CMS Requirements for Life Safety Code (LSC).

Introduction About me DHEC Bureau of Certification CMS (Centers for Medicare & Medicaid Services) Life Safety Survey Process NFPA 101 – Life Safety Code NFPA 99 – Health Care Facilities Code Form CMS 2786R Form CMS 2567 Survey and Certification Letter (S & C Letter)

Bureau of Certification Organizational chart http://www.scdhec.gov/library/CR-010075.pdf

Bureau of Certification We are contracted by the Centers for Medicare & Medicaid Services (CMS) to perform federal surveys of facilities who participate in Title 18 (Medicare) and Title19 (Medicaid). Our work is overseen by the CMS Regional Office in Atlanta, GA

CMS (Centers for Medicare & Medicaid Services) https://www.youtube.com/watch?v=Kahh9MO8lYE&fe ature=youtu.be

Bureau of Certification The mission of the survey and certification (S&C) program is to assure basic levels of quality and safety for Medicare (1) and Medicaid (2) beneficiaries.  Survey and certification is the only system that provides onsite, objective, and outcome-based verification by knowledgeable and trained individuals to assure that basic standards of quality are being met by health care providers across the nation or, if not met, that appropriate remedies are promptly applied and implemented effectively.

Bureau of Certification The primary function of the Bureau of Certification is to ensure that all residents, patients and clients of providers which receive Medicare and Medicaid payments are afforded the quality of care which will attain or maintain the highest practicable level of physical, mental, and psychosocial well-being. This is accomplished by an on-site survey process which includes record review (medical records and facility inspections), facility file review, observation, and resident and staff interviews.  

Bureau of Certification The Bureau of Certification surveys Health Care Facilities that participate in the Medicare and Medicaid programs, These facilities are surveyed with unannounced site visits. Survey teams include: Nurses Pharmacists Social Workers Dieticians Qualified Intellectual Disability Professionals Life Safety Inspectors Generalists

Bureau of Certification The Bureau includes two Divisions: Division of Nursing Home - surveys only Skilled Nursing Facilities (SNF) Division of Health Provider - surveys 14 other facility types

Bureau of Certification The Bureau of Certification surveys 15 difference facility types including: Skilled Nursing Facilities (SNF) Hospitals – includes Critical Access Hospitals, Rehabilitation, Psychiatric, Acute Care, Long Term Care Hospital. Home Health Agencies Hospices (including inpatient) End Stage Renal Dialysis Facilities (ESRD) Ambulatory Surgery Centers Rural Health Clinics Outpatient Physical Therapy/Speech Therapy (OPT/ST) Comprehensive Outpatient Rehabilitation Facilities (CORF) Swing Bed Units PPS Excluded Psychiatric Units PPS Excluded Rehabilitation Units Community Mental Health Centers Psychiatric Residential Treatment Facilities (PRTF) Portable X-ray Facilities

Bureau of Certification The Life Safety Code (LSC) portion of the survey is only conducted for the following facility types: Skilled Nursing Centers (SNF) Hospitals Ambulatory Surgery Centers (ASC) Inpatient Hospices Intermediate Care Facilities (ICF) (Note: Some ESRD’s facilities can be subject to LSC on a case-by-case basis depending on specific locations.)

Bureau of Certification We conduct several different types of Medicare Certification surveys including: Initial Recertification Validation Complaint Follow-up (in person/desk review) or Revisit Survey Length/Frequency Must be consecutive days Generally last 4-5 days but could be more.

Life Safety Survey Process Task 1 - Offsite Survey Preparation Task 2 - Entrance Conference/Onsite Preparatory Activities Task 3 - Orientation Tour Task 4 - Information Gathering Task 5 - Information Analysis and Decision Making Task 6 - Exit Conference

NFPA 101 Life Safety Code (LSC). The LSC is a set of fire protection requirements designed to provide a reasonable degree of safety from fire. It covers construction, protection, and operational features designed to provide safety from fire, smoke, and panic. The LSC, which is revised periodically, is a publication of NFPA, which was founded in 1896 to promote the science and improve the methods of fire protection.

NFPA 101 Life Safety Code (LSC). CMS has currently adopted the 2012 edition of NFPA 101 LSC as of November 2016. Facilities are required to be in compliance with the states current regulations as well as federal regulations, which also include all NFPA codes referenced by the 2012 edition of NFPA 101 LSC.

NFPA 99 Health Care Facilities Code NFPA 99 establishes criteria for levels of health care services or systems based on risk to the patients, staff, or visitors in health care facilities to minimize the hazards of fire, explosion, and electricity.

NFPA 99 Health Care Facilities Code CMS has currently adopted the 2012 edition of NFPA 99 as of November 2016. Facilities are required to be in compliance with the states current regulations as well as federal regulations, which also include all NFPA codes referenced by the 2012 edition of NFPA 99.

Form CMS 2786R This document is the Fire Safety Survey Report, which is used as a guideline for documenting any deficiency found during the LSC survey process.

Form CMS 2786R Form CMS 2786R can be accessed using the following URL: https://www.cms.gov/Medicare/CMS-Forms/CMS- Forms/CMS-Forms-Items/CMS009335.html

Form CMS 2567 This is the Statement of Deficiency/Plan of Correction or the survey results. This document contains a listing of any deficiency cited by the surveying State Agency (SA) or Regional Office (RO) as requiring correction. The Summary Statement of Deficiencies is based on the facilities compliance or non-compliance with federal Medicare regulations.

Form CMS 2567 Mailed to the facility within 10 business days (excluding weekends/holidays) from the survey exit date. The facility has 10 calendar days (including weekends/holidays) to return a Plan of Correction and/or Administrative Sign-Off

Form CMS 2567 Form CMS 2567 can be accessed using the following URL: https://www.cms.gov/Medicare/CMS-Forms/CMS- Forms/CMS-Forms-Items/CMS008860.html

Survey and Certification Letters (S&C Letter) The Centers for Medicare & Medicaid Services uses transmittals to communicate new or changed policies or procedures that will be incorporated into the CMS Online Manual System. The cover or transmittal page summarizes and specifies the changes. Transmittals are updated weekly (generally on Friday) if there is any interim, revised, or new guidelines pertaining to the State Operating Manual (SOM). Most Compliance Officers at facilities access these updates.

Survey and Certification Letter (S&C Letter) The transmittals can be accessed using the following URL: http://www.cms.gov/SurveyCertificationGenInfo/

Closing Remarks/Questions

Resources http://www.scdhec.gov/library/CR-010075.pdf - DHEC organization chart http://www.nfpa.org/codes-and-standards/resources/free-access - free NFPA Codes (viewing only) https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms- Items/CMS009335.html - CMS Form 2786 https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms- Items/CMS008860.html - CMS Form 2567 http://www.cms.gov/SurveyCertificationGenInfo/ - CMS Transmittals (S&C Letter) https://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/downloads/som107_appendixtoc.pdf - State Operating Manual (SOM)

Derrick L. Jones Bureau of Certification/Health Regulation 2600 Bull street, Columbia, SC 29201 Office : 803-545-4218 Fax: 803-545-4292 Email: jonesdl@dhec.sc.gov