complete sprinkler protection for a three-
story wood frame building;
* Beauty salon closet was missing sprinkler.
CMS regional office (state): Boston (Connecticut, Massachusetts, and
New Hampshire);
Federal fire safety standard: Sprinkler system is operational and
properly maintained;
Fire safety deficiencies missed or not cited by state surveyors:
* Sprinkler in storage area was obstructed.
CMS regional office (state): Boston (Connecticut, Massachusetts, and
New Hampshire);
Federal fire safety standard: Doors are provided with latching devices,
which will keep the doors tightly closed in their frames;
Fire safety deficiencies missed or not cited by state surveyors:
* Home failed to maintain corridor doors so that they closed tightly
to resist the passage of smoke;
* Two resident room doors had obstructions that did not allow them to
close completely.
CMS regional office (state): Boston (Connecticut, Massachusetts, and
New Hampshire);
Federal fire safety standard: Vertical openings or penetrations between
floors are required to be protected (fire-rated and resistant to the
passage of smoke);
Fire safety deficiencies missed or not cited by state surveyors:
* Linen chute did not have a fire-resistance rating of at least 1 hour.
CMS regional office (state): Boston (Connecticut, Massachusetts, and
New Hampshire);
Federal fire safety standard: Fire drills are conducted quarterly on
all shifts, and all staff are familiar with facility fire plan and
appropriate procedures;
Fire safety deficiencies missed or not cited by state surveyors:
* Home failed to conduct fire drill on third shift (from 11 p.m. to 7
a.m.
CMS regional office (state): Chicago (Illinois, Michigan,
Minnesota, Ohio, and Wisconsin);
Federal fire safety standard: Depending on construction type and number
of stories, sprinklers required throughout home;
Fire safety deficiencies missed or not cited by state surveyors:
* Two exterior combustible canopies were not sprinklered;
* Soiled- linen room in the basement contained unprotected steel
framing for the floor above, which required the building to have
complete sprinkler protection.
CMS regional office (state): Chicago (Illinois, Michigan,
Minnesota, Ohio, and Wisconsin);
Federal fire safety standard: Sprinkler system is operational and
properly maintained;
Fire safety deficiencies missed or not cited by state surveyors:
* Home failed to properly maintain sprinkler system;
* Home did not replace six sprinklers on known recall list.
CMS regional office (state): Chicago (Illinois, Michigan,
Minnesota, Ohio, and Wisconsin);
Federal fire safety standard: Hazardous areas have an approved fire
extinguishing system or a 1-hour fire-rated construction. Doors shall
be self-closing;
Fire safety deficiencies missed or not cited by state surveyors:
* Hazardous area not separated with 1-hour fire-rated construction;
* Employee lockers were not properly separated by a 1-hour fire-rated
construction from the means of egress;
* Mechanical room ceiling had a large opening and unprotected hole.
CMS regional office (state): Chicago (Illinois, Michigan,
Minnesota, Ohio, and Wisconsin);
Federal fire safety standard: Corridor walls must be fire-rated, extend
from the floor to the roof deck or floor above, and resist the passage
of smoke. In a fully sprinklered facility, corridor walls may terminate
at the underside of the ceiling, need not be fire-rated, and must only
resist the passage of smoke;
Fire safety deficiencies missed or not cited by state surveyors:
* Smoke barrier above the ceiling at the corridor doors was open the
entire width of corridor.
CMS regional office (state): Chicago (Illinois, Michigan,
Minnesota, Ohio, and Wisconsin);
Federal fire safety standard: Doors are provided with latching devices,
which will keep the doors tightly closed in their frames;
Fire safety deficiencies missed or not cited by state surveyors:
* Corridor doors separating the second floor dining room from the
corridor had been removed.
CMS regional office (state): Chicago (Illinois, Michigan,
Minnesota, Ohio, and Wisconsin);
Federal fire safety standard: Vertical openings or penetrations between
floors are required to be protected (fire-rated and resistant to the
passage of smoke);
Fire safety deficiencies missed or not cited by state surveyors:
* Linen chute discharge door was not self-closing and remained open.
CMS regional office (state): Dallas (Louisiana and New Mexico);
Federal fire safety standard: Corridor walls must be fire-rated, extend
from the floor to the roof deck or floor above, and resist the passage
of smoke. In a fully sprinklered facility, corridor walls may terminate
at the underside of the ceiling, need not be fire-rated, and must only
resist the passage of smoke;
Fire safety deficiencies missed or not cited by state surveyors:
* Home failed to ensure that the corridor walls formed a smoke-tight
barrier between the corridor and other areas of the facility;
* Home failed to ensure that smoke barriers were maintained, which
would ensure appropriate resistance to the passage of smoke by making
penetrations smoke-tight;
* Two separate holes in the smoke barrier were identified above the
doors outside the staff conference room;
* Home had a hole in the smoke barrier above the ceiling between the
cardiac clinic equipment and the nursing home conference room.
CMS regional office (state): Dallas (Louisiana and New Mexico);
Federal fire safety standard: Fire drills are conducted quarterly on
all shifts, and all staff are familiar with facility fire plan and
appropriate procedures;
Fire safety deficiencies missed or not cited by state surveyors:
* Home failed to ensure that fire drills were carried out at least
quarterly for day and evening shifts to ensure staff competence in the
event of a fire.
CMS regional office (state): Dallas (Louisiana and New Mexico);
Federal fire safety standard: Sprinkler system is operational and
properly maintained;
Fire safety deficiencies missed or not cited by state surveyors:
* Home failed to ensure that there were no obstructions to the water
flow of installed sprinklers;
* Home failed to ensure that replacement sprinklers and a wrench of
appropriate size were available in the main sprinkler room.
CMS regional office (state): Dallas (Louisiana and New Mexico);
Federal fire safety standard: HVAC system shall comply with fire safety
standards and be installed in accordance with the manufacturer's
specifications;
Fire safety deficiencies missed or not cited by state surveyors:
* Corridor was used as a part of the return air system, which would
allow the spread of smoke to resident rooms during a fire.
CMS regional office (state): Dallas (Louisiana and New Mexico);
Federal fire safety standard: Doors in fire separation walls, hazardous
area enclosures, horizontal exits, or smoke partitions may be held open
only by devices arranged to automatically close all such doors by zone
or throughout the facility upon activation of fire detection systems;
Fire safety deficiencies missed or not cited by state surveyors:
* One of the exit doors had panic hardware that did not permit the door
to close to form a tight seal that would resist the passage of fire and
smoke.
CMS regional office (state): Denver (Colorado, North Dakota, South
Dakota, Utah, and Wyoming);
Federal fire safety standard: Sprinkler system is operational and
properly maintained;
Fire safety deficiencies missed or not cited by state surveyors:
* Several sprinklers on known recall list were not replaced;
* Four large coffee pots on the top shelf of the store room could
obstruct the spray pattern of the adjacent sprinkler;
* Two hoses from the floor-cleaning machine were hanging on the
sprinkler piping in the basement housekeeping room.
CMS regional office (state): Denver (Colorado, North Dakota, South
Dakota, Utah, and Wyoming);
Federal fire safety standard: Hazardous areas have an approved fire
extinguishing system or a 1-hour fire-rated construction. Doors shall
be self-closing;
Fire safety deficiencies missed or not cited by state surveyors:
* Double doors to the clean linen side of the laundry and to the
soiled- linen holding room were damaged and unable to resist the
passage of smoke;
* Boiler room doors to the corridor were missing self-closing devices;
* Boiler room door was lacking a strike plate to complete the required
latch;
* Door to the clean linen room of the basement laundry was sagging so
that it did not fit its frame. Also, the latch was not engaging its
strike plate.
CMS regional office (state): Denver (Colorado, North Dakota, South
Dakota, Utah, and Wyoming);
Federal fire safety standard: Corridor walls must be fire-rated, extend
from the floor to the roof deck or floor above, and resist the passage
of smoke. In a fully sprinklered facility, corridor walls may terminate
at the underside of the ceiling, need not be fire-rated, and must only
resist the passage of smoke;
Fire safety deficiencies missed or not cited by state surveyors:
* Three pipes penetrated a wall with a 2-inch opening around the
pipes;
* There was an opening 1 inch in diameter larger than a pipe
penetrating a smoke barrier;
* Smoke barrier had open flutes above the wall and had an opening
around two pipes 2 inches in diameter larger than the pipes;
* Openings were observed that were approximately 2 inches larger than
the size of all 26 electrical conduits where they passed through the
basement ceiling;
* A TV lounge was not separated from the corridor with a smoke-
resistant wall.
CMS regional office (state): Denver (Colorado, North Dakota, South
Dakota, Utah, and Wyoming);
Federal fire safety standard: Doors are provided with latching devices,
which will keep the doors tightly closed in their frames;
Fire safety deficiencies missed or not cited by state surveyors:
* Door to a conference room was held open with a wastebasket during the
entire survey;
* A resident room door had a piece of duct tape over the strike plate,
which made the latch inoperative;
* One resident room had no door latch and the roller latches for three
resident rooms were not engaging their strike plates;
* The door to the TV room did not close to a positive latch;
* A resident room door was obstructed from closing due to a hook over
the door holding a decoration.
CMS regional office (state): Denver (Colorado, North Dakota, South
Dakota, Utah, and Wyoming);
Federal fire safety standard: Vertical openings or penetrations between
floors are required to be protected (fire-rated and resistant to the
passage of smoke);
Fire safety deficiencies missed or not cited by state surveyors:
* Stair leading from the basement to the first floor did not have a
fire-rated construction between it and the elevator equipment room;
* A metal grate in the floor behind the walk-in freezer and cooler in
the kitchen opened into a shaft located in the basement, consisting of
8-inch-by-12-inch access holes. These access holes were not closed with
a fire-rated material;
* The door at the top of the basement stair did not have a self-
closing device;
* Basement stair door was missing its latch;
* All three stairway doors were not at least 1-hour fire-rated.
CMS regional office (state): Denver (Colorado, North Dakota, South
Dakota, Utah, and Wyoming);
Federal fire safety standard: Approved smoke detectors are installed,
approved, maintained, inspected, and tested in accordance with the
manufacturer's specifications;
Fire safety deficiencies missed or not cited by state surveyors:
* TV lounge did not have a smoke detection system;
* Smoke detectors were located only on one side of all six smoke
barrier doors.
CMS regional office (state): Philadelphia (Delaware and Pennsylvania);
Federal fire safety standard: Hazardous areas have an approved fire
extinguishing system or a 1-hour fire-rated construction. Doors shall
be self-closing;
Fire safety deficiencies missed or not cited by state surveyors:
* Soiled utility room had a door without a self-closing mechanism;
* Two soiled utility rooms had doors that were not self- closing.
CMS regional office (state): Philadelphia (Delaware and Pennsylvania);
Federal fire safety standard: Complete fire and smoke barriers required
on each floor and between corridor and resident rooms. Doors are
provided with latching devices, which will keep the doors tightly
closed in their frames;
Fire safety deficiencies missed or not cited by state surveyors:
* Wall separating personal care area and the nursing home had unsealed
penetrations around pipes above the exit door;
* A resident room door could not be closed and latched at all times.
Source: GAO analysis of federal comparative and corresponding state
surveys.
[End of table]
[End of section]
Appendix III: Comments from the Centers for Medicare & Medicaid
Services:
DEPARTMENT OF HEALTH & HUMAN SERVICES:
Centers for Medicare & Medicaid Service:
Administrator:
Washington, DC 20201:
DATE: JUN 29 2004:
TO: Kathryn G. Allen:
Director, Health Care-Medicaid And Private Health Insurance Issues:
FROM: Mark B. McClellan, MD, PHD:
Administrator:
SUBJECT: General Accounting Office Draft Report: "NURSING HOME FIRE
SAFETY: Recent Fires Highlight Weaknesses in Federal Standards and
Oversight" (GAO-04-660):
Thank you for the opportunity to review and comment on the above
report.
Protecting nursing home residents from fire hazards is an important
goal for CMS. We therefore conducted our own analysis of nursing home
fire risk at the same time as the General Accounting Office (GAO) study
has been underway.
Among the actions we have already initiated as a consequence of our CMS
review are the following:
Five fold Increase in CMS Validation Surveys: We re-prioritized
contract resources within the Survey & Certification budget to increase
in FFY 2005 the number of validation surveys CMS conducts to monitor
the adequacy of state life-safety code surveys. When combined with
additional future actions described later in this letter, we believe we
will substantially address GAO recommendation #1.
Data Improvements: We changed CMS data forms and re-programmed our
automated information systems to ensure that the sprinkler status of
each nursing home is reflected in the electronic information available
to all surveyors. This means that GAO recommendations #2 and #3 have
already been addressed.
Strengthen Review of Waivers: New CMS procedures require that all
requests from nursing homes for any permitted waivers of life-safety
code matters are first reviewed by the CMS regional office (in addition
to state review). This addresses GAO recommendation #4.
Strengthening Fire Protection Standards: Our regulatory agenda now
includes plans to strengthen fire protection standards for nursing
homes. This exceeds the GAO general recommendation #6.
Fire Investigations: We issued new instructions to states and CMS
regional offices to ensure prompt investigation of all fires that
involve injury.
State Up-to-Date Knowledge: We issued to each state agency a complete,
up-to-date set of all national life-safety code manuals to ensure that
states are fully informed of all applicable standards.
We appreciate the added information that GAO has contributed. The GAO
findings, together with other findings from our own review of the
issues, are helping us to develop additional action steps that can
improve the safety of nursing home residents.
The GAO report examines (1) the rationale for not requiring all nursing
homes to have sprinklers and the status of initiatives to change that
requirement, (2) the adequacy of federal tire safety standards for, and
their application to, nursing homes that lack automatic sprinkler
systems, and (3) the effectiveness of state and federal oversight of
nursing home fire safety.
The GAO draft report makes several recommendations to (1) improve CMS
oversight of nursing home tire safety, such as reviewing the
appropriateness of exemptions to federal standards granted to
unsprinklered facilities, and (2) strengthen the fire safety standards
and ensure thorough investigations of any future multiple-death nursing
home fires in order to reevaluate the adequacy of fire safety
standards.
Detailed responses to each of the GAO recommendations are provided
below. We are also providing some technical comments on the report
itself.
Background:
In 2003, 31 residents died in nursing home fires in Hartford, CT and
Nashville, TN. Federal standards did not require either home to have
sprinklers installed. Senators Grassley and Frist asked the GAO to
report on:
* The rationale for not requiring nursing homes to be sprinklered;
* Adequacy of federal fire safety standards for nursing homes that lack
automatic sprinklers;
* Effectiveness of state and federal oversight of fire safety in
nursing homes.
To ensure the health and safety of nursing home residents; the Centers
for Medicare & Medicaid Services (CMS) adopts and enforces standards
that all nursing homes serving Medicare or Medicaid beneficiaries must
meet, and state survey agencies conduct periodic (annual) inspections.
The purpose of these inspections, known as surveys, is to determine
whether nursing homes meet applicable standards. The current standard
is the 2000 edition of the National Fire Protection Association's
(NFPA), Life Safety Code 101 (LSC), as adopted by regulation by CMS.
CMS regional office staff also conduct surveys on a sample of nursing
homes within 60 days of a state survey, for the purpose of assessing
the adequacy of the state survey. This quality control function is
called a "CMS validation survey."
Not all nursing homes are required to have sprinklers installed. The
LSC makes exceptions for facilities that have been constructed of
certain non-combustible or fire resistive materials and are considered
to meet the requirements of the LSC by CMS. Even so, we encourage all
facilities to be sprinklered because there has never been a multiple
death fire in a fully sprinklered health care facility.
GAO Recommendation:
1) Ensure that CMS regional offices fully comply with the statutory
requirement to conduct annual federal monitoring surveys by including
an assessment of the tire safety component of states' standard surveys,
with an emphasis on unsprinklered homes.
Comment:
By the end of FFY 2005 CMS will have completed life safety code
validation (monitoring) surveys in sufficient numbers to fulfill the
statutory requirement, with priority attention to unsprinklered
facilities (estimated to be about 30% of all facilities).
We have already re-prioritized contract resources within the Survey &
Certification budget to accomplish a live-fold increase in the number
of validation surveys CMS conducts in FFY 2005 to monitor the adequacy
of state life-safety code surveys. CMS regional offices are in the
process of redesigning workplans to accomplish the remainder of the
added validation surveys that will be required to address the above
recommendation.
We will need to phase in some of the added work in order to stay within
existing resources and avoid too much impairment of our ability to
fulfill other responsibilities as we seek to accomplish the substantial
increase in CMS life safety code validation surveys that the GAO report
recommends. In such phase-in efforts, we will follow the GAO
recommendation to give priority to unsprinklered facilities.
2) Ensure that data on sprinkler coverage in nursing homes are
consistently obtained and reflected in the CMS database.
Comment:
We concur and have already undertaken such action. We have implemented
changes to all Fire Safety Survey Report forms used in the LSC surveys
to capture the status of sprinkler systems in all health care provider
types, not limited to nursing homes. Currently the revised forms are
available to all surveyors on the CMS forms website. (See
www.cms.hhs.gov/forms). Further, we have rc-programmed the automated
information systems operated by CMS to ensure that the sprinkler status
of each nursing home is reflected in the electronic information
available to all surveyors.
GAO Recommendation:
3) Until sprinkler coverage data are routinely available in CMS's
database, work with state survey agencies to identity the extent to
which each nursing home is sprinklered or not sprinklered.
Comment:
We concur and have already undertaken such action. CMS estimates that
70% of the nation's nursing homes are fully sprinklered. This
information will be confirmed on an individual basis during facility
surveys. Upon confnnation by survey, this information will be entered
into CMS electronic data systems as it is obtained.
GAO Recommendation:
4) On an expedited basis, review all waivers and FSES assessments for
homes that are not fully sprinklered to determine their
appropriateness.
Comment:
We concur and have already taken such action. CMS has instructed
Regional Offices and State Agencies to submit all waiver requests from
facilities to the Regional Offices for review and disposition. As
facilities seek to renew their waivers, this means that over the course
of a year almost all waivered facilities will be subject to this higher
level of review. Further, we will separately examine any existing
waiver that is not subject to annual review.
CMS has also instructed the Regional Offices and State Agencies to
submit FSES assessments on an annual basis to the Regional Office. (See
memo S&C-04-33 dated 5/13/04 and State Operations Manual sections 2470,
2478, and 7410F.)
GAO Recommendation:
5) Make information on fire safety deficiencies available to the public
via the Nursing Home Compare Web site, including information on whether
a home has automatic sprinklers.
Comment:
We concur and have already made such arrangements. LSC deficiencies and
information concerning whether a nursing home is sprinklered will be
included on the Nursing I Tome Compare Web site as data becomes
available. We expect that LSC deficiency information will be available
on line in June-August, 2005 and sprinkler information will be
available soon thereafter.
GAO Recommendation:
6) Work with the NFPA to strengthen tire safety standards for
unsprinklered nursing homes, such as requiring smoke detectors in
resident rooms, exploring the feasibility of requiring sprinklers in
all nursing homes, and developing a strategy for financing such
requirements.
Comment:
We have placed on our regulatory agenda plans to strengthen fire
protection standards for nursing homes. In particular, we think it is
important that every, resident room have a fire and smoke detector
(battery-operated or hard-wired). We will pursue a regulatory change to
this effect, as well as explore the feasibility of further action
(including the type of exploration suggested by GAO).
In addition, CMS has membership on several NFPA committees including:
1) Healthcare, 2) Board and Care, and 3) Technical Correlating of NFPA
99, Health Care Facilities. These committees oversee changes to several
chapters of the Life Safety Code and related documents. We will
continue to work with NFPA to strengthen fire safely standards in all
health care facilities.
GAO Recommendation:
7) Ensure that thorough investigations are conducted following
multiple-death nursing home tires so that fire safety standards can be
reevaluated and modified where appropriate.
Comment:
We have already instructed State Agencies to consider nursing home
fires with injuries to be investigated using CMS complaint policies and
procedures for the level of "immediate and serious jeopardy" requiring
investigation within 2 days. (See memo S&C-04-23 dated 3/11/04).
Regional Offices and State Agencies communicate findings with each
other to determine an appropriate response to the situation.
Information concerning these complaints will also be entered into the
complaint database (ASPEN Complaint/Incidents Tracking System) for
tracking purposes.
[End of section]
FOOTNOTES
[1] Federal fire safety standards for nursing homes are based on
requirements developed and periodically updated by the National Fire
Protection Association, a nonprofit membership organization.
[2] While cooking and dryers were the leading causes of fires, resident
deaths were largely due to smoking, and resident rooms were the leading
areas of fire origin. These data, published by the National Fire
Protection Association, are based on fires reported to municipal fire
departments.
[3] Fire safety experts often focus on fires that result in multiple-
deaths (three or more) because they may suggest the need to reevaluate
the adequacy of the standards.
[4] Both NFPA and CMS refer to fire safety standards as the "Life
Safety Code." The purpose of the code is to provide minimum
requirements for the design, operation, and maintenance of buildings
and structures for minimizing danger to life from fire, including
smoke, fumes, or panic. The federal code is based on NFPA's life safety
code, known as NFPA 101. Throughout this report, we use the term
federal fire safety standards when referring to the Life Safety Code.
[5] CMS proposed updating federal fire safety standards in 1990, but no
changes were adopted because of the estimated cost of implementing some
of the new requirements.
[6] Under federal law, CMS is generally required to specify in
regulation which provisions of the NFPA fire safety code are applicable
to nursing homes. See 42 U.S.C. § 1395i-3(d)(2)(B) (2000). Until 2003,
CMS adopted the NFPA standards without any changes. In adopting NFPA's
2000 code, however, CMS modified the application of the code's roller
latch requirement in unsprinklered buildings and strengthened
requirements for emergency lighting.
[7] See 42 U.S.C. § 1395i-3(g)(2) and 42 U.S.C. § 1396r(g)(2). Among
other things, these statutory provisions require standard surveys to
include assessments of the physical environment, which is defined by
CMS to include fire safety standards. See 42 C.F.R. § 483.70(a) (2003).
[8] See 42 C.F.R. § 488.110. CMS guidance also contains a specific
reference to the fire safety component of a standard survey.
[9] Most fire safety deficiencies identified during routine inspections
are cited at less than actual harm because actual harm is reserved for
fire-related injuries. Nationwide, only 43 deficiencies on current fire
safety surveys as of December 1, 2003, were cited at the actual harm or
higher level. A somewhat higher proportion of deficiencies were cited
at the D-F level (57 percent) than at the A-C level (43 percent).
[10] The institute was formerly known as the National Bureau of
Standards.
[11] Point values are assigned to various fire safety features, such as
sprinklers, smoke detectors, construction types, and corridor doors. A
facility passes FSES if its point score meets or exceeds that of the
hypothetical facility.
[12] See 42 U.S.C. § 1395i-3(g)(3) and 42 U.S.C. § 1396r(g)(3).
[13] The monitoring surveys must be sufficient in number to allow
inferences about the adequacy of the states' surveys. CMS is required
to conduct monitoring surveys using the same protocols as states are
required to use in their surveys. In addition, CMS may determine that a
nursing home does not meet applicable requirements, including fire
safety requirements.
[14] Various authorities, including the state fire marshal's office,
the local fire departments, and the state survey agencies, conducted
investigations of these two nursing home fires.
[15] On March 11, 2004, CMS issued new guidance outlining procedures to
be followed by state survey agencies, CMS regional offices, and the CMS
central office in the event of a fire resulting in serious injury or
death in a Medicare-or Medicaid-certified health facility. The guidance
directs the state survey agency to inform the CMS regional office and
to conduct an on-site fire safety survey of the facility as part of its
investigation. Regional office and central office staff are available
to consult and may, at their discretion, accompany state survey agency
staff during their on-site survey. The CMS central office is directed
to consult with the regional office following the state survey agency
investigation to determine if further investigation is warranted
concerning the adequacy and application of current standards.
[16] States can enforce such requirements because facilities must
obtain a state license in order to operate. During the course of our
work, we contacted state survey agencies and fire marshals in several
states that were reported to have required existing nursing homes to
install sprinklers. We were able to confirm that the following states
had required homes to be retrofitted with sprinklers: Ohio, Utah,
Virginia, Vermont, and West Virginia. In addition, a 1990 New Jersey
statute required many, but not all, existing homes to install
sprinklers.
[17] In Arkansas and Mississippi, nursing home fires in 1990 and 1995,
respectively, resulted in the deaths of three residents in each
facility.
[18] To determine the sprinkler status of facilities, Connecticut state
survey officials relied on data collected during prior surveys and, if
there was a question, sent a surveyor out to the home. Of Connecticut's
254 nursing homes, 206 are fully sprinklered, 31 are partially
sprinklered, and 17 have no sprinklers. In contrast, state survey
officials in Tennessee visited each nursing home. Of Tennessee's 343
nursing homes, 229 are fully sprinklered, 90 are partially sprinklered,
and 24 have no sprinklers.
[19] In the NFPA code development process, the proposal will be
reviewed again in November 2004 and presented to the NFPA membership in
June 2005.
[20] To update federal fire safety standards, CMS must publish and
solicit comments on the proposed new standards in the Federal Register.
After reviewing public comments, CMS publishes a final version of its
standards with an effective date. The process of adopting NFPA's 2000
standards in 2003 took CMS about 16 months.
[21] Although it may vary from state to state, a portion of the cost of
installing sprinklers, equal to a home's percentage of Medicaid
beneficiaries, may be eligible for reimbursement as a capital
improvement under the Medicaid program.
[22] For example, a partially sprinklered home could have sprinklers in
hazardous areas only (laundry rooms and storage areas), lack sprinklers
only in areas such as attics or closets in residents' rooms, or have
sprinklers in only one wing of a multiwing facility.
[23] Neither of the informal CMS or AHCA surveys conducted after the
2003 fires asked for data on partially sprinklered homes. CMS asked for
the number of sprinklered and unsprinklered homes in each state, while
the AHCA survey of its state affiliates requested data on the
proportion of homes fully sprinklered. CMS obtained information for 30
states, and 33 state affiliates responded to the AHCA survey. Since
AHCA represents primarily for-profit nursing homes, its state
affiliates' survey excludes many not-for-profit nursing homes.
[24] NFPA was on-site following the Harford fire but did not conduct a
full investigation or publish its own investigation report. Although
the Connecticut and Tennessee state survey agencies each conducted
complaint investigations after the fires in their respective states,
the objective of such complaint surveys is to determine whether the
homes had failed to comply with any federal fire safety standards, not
to assess the adequacy of the standards.
[25] In contrast, the presence of smoke detectors in resident rooms
made a significant difference in a December 2003 nursing home fire in
Nevada. A resident smoking in bed while on oxygen started a fire at
2:20 a.m. Staff were alerted by the in-room smoke detector, and the
fire was extinguished before it caused a significant amount of damage.
While the resident who started the fire subsequently died as a result
of the fire, no other deaths were reported. Although the facility was
equipped with automatic sprinklers, the buildup of heat from the fire
had not reached a level sufficient to activate the sprinklers.
[26] Although it was not enacted, the bill originally required all
unsprinklered nursing homes to install smoke detectors in resident
rooms if a sprinkler system had not been installed within 1 year of the
legislation's effective date.
[27] Because the facility was originally certified when the 1967
federal fire safety standards were in effect, it was grandfathered and
continued to be surveyed under the 1967 standards.
[28] Even though the fire safety standards call for closing all doors
in the event of a fire, an NFPA official acknowledged it can be
difficult for staff to abandon a resident who cannot be evacuated from
the room of fire origin in order to focus on the safety of other
residents.
[29] Multiple-death nursing home fires investigated by CMS, NFPA, or
both included fires in Ocean Springs, Mississippi (1995); Dardanelle,
Arkansas (1990); Norfolk, Virginia (1989); Memphis, Tennessee (1988);
and Little Rock, Arkansas (1984).
[30] An NFPA official told us that the organization did work on-site
with Hartford authorities but did not conduct a full investigation or
issue a report. However, NFPA did publish an article on the fire in the
May/June 2003 Fire Journal.
[31] We focused on examining waivers and FSES results in four states
reported by CMS to have high proportions of unsprinklered nursing
homes: Arkansas, Iowa, Pennsylvania, and Wisconsin. We examined waiver
and FSES documentation for selected facilities that were not fully
sprinklered and had deficiencies that could contribute to the spread of
smoke, the factor that led to most of the deaths in the Hartford and
Nashville nursing home fires.
[32] CMS officials disagreed with this characterization, emphasizing
that a waiver is granted to a specific home and therefore is not
applicable to other nursing homes. However, we identified CMS program
guidance that set out criteria for granting specific types of waivers,
demonstrating that waivers have been used to set across-the-board
nursing home fire safety standards.
[33] Construction type refers to whether combustible or noncombustible
materials were used to build a facility and to the number of floors. An
unsprinklered facility that is required to be fully sprinklered might
be cited for a deficiency of construction standards, sprinkler
standards, or both.
[34] "Protected" refers to construction materials designed or rated to
withstand fire for a minimum of 1 hour.
[35] The type of construction was unclear from the available
documentation. While the statement of deficiencies from the facility
survey indicated the one-story facility was of protected wood-frame
construction, the FSES documentation identified it as unprotected wood-
frame construction. According to CMS guidance, no waiver of sprinkler
requirements may be granted for unprotected wood construction.
[36] This facility was of unprotected noncombustible construction,
requiring sprinkler protection according to federal standards.
[37] During the prefire survey, Connecticut surveyors reviewed the
records of 25 residents, including smokers and non-smokers and
residents with and without cognitive impairments. Following the fire,
approximately 48 residents were a part of the state's investigation--
focusing specifically on residents who smoked and had cognitive
impairments.
[38] While not a federal requirement, Connecticut and Tennessee fire
safety surveyors routinely pull the fire alarm during fire safety
surveys to determine if staff follow the home's fire plan.
[39] Tennessee survey agency officials said that their investigation
was limited because the fire was treated as a crime scene An official
with the Nashville Fire Department told us that the facility was
treated as a crime scene with restricted access for less than 24 hours.
Once the restriction was lifted, he indicated, nothing prevented the
state survey agency from following up on concerns identified during its
walk-through.
[40] Federal fire safety survey protocols do not require state
surveyors to test the ventilation shut-off safety feature during fire
safety surveys by pulling the fire alarm to see if ventilation systems
shut down as required. Because Tennessee typically only checks such a
fire safety feature on initial surveys, it may not have been reviewed
by the state survey agency since the home began operating in 1967.
[41] The nursing home's fire plan also called for staff to shut off
blowers, fans, and air conditioners during a fire to prevent the spread
of fire and smoke. In addition, staff were expected to prevent
residents from reentering the building during a fire. With the
exception of the resident who died in the room where the fire began,
all the victims died as a result of smoke inhalation, and one resident
was severely injured upon reentering the building after having been
safely evacuated. Because of the limited investigation, it is unclear
to what extent the nursing home staff followed these two fire plan
procedures designed to minimize the loss of life.
[42] Because actual harm is reserved for fire-related injuries, most
fire safety deficiencies are cited at less than actual harm. Of the
approximately 39,000 fire safety deficiencies cited nationally during
the most recent nursing home surveys, 19 states cited a total of 43
deficiencies at the level of actual harm or higher.
[43] We excluded 12 states and the District of Columbia from our
analysis because they had fewer than 100 homes, and even a small number
of homes with fire safety deficiencies produces a relatively large
percentage of homes with such deficiencies. The 12 states excluded were
Alaska, Delaware, Hawaii, Idaho, Nevada, New Hampshire, New Mexico,
North Dakota, Rhode Island, Utah, Vermont, and Wyoming.
[44] As a result of a CMS regional office investigation, a state
official was ultimately charged with falsifying fire safety survey
forms. While the official admitted to misrepresenting information on
fire safety survey forms, a federal jury acquitted her in February
2004. According to a CMS regional office official, criminal intent
could not be proven.
[45] In some cases, state surveyors identified deficiencies that
federal surveyors did not cite. Several regions stated that this
situation typically occurs when homes correct deficiencies identified
by the state before federal surveyors arrive to conduct their survey.
[46] Our examination of quality-of-care comparative surveys has
consistently found that federal surveyors find serious deficiencies
missed or not cited by state surveyors in a sizeable percentage of
surveys conducted. See U.S. General Accounting Office, Nursing Home
Quality: Prevalence of Serious Problems, While Declining, Reinforces
Importance of Enhanced Oversight, GAO-03-561 (Washington, D.C.: July
15, 2003).
[47] Homes completely lacking fire alarm systems are to be cited for
immediate jeopardy.
[48] A Connecticut survey agency official stated that missed
deficiencies can also be attributed to the lack of surveyor training
and the infrequency of fire safety training courses offered by CMS. In
addition, while we did not look at this issue in depth, officials in
several regional offices stated that inadequate surveyor training and
lack of experience may explain some of the interstate variability in
reported fire safety deficiencies.
[49] However, in 22 states, fewer than 5 percent of homes have such
quick surveys.
[50] See http://www.medicare.gov/NHCompare.
[51] See http://app2.health.state.pa.us/commonpoc/nhlocatorie.asp.
[52] A federal monitoring survey may be either comparative or
observational. A comparative survey is conducted within 2 months of the
state survey and provides an independent evaluation of whether state
surveyors identified all deficiencies of federal standards and an
observational survey allows federal surveyors who accompany a state
survey team to observe the team's performance.
[53] Some regions conducted informal fire safety training surveys with
state surveyors. In addition, while one region does not conduct fire
safety comparative surveys, its fire safety specialist does cite fire
safety deficiencies noted while on-site during quality-of-care
comparative surveys.
[54] There is no data field in OSCAR to capture the sprinkler status of
nursing homes. Another CMS database has the capacity to store nursing
home sprinkler coverage information; however, CMS does not require
states to report such data.
[55] One CMS regional office did not require a particular state to
submit waiver requests or FSES results because the state was operating
under a later edition of the fire safety code. From February 1997
through September 2003, CMS allowed the state to implement the 1994
NFPA life safety code in lieu of the older federal standards, which
were based on NFPA's 1985 code. During these 6 years, there was no
federal oversight of the state's enforcement of fire safety standards
for nursing homes.
[56] Three of the specialists in these five regions devote all of their
time to fire safety oversight activities while the other two are part-
time fire safety specialists. As of April 2004, a sixth region was
working to fill a vacancy due to the retirement of its fire safety
specialist. A civil engineer is trained in the design and construction
of public works, including buildings, roads, and bridges.
[57] Our prior work found that nursing home records can contain
misleading information or omit important data, making it difficult for
surveyors to identify deficiencies during their on-site reviews. See
U.S. General Accounting Office, California Nursing Homes: Care
Problems Persist Despite Federal and State Oversight, GAO/HEHS-98-202
(Washington, D.C.: July 27, 1998).
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