Centers for Medicare and Medicaid Services Emergency Preparedness Regulations, Standards and Guidance

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1 Centers for Medicare and Medicaid Services Emergency Preparedness Regulations, Standards and Guidance Physical Environment State Operation Manual Guidance to Surveyors for Long Term Care Facilities The facility must be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel and the public (a) Life Safety From Fire (a)(1) Except as otherwise provided in this section (a)(1)(i) the facility must meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. The Director of the Office of the Federal Register has approved the NFPA edition of the Life Safety Code, issued January 14, 2000, for incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. A copy of the Code is available for inspection at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call , or go to Copies may be obtained from the National Fire Protection Association, 1 Batterymarch Park, Quincy, MA If any changes in this edition of the Code are incorporated by reference, CMS will publish notice in the FEDERAL REGISTER to announce the changes (a)(1)(ii) Chapter , exception number 2 of the adopted edition of the LSC does not apply to long-term care facilities (a)(2) After consideration of State survey agency findings, CMS may waive specific provisions of the Life Safety Code which, if rigidly applied, would result in unreasonable hardship upon the facility, but only if the waiver does not adversely affect the health and safety of the patients (a)(3) The provisions of the Life Safety Code do not apply in a State where CMS finds, in accordance with applicable provisions of sections 1819(d)(2)(B)(ii) and 1919(d)(2)(B)(ii) of the Act, that a fire and safety code imposed by State law adequately protects patients, residents and personnel in long term care facilities (a)(4) Beginning March 13, 2006, a long-term care facility must be in compliance with Chapter , Emergency Lighting.

2 483.70(a)(5) Beginning March 13, 2006, Chapter , exception number 2 does not apply to long-term care facilities (a)(6) Notwithstanding any provisions of the 2000 edition of the Life Safety Code to the contrary, a long-term care facility may install alcohol-based hand rub dispensers in its facility if (a)(6)(i) Use of alcohol-based hand rub dispensers does not conflict with any State or local codes that prohibit or otherwise restrict the placement of alcohol-based hand rub dispensers in health care facilities; (a)(6)(ii) The dispensers are installed in a manner that minimizes leaks and spills that could lead to falls; (a)(6)(iii) The dispensers are installed in a manner that adequately protects against access by vulnerable populations; and (a)(6)(iv) The dispensers are installed in accordance with chapter or chapter of the 2000 edition of the Life Safety Code, as amended by NFPA Temporary Interim Amendment 00-1(101), issued by the Standards Council of the National Fire Protection Association on April 15, The Director of the Office of the Federal Register has approved NFPA temporary interim Amendment 00-1(101) for incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. A copy of the amendment is available for inspection at CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD and at the Office of the Federal Register, 800 North Capitol Street NW, Suite 700, Washington, DC. Copies may be obtained from the National Fire Protection Association, 1 Battery March Partk, Quincy, MA If any additional changes are made to this amendment, CMS will publish notice in the Federal Register to announce the changes (a)(7) A long-term care facility must: (a)(7)(i) Install battery-operated smoke detectors in resident sleeping rooms and public areas by May 24, (a)(7)(ii) Have a program for testing, maintenance, and battery replacement to insure the reliability of the smoke detectors (a)(7)(iii) Exception: (a)(7)(iii)(A) The facility has a hard-wired AC smoke detection system in patient rooms and public areas that is installed, tested, and maintained in accordance with NFPA 72, National Fire Alarm Code, for hard-wired AC systems; or (a)(7)(iii)(B) The facility has a sprinkler system throughout that is installed, tested, and maintained in accordance with NFPA 13, Automatic Sprinklers. Interpretive Guidelines: (a) A waiver of specific provisions of the Life Safety Code is reviewed each time a facility is certified. The State fire authority will determine if the waiver continues to be justified, in that compliance with the requirement would result in an unreasonable hardship upon the facility and does not adversely affect the health and safety of residents or personnel. The State fire authority will forward its findings and recommendation as soon as possible to the State survey agency which will forward it to the CMS RO for a decision on granting a waiver.

3 Procedures: (a) The survey for safety from fire is normally conducted by the designated State fire authority. The State agency must establish a procedure for the State fire authority to notify them whether the facility is or is not in compliance with the requirement. If the survey team observes fire hazards or possible deficiencies in life safety from fire, they must notify the designated State fire authority or the RO Physical Environment The facility must be designed, constructed, equipped, and maintained to protect the health and safety of residents, personnel and the public (a) Life Safety From Fire (a)(1) Except as otherwise provided in this section (a)(1)(i) the facility must meet the applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association. The Director of the Office of the Federal Register has approved the NFPA edition of the Life Safety Code, issued January 14, 2000, for incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. A copy of the Code is available for inspection at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call , or go to Copies may be obtained from the National Fire Protection Association, 1 Batterymarch Park, Quincy, MA If any changes in this edition of the Code are incorporated by reference, CMS will publish notice in the FEDERAL REGISTER to announce the changes (a)(1)(ii) Chapter , exception number 2 of the adopted edition of the LSC does not apply to long-term care facilities (a)(2) After consideration of State survey agency findings, CMS may waive specific provisions of the Life Safety Code which, if rigidly applied, would result in unreasonable hardship upon the facility, but only if the waiver does not adversely affect the health and safety of the patients (a)(3) The provisions of the Life Safety Code do not apply in a State where CMS finds, in accordance with applicable provisions of sections 1819(d)(2)(B)(ii) and 1919(d)(2)(B)(ii) of the Act, that a fire and safety code imposed by State law adequately protects patients, residents and personnel in long term care facilities (a)(4) Beginning March 13, 2006, a long-term care facility must be in compliance with Chapter , Emergency Lighting (a)(5) Beginning March 13, 2006, Chapter , exception number 2 does not apply to long-term care facilities (a)(6) Notwithstanding any provisions of the 2000 edition of the Life Safety Code to the contrary, a long-term care facility may install alcohol-based hand rub dispensers in its facility if (a)(6)(i) Use of alcohol-based hand rub dispensers does not conflict with any State or local codes that prohibit or otherwise restrict the placement of alcohol-based hand rub dispensers in health care facilities;

4 483.70(a)(6)(ii) The dispensers are installed in a manner that minimizes leaks and spills that could lead to falls; (a)(6)(iii) The dispensers are installed in a manner that adequately protects against access by vulnerable populations; and (a)(6)(iv) The dispensers are installed in accordance with chapter or chapter of the 2000 edition of the Life Safety Code, as amended by NFPA Temporary Interim Amendment 00-1(101), issued by the Standards Council of the National Fire Protection Association on April 15, The Director of the Office of the Federal Register has approved NFPA temporary interim Amendment 00-1(101) for incorporation by reference in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. A copy of the amendment is available for inspection at CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD and at the Office of the Federal Register, 800 North Capitol Street NW, Suite 700, Washington, DC. Copies may be obtained from the National Fire Protection Association, 1 Battery March Partk, Quincy, MA If any additional changes are made to this amendment, CMS will publish notice in the Federal Register to announce the changes (a)(7) A long-term care facility must: (a)(7)(i) Install battery-operated smoke detectors in resident sleeping rooms and public areas by May 24, (a)(7)(ii) Have a program for testing, maintenance, and battery replacement to insure the reliability of the smoke detectors (a)(7)(iii) Exception: (a)(7)(iii)(A) The facility has a hard-wired AC smoke detection system in patient rooms and public areas that is installed, tested, and maintained in accordance with NFPA 72, National Fire Alarm Code, for hard-wired AC systems; or (a)(7)(iii)(B) The facility has a sprinkler system throughout that is installed, tested, and maintained in accordance with NFPA 13, Automatic Sprinklers. Interpretive Guidelines: (a) A waiver of specific provisions of the Life Safety Code is reviewed each time a facility is certified. The State fire authority will determine if the waiver continues to be justified, in that compliance with the requirement would result in an unreasonable hardship upon the facility and does not adversely affect the health and safety of residents or personnel. The State fire authority will forward its findings and recommendation as soon as possible to the State survey agency which will forward it to the CMS RO for a decision on granting a waiver. Procedures: (a) The survey for safety from fire is normally conducted by the designated State fire authority. The State agency must establish a procedure for the State fire authority to notify them whether the facility is or is not in compliance with the requirement. If the survey team observes fire hazards or possible deficiencies in life safety from fire, they must notify the designated State fire authority or the RO (h) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.

5 The facility must (h)(1) Establish procedures to ensure that water is available to essential areas when there is a loss of normal water supply; Interpretive Guidelines: (h)(1) The facility should have a written protocol which defines the source of water, provisions for storing the water, both potable and non-potable, a method for distributing water, and a method for estimating the volume of water required. Procedures (h)(1) During the entrance conference, ask the administrator the facility s procedure to ensure water availability (l) Clinical Records (1) The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are-- (i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized. Intent (l)(1) To assure that the facility maintains accurate, complete and organized clinical information about each resident that is readily accessible for resident care. Interpretive Guidelines (l)(1) A complete clinical record contains an accurate and functional representation of the actual experience of the individual in the facility. It must contain enough information to show that the facility knows the status of the individual, has adequate plans of care, and provides sufficient evidence of the effects of the care provided. Documentation should provide a picture of the resident s progress, including response to treatment, change in condition, and changes in treatment. The facility determines how frequently documentation of an individual s progress takes place apart from the annual comprehensive assessment, periodic reassessments when a significant change in status occurs, and quarterly monitoring assessments. Good practice indicates that for functional and behavioral objectives, the clinical record should document change toward achieving care plan goals. Thus, while there is no right frequency or format for reporting progress, there is a unique reporting schedule to chart each resident s progress in maintaining or improving functional abilities and mental and psychosocial status. Be more concerned with whether the staff has sufficient progress information to work with the resident and less with how often that information is gathered. In cases in which facilities have created the option for an individual s record to be maintained by computer, rather than hard copy, electronic signatures are acceptable. In cases when such attestation is done on computer records, safeguards to prevent unauthorized access, and reconstruction of information must be in place. The following guideline is an example of how such a system may be set up: There is a written policy, at the health care facility, describing the attestation policy(ies) in force at the facility. The computer has built-in safeguards to minimize the possibility of fraud. Each person responsible for an attestation has an individualized identifier.

6 The date and time is recorded from the computer s internal clock at the time of entry An entry is not to be changed after it has been recorded. The computer program controls what sections/areas any individual can access or enter data, based on the individual s personal identifier (and, therefore his/her level of professional qualifications). Procedures (l)(1) In reviewing sampled residents clinical records: Is there enough record documentation for staff to conduct care programs and to revise the program, as necessary, to respond to the changing status of the resident as a result of interventions? How is the clinical record used in managing the resident s progress in maintaining or improving functional abilities and mental and psychosocial status? (l)(5) the clinical record must contain (i) Sufficient information to identify the resident; (ii) A record of the resident s assessments; (iii) The plan of care and services provided; (iv) The results of any preadmission screening conducted by the State; and (v) progress notes (m) Disaster and Emergency Preparedness (m)(1) The facility must have detailed written plans and procedures to meet all potential emergencies and disasters, such as fire, severe weather, and missing residents (m)(2) The facilities must train all employees in emergency procedures when they begin to work in the facility, periodically review the procedures with existing staff, and carry out unannounced staff drills using those procedures. Interpretive Guidelines (m) The facility should tailor its disaster plan to its geographic location and the types of residents it serves. Periodic review is a judgment made by the facility based on its unique circumstances changes in physical plant or changes external to the facility can cause a review of the disaster review plan The purpose of a staff drill is to test the efficiency, knowledge, and response of institutional personnel in the event of an emergency. Unannounced staff drills are directed at the responsiveness of staff, and care should be taken not to disturb or excite residents. Procedures; (m) Review and disaster and emergence preparedness plan, including plans for natural or man made disasters Probes: (m) Ask two staff persons separately (e.g., nurse aide, housekeeper, maintenance person) and the charge nurse: If the fire alarm goes off, what do you do? If you discover that a resident missing, what do you do? What would you do if you discovered a fire in a resident s room? Where are fire alarms and fire extinguisher(s) located on this unit?

7 How do you use the fire extinguisher? NOTE: Also, construct probes relevant to a geographically specific natural emergencies (e.g., for areas prone to hurricanes, tornadoes, earthquakes, or floods, each of which may require a different response).