ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR...
Transcript of ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR...
![Page 1: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/1.jpg)
ICF-IIDLife Safety Code/Emergency Preparedness Update
Kevin Knippa, Architect
Long Term Care Regulatory
512-438-2765
![Page 2: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/2.jpg)
LTC Regulatory Regional Map
11/16/2017 2
![Page 3: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/3.jpg)
Statewide TotalsSeptember 2017
Adult Day Care (DAHS) 465
Assisted Living 1,885
ICF-IID/RC 810
Nursing 1,241
Total Facilities 4,405
HCSSA agencies 6,270
11/16/2017 3
![Page 4: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/4.jpg)
ICF/IID 810
Government Based Small 81
Privately Owned Large 3
Privately Owned Small 711
Centers 15
Total 810
11/16/2017 4
![Page 5: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/5.jpg)
Life Safety Code (LSC)
PurposeEstablish minimum requirements for safety to life from fire.
11/16/2017 5
![Page 6: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/6.jpg)
Life Safety Code (LSC)
ProtectionPrevent ignition
Detect fire
Control fire development
Extinguish fire
Refuge or evacuation
Staff reaction
Fire safety information
11/16/2017 6
![Page 7: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/7.jpg)
March 21, 2009 Fire at Riverview IRA, Wells, NY
11/16/2017 7
![Page 8: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/8.jpg)
March 21, 2009Fire at Riverview IRA, Wells, NY
11/16/2017 8
![Page 9: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/9.jpg)
March 21, 2009Fire at Riverview IRA, Wells, NY
Facts
Facility opened in May, 2008
Fire sprinkler system complied
Sprinklers worked
Water supply was adequate
Nine residents (Impractical E-Score)
Two staff
11/16/2017 9
![Page 10: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/10.jpg)
March 21, 2009Fire at Riverview IRA, Wells, NY
What went wrong?
Fire started on covered porch
Fire spread through attic
Fire burned through ceiling into interior
Residents relocated to mudroom
Fire drill records not accurate
11/16/2017 10
![Page 11: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/11.jpg)
March 21, 2009Fire at Riverview IRA, Wells, NY
OutcomeFire alarm activated at 5:25 a.m.
Fire department arrived in eight minutes
Four residents evacuated by fire department
One resident survived in her bedroom
Three residents were rescued but died from smoke inhalation
Remaining resident was found deceased
11/16/2017 11
![Page 12: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/12.jpg)
March 21, 2009Fire at Riverview IRA, Wells, NY
ConsequencesBuilding was properly constructed and fire safety systems worked, yet fire ignited and developed through areas not requiring fire sprinkler protection
Poor staff response to the emergency
11/16/2017 12
![Page 13: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/13.jpg)
March 21, 2009Fire at Riverview IRA, Wells, NY
What could have changed the outcome?
11/16/2017 13
![Page 14: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/14.jpg)
NFPA 101, Life Safety Code, 2012 ed.Chapter 32, New Small ICF-IID
NFPA 13D or NFPA 13R sprinkler systems
Protect roofed porches, decks and balconies
Protect attics
• Fire sprinklers connected to sprinkler system*
• Heat detection system that activates fire alarm
• Constructed of non/limited-combustible construction or fire retardant-treated wood
* Sprinklers required if natural gas- or propane-fired equipment in attic (furnaces, water heaters)
11/16/2017 14
![Page 15: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/15.jpg)
NFPA 101, Life Safety Code, 2012 ed.Chapter 33, Existing Small ICF-IID
NFPA 13D or NFPA 13R sprinkler systems
Protect attics
• Fire sprinklers connected to sprinkler system*
• Heat detection system that activates fire alarm
• Constructed of non/limited-combustible construction or fire retardant-treated wood
* Sprinklers required if natural gas- or propane-fired equipment in attic (furnaces, water heaters)
11/16/2017 15
![Page 16: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/16.jpg)
NFPA 101 2012 Edition
Code Book Cost $101.00 + S&H
http//catalog.nfpa.org
1-800-344-3555
11/16/2017 16
![Page 17: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/17.jpg)
http://www.nfpa.org/
11/16/2017 17
![Page 18: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/18.jpg)
CMS adopts 2012 editionof LSC
The Centers for Medicare & Medicaid Services (CMS) adopted the 2012 edition by regulation effective July 5, 2016.
CMS and HHSC began surveying for compliance with the 2012 LSC on November 1, 2016.
11/16/2017 18
![Page 19: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/19.jpg)
CMS adopts 2012 editionof LSC
Buildings constructed before July 5, 2016 can meet Existing Occupancy requirements.
Buildings that received building permits for construction before July 5, 2016 can meet Existing Occupancy requirements.
All other building construction must meet New Occupancy requirements.
11/16/2017 19
![Page 20: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/20.jpg)
Code of Federal Regulations (CFR)Title 42, §483.470 (j)(1)(iv)
Beginning July 5, 2019, an ICF-IID must be in compliance with Chapter 33.2.3.5.7.1 or Chapter 33.2.3.5.7.2 of the Life Safety Code.
11/16/2017 20
CMS adopts 2012 editionof LSC
![Page 21: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/21.jpg)
HHSC adopts 2012 editionof LSC
HHSC adopted amended rules in Texas Administrative Code, Title 40,Chapter 90, effective October 12, 2017.
Changed references to the edition of the Life Safety Code.
Changed the dates delineating New facilities from Existing facilities, matching the Federal rule.
11/16/2017 21
![Page 22: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/22.jpg)
I got a great deal on insurance
11/16/2017 22
![Page 23: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/23.jpg)
How sprinklers work
11/16/2017 23
![Page 24: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/24.jpg)
Sprinkler Maintenance
§90.74(b)
The facility must have a program to inspect, test, and maintain the sprinkler system, and must execute the program at least once every three months for large facilities and at least once every six months for small facilities.
11/16/2017 24
![Page 25: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/25.jpg)
Sprinkler Maintenance
§90.74(b)(1)
The facility must contract with a company that is registered by the State Fire Marshal’s Office to execute the program.
11/16/2017 25
![Page 26: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/26.jpg)
SprinklerMaintenance
§90.74(b)(2)
The person who performs a service under the contract must be licensed by the state Fire Marshal’s Office to perform the service, and must complete, sign, and date an inspection form similar to the inspection and testing form in NFPA 25 for services provided under the contract.
11/16/2017 26
![Page 27: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/27.jpg)
§90.74(b)(7)
The facility must maintain onsite documentation of compliance with this subsection.
11/16/2017 27
SprinklerMaintenance
![Page 28: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/28.jpg)
The facility must retain one set of the fire sprinkler system plans and hydraulic calculations on the property in accordance with NFPA 25.
11/16/2017 28
SprinklerMaintenance
![Page 29: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/29.jpg)
Fire Alarm Maintenance
§90.74(a)
The facility must have a program to inspect, test, and maintain the fire alarm system, and must execute the program at least once every three months for large facilities and at least once every six months for small facilities.
11/16/2017 29
![Page 30: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/30.jpg)
Fire Alarm Maintenance
§90.74(a)(1)
The facility must contract with a company that is registered by the State Fire Marshal’s Office to execute the program.
11/16/2017 30
![Page 31: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/31.jpg)
Fire AlarmMaintenance
§90.74(a)(2)
The person who performs a service under the contract must be licensed by the State Fire Marshal’s Office to perform the service, and must complete, sign, and date an inspection and testing form similar to the inspection and testing form in NFPA 72 for a service under the contract.
11/16/2017 31
![Page 32: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/32.jpg)
§90.74(a)(7)
The facility must maintain onsite documentation of compliance with this subsection.
11/16/2017 32
Fire AlarmMaintenance
![Page 33: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/33.jpg)
Top 10 Most Frequently Cited ICF LSC Tags FY 2016
11/16/2017 33
![Page 34: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/34.jpg)
Top 10 Deficiencies (Cert.) FY 2016
1. The facility failed to provide doors to sleeping rooms that met LSC for latching hardware or closers.
11/16/2017 34
![Page 35: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/35.jpg)
2. The facility failed to provide a working manual fire alarm as required.
11/16/2017 35
Top 10 Deficiencies (Cert.) FY 2016
![Page 36: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/36.jpg)
Manual Pull Disguised
11/16/2017 36
![Page 37: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/37.jpg)
Manual Pull Disguised
11/16/2017 37
![Page 38: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/38.jpg)
Manual Pull with Spider
11/16/2017 38
![Page 39: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/39.jpg)
The facility failed to provide a working manual fire alarm as required.
11/16/2017 39
![Page 40: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/40.jpg)
The facility failed to provide a working manual fire alarm as required.
11/16/2017 40
![Page 41: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/41.jpg)
Flow Switch
11/16/2017 41
![Page 42: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/42.jpg)
3. The facility failed to meet applicable requirements for sprinkler coverage.
11/16/2017 42
Top 10 Deficiencies (Cert.) FY 2016
![Page 43: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/43.jpg)
4. The facilities failed to provide utilities that met the requirements of the Life Safety Code.
11/16/2017 43
Top 10 Deficiencies (Cert.) FY 2016
![Page 44: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/44.jpg)
The facility failed to provide utilities that met the requirements of the Life Safety Code.
11/16/2017 44
![Page 45: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/45.jpg)
You’re getting a legendary desk. Some of these cords go back six, seven managers ago.
11/16/2017 45
![Page 46: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/46.jpg)
The facility failed to provide utilities that met the requirements of the Life Safety Code.
11/16/2017 46
![Page 47: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/47.jpg)
5. The facility failed to provide approved smoke detectors in all the required areas, or failed to ensure that they met requirements for power, or failed to ensure they were audible in all sleeping areas.
11/16/2017 47
Top 10 Deficiencies (Cert.) FY 2016
![Page 48: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/48.jpg)
6. The facility failed to ensure that evacuation drills were held in the manner and with the frequency required for fire safety.
11/16/2017 48
Top 10 Deficiencies (Cert.) FY 2016
![Page 49: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/49.jpg)
Top 10 Deficiencies (Cert.) FY 2016
7.The facility failed to provide an acceptable means of escape from every sleeping room or living area as required for fire safety.
11/16/2017 49
![Page 50: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/50.jpg)
Top 10 Deficiencies (Cert.) FY 2016
8.The facility failed to provide appropriate receptacles for smoking materials in all areas where smoking is permitted.
11/16/2017 50
![Page 51: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/51.jpg)
Ash Tray and Metal Container
11/16/2017 51
![Page 52: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/52.jpg)
Top 10 Deficiencies (Cert.) FY 2016
9.The facility failed to have a written fire safety plan that was updated, readily available, understood by all employees, and the subject of required staff instruction.
11/16/2017 52
![Page 53: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/53.jpg)
All employees shall be periodically instructed and kept informed with respect to their duties under the plan.
11/16/2017 53
![Page 54: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/54.jpg)
Top 10 Deficiencies (Cert.) FY 2016
10.The facility failed to ensure that no door providing escape from the facility in the event of fire was ever locked.
11/16/2017 54
![Page 55: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/55.jpg)
Open with a single motion
11/16/2017 55
![Page 56: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/56.jpg)
CMS Emergency Preparedness Rule
Understanding the Emergency Preparedness Final Rule
11/16/2017 56
![Page 57: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/57.jpg)
Final Rule
Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers
Publication Date: September 8, 2016
Effective Date: November 16, 2016
Compliance and Implementation Date: November 15, 2017
11/16/2017 57
![Page 58: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/58.jpg)
Provider Letter
PL 17-33 – The Centers for Medicare & Medicaid Services (CMS) Emergency Preparedness Requirements
Publication Date: November 3, 2017
No change to licensing standards—contain main elements of the federal program
Facilities must comply with both the Federal rule and current state rules
11/16/2017 58
![Page 59: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/59.jpg)
Four Core Elements of Emergency Preparedness
Emergency PlanPolicies and Procedures
Communication Plan
Training and Testing
Emergency Preparedness
Program
11/16/2017 59
![Page 60: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/60.jpg)
Establishment of the Emergency Program (EP)
Develop an emergency preparedness program that meets all the standards specified in the Condition of Participation (42 CFR §483.475)
Refer to Interpretive Guidance in State Operations Manual, Appendix Z.
• All-Hazards Approach
• Specific to the location of the facility
• Address challenges to mobility during emergencies
• Comprehensive—facilities must try to identify every possible event that could occur
11/16/2017 60
![Page 61: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/61.jpg)
Establishment of the Emergency Program (EP)
All-Hazards approach—identify hazards and develop emergency preparedness capacity/capabilities to address those hazards as well as a wide spectrum of emergencies and disasters.
• Natural, man-made or facility emergencies
• Care-related emergencies
• Equipment and power failures
• Interruptions in communications
• Loss of a portion or all of a facility
• Interruptions in normal supply of essentials
11/16/2017 61
![Page 62: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/62.jpg)
March 22, 2017—Fire because of careless smoking at an ICF-IID causes $100,000 damageOverland Park, Kansas
11/16/2017 62
![Page 63: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/63.jpg)
January 14, 2017—Diesel fuel spill in garage at Sunrise of La Jolla ALF in San Diego, CA. Fuel vendor overfilled tank by 200 gallons.
11/16/2017 63
![Page 64: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/64.jpg)
January 16, 2017—Most of the fuel had been cleaned up immediately, but firefighters returned to deal with leftover fuel in the drainage system.
11/16/2017 64
![Page 65: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/65.jpg)
December 30, 2016—A sport utility vehicle (SUV) crashed into group home2901 Konnoak Drive in Winston-Salem, NC.
11/16/2017 65
![Page 66: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/66.jpg)
April 17, 2013—Explosion at West Fertilizer Co. destroys assisted living facility and nursing homeWest, Texas
11/16/2017 66
![Page 67: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/67.jpg)
Emergency PlanDevelop and maintain a plan that is reviewed and updated annually
Document facility-based and community-based risk assessments using all-hazards approach, including missing residents
Strategies to address emergencies
Address special needs of resident population—types of services required; continuity of operations
Cooperation and collaboration with emergency preparedness officials at all levels—who to contact and how; pre-planning
11/16/2017 67
![Page 68: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/68.jpg)
Policies and ProceduresDevelop and implement policies and procedures that support the plan
Subsistence needs for staff and residents, whether they evacuate or shelter in place
A system to track the location of on-duty staff and residents
Safe evacuation procedures
Means to shelter in place
System of medical documentation
The use of volunteers
Sheltering arrangements with other facilities
Facility role under an 1135 waiver
11/16/2017 68
![Page 69: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/69.jpg)
Communication PlanFacility interaction and coordination within facility and with outside parties
Names and contact info—staff, service providers, physicians, other facilities, volunteers, governmental emergency preparedness staff, other sources of assistance, HHSC, Disability Rights Texas
Primary/alternate means of communication—something in addition to telephones
Method for sharing info and medical documentation with health care providers
Means to release patient info within HIPAA
Means to contact SOC—occupancy, needs, ability to help—and families/responsible parties
11/16/2017 69
![Page 70: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/70.jpg)
Training and TestingDevelop a program based on emergency plan
Initial training for all new and existing staff and volunteers
Additional training at least annually
Maintain documentation of training
Demonstrate staff knowledge of emergency procedures
Two drills each year—one live full-scale drill with option to perform live full-scale drill or a tabletop exercise for the second
Analyze facilities response, maintain documentation of drills, revise plan as needed
11/16/2017 70
![Page 71: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/71.jpg)
State Operations ManualAppendix Z
11/16/2017 71
![Page 72: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/72.jpg)
Changes to Survey Process
Survey process does not change how facilities are currently surveyed
Surveyors will VERIFY all the required elements are included and training/testing requirements are completed
The EP requirements might be evaluated by Health surveyor or LSC surveyors
Must comply with the two training exercise requirements by November 15, 2017
Will issue a separate CMS Form 2567 for E-tags
11/16/2017 72
![Page 73: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/73.jpg)
Be Emergency Ready!
11/16/2017 73
![Page 74: ICF-IID Life Safety Code/ Emergency Preparedness Update · Condition of Participation (42 CFR §483.475) Refer to Interpretive Guidance in State Operations Manual, Appendix Z. •All-Hazards](https://reader033.fdocuments.in/reader033/viewer/2022050503/5f954d32ae9d926904484b2a/html5/thumbnails/74.jpg)
Thank youAny Questions?
11/16/2017 74