Nursing Home Fire Safety:

Recent Fires Highlight Weaknesses in Federal Standards and Oversight

GAO-04-660: Published: Jul 16, 2004. Publicly Released: Jul 16, 2004.

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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 for Executive Action

  1. Status: Closed - Implemented

    Comments: CMS issued regulations effective May 24, 2005 requiring nursing facilities to install smoke detectors in resident rooms and public areas if they do not have a sprinkler system installed throughout the facility or a hard-wired smoke detection system in those areas. Facilities have one year--until May 24, 2006--to come into compliance with this requirement. In addition, in July 2005, the National Fire Protection Association approved a revision to the 2006 Life Safety Code which will require the installation of automatic sprinkler systems in all existing facilities.

    Recommendation: 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, the Administrator of CMS should work with the National Fire Protection Association 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.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

  2. Status: Closed - Implemented

    Comments: The CMS Nursing Home Compare web site now contains information on nursing homes' fire safety deficiencies as well as whether the home has automatic sprinklers. According to CMS, this information was posted on the web site as of October 2006.

    Recommendation: 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, the Administrator of CMS should 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.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

  3. Status: Closed - Implemented

    Comments: CMS instructed its regional offices and state survey agencies to submit all waiver requests to the regional offices for disposition. All waivered facilities will receive this higher level of review over the course of the year as they receive their annual survey and seek to renew their waivers. In addition, CMS has instructed state survey agencies to submit Fire Safety Evaluation System (FSES) assessments to the CMS regional offices for review on an annual basis. CMS officials expect to complete their reviews of life safety code waivers and FSES assessments by the end of 2005. According to an August 2006 update, Jim Merrill of CMS indicated that CMS had completed its waiver and FSES review and noted that the number of homes using FSES had dropped significantly as a result of the review.

    Recommendation: 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, the Administrator of CMS should on an expedited basis, review all waivers and Fire Safety Evaluation System assessments for homes that are not fully sprinklered to determine their appropriateness.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

  4. Status: Closed - Implemented

    Comments: CMS has contacted state survey agencies and collected data on the sprinkler status of approximately 95 percent of nursing homes. This data is being validated during each nursing home's next annual survey. In an update obtained in August 2006, Jim Merrill of CMS indicated that the agency had collected data on the sprinkler status of 99+ percent of nursing homes.

    Recommendation: 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, the Administrator of CMS should 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.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

  5. Status: Closed - Implemented

    Comments: CMS made changes to the Fire Safety Survey Report forms used in the Life Safety Code Surveys to capture the sprinkler status of facilities. The revised forms were made available to all surveyors by means of the CMS web site. In addition, CMS officials report that its automated information systems have been reprogrammed to ensure that the sprinkler status of each nursing home is reflected in its Online Survey, Certification and Reporting (OSCAR) database. Data is being gathered and verified as each nursing home undergoes its annual survey. By early to mid-2006, data on the sprinkler status of all nursing homes should be in OSCAR. In an August 2006 update, Jim Merrill of CMS indicated that this effort was virtually complete with the sprinkler status of 99+ percent of nursing homes ascertained during routine surveys

    Recommendation: 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, the Administrator of CMS should ensure that data on sprinkler coverage in nursing homes are consistently obtained and reflected in the CMS database.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

  6. Status: Closed - Implemented

    Comments: CMS regional offices now routinely include fire safety as part of the statutory requirement to conduct annual federal monitoring surveys in at least 5 percent of surveyed nursing homes. CMS expects to have completed life safety code validation surveys in sufficient numbers to meet the statutory requirement by the end of fiscal year 2005, giving priority to conducting such surveys in unsprinklered facilities. In Dec. 2005, we reported that CMS completed a total of 859 fire safety comparative surveys in FY 2005, exceeding the statutory requirement of 5 percent by about 40 surveys (GAO-06-117, p. 29).

    Recommendation: 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, the Administrator of CMS should 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.

    Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

  7. Status: Closed - Implemented

    Comments: CMS developed and issued a standardized procedure to ensure that both state survey agencies and its own staff take appropriate action to investigate fires that result in serious injury or death. CMS directed state survey agencies to investigate any nursing home fire that results in injury using CMS complaint procedures for the level of "immediate and serious jeopardy" requiring investigation within 2 days. Information regarding these incidents will be tracked in CMS's complaint database.

    Recommendation: 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, the Administrator of CMS should 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 Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

 

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