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. The agency has the authority to modify or make exceptions to the  NFPA standards but has rarely done so. 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.  A standard survey is conducted by state survey agency personnel and  entails an assessment of both federal quality of care and fire safety  requirements. 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). States are required to  enter information about surveys and complaint investigations, including  the scope and severity of deficiencies identified, in CMS’s OSCAR  database.
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. 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. 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.

		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. The federal monitoring surveys are  required to include an assessment of the fire safety component of states’  standard surveys. 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. 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.

	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.
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. From  1990 through 2002, there were no major nursing home fires with such a  high number of fatalities.
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. 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. 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. 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.
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. Furthermore, CMS as well as states lack  complete and reliable data on the extent to which homes are partially  sprinklered. 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. 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.
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. 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.
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.
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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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.
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. 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.
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. 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. Figure 2 shows the considerable  variation that exists in states with at least 100 nursing homes.
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.”
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. 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. 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.
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. 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).  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.
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. 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. 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. 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. 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.
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. 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. 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. 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.
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.

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

	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.
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.
Depending on construction type and number of  stories, sprinklers required throughout home.
Approximately 95 percent of the building was not  protected by an automatic sprinkler system, even  though the building construction type required  complete sprinkler protection.
Depending on construction type and number of  stories, sprinklers required throughout home.
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.
Sprinkler system is operational and properly  maintained.
Sprinkler in storage area was obstructed.
Doors are provided with latching devices, which  will keep the doors tightly closed in their frames.
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.
Vertical openings or penetrations between  floors are required to be protected (fire-rated  and resistant to the passage of smoke).
Linen chute did not have a fire-resistance rating of  at least 1 hour.
Fire drills are conducted quarterly on all shifts,  and all staff are familiar with facility fire plan and  appropriate procedures.
Home failed to conduct fire drill on third shift (from  11 p.m. to 7 a.m.
Depending on construction type and number of  stories, sprinklers required throughout home.
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.
Sprinkler system is operational and properly  maintained.
Home failed to properly maintain sprinkler system.
Home did not replace six sprinklers on known  recall list.
Hazardous areas have an approved fire  extinguishing system or a 1-hour fire-rated  construction. Doors shall be self-closing.
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.
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.
Smoke barrier above the ceiling at the corridor  doors was open the entire width of corridor.
Doors are provided with latching devices, which  will keep the doors tightly closed in their frames.
Corridor doors separating the second floor dining  room from the corridor had been removed.
Vertical openings or penetrations between  floors are required to be protected (fire-rated  and resistant to the passage of smoke).
Linen chute discharge door was not self-closing  and remained open.
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.
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.
Fire drills are conducted quarterly on all shifts,  and all staff are familiar with facility fire plan and  appropriate procedures.
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.
Sprinkler system is operational and properly  maintained.
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.
HVAC system shall comply with fire safety  standards and be installed in accordance with  the manufacturer’s specifications.
Corridor was used as a part of the return air  system, which would allow the spread of smoke to  resident rooms during a fire.
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.
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.
Sprinkler system is operational and properly  maintained.
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.
Hazardous areas have an approved fire  extinguishing system or a 1-hour fire-rated  construction. Doors shall be self-closing.
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.
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.
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.
Doors are provided with latching devices, which  will keep the doors tightly closed in their frames.
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.
Vertical openings or penetrations between  floors are required to be protected (fire-rated  and resistant to the passage of smoke).
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.
Approved smoke detectors are installed,  approved, maintained, inspected, and tested in  accordance with the manufacturer’s  specifications.
TV lounge did not have a smoke detection  system.
Smoke detectors were located only on one side of  all six smoke barrier doors.
Hazardous areas have an approved fire  extinguishing system or a 1-hour fire-rated  construction. Doors shall be self-closing.
Soiled utility room had a door without a self- closing mechanism.
Two soiled utility rooms had doors that were not  self-closing.
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.
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.

Appendix III: Comments from the Centers for Medicare & Medicaid Services

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Summary:
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.