| Do You Maintain a Compliant Fire Safety Plan? | https://www.ahcancal.org/News-and-Communications/Blog/Pages/Do-You-Maintain-a-Compliant-Fire-Safety-Plan.aspx | Do You Maintain a Compliant Fire Safety Plan? | | | | | 1/22/2025 5:00:00 AM | | <p><span style="font-size:11pt;">F</span><span style="font-size:11pt;">ire safety is a critical component of any healthcare organization’s overall safety program. As such, healthcare providers are required to develop facility-specific fire and evacuation procedures, provide fire safety training, and conduct regularly scheduled fire drills. </span></p><div><span style="font-size:11pt;">Most facility fire procedures correctly focus on the critical actions to take upon discovery of a fire. These actions are often simplified into an acronym such as RACE (rescue, alarm, contain, evacuate) or something similar. However, the Life Safety Code® requires some very specific information to be included in a healthcare occupancy’s fire safety plan. Review your fire safety plan and fire procedures against these nine (9) required components to ensure they are comprehensive and compliant with Section 19.7.2.2 of the Life Safety Code® (2012 edition) and CMS tag K-711. </span></div><div><br></div><div><ol><li><span style="font-size:11pt;"><strong>Use of Alarms:</strong> Upon discovery of a fire, procedures should direct staff to quickly activate the fire alarm system via the closest manual pull station. In addition to building-wide notification, activation of the fire alarm will likely initiate a variety of automatic actions such as door release, HVAC shutdown, and fire department notification. <br><br></span></li><li><strong>Transmission of Alarms to the Fire Department:</strong> Your fire alarm system most likely maintains some direct connection to ensure the fire department is automatically notified when the alarm is activated. This is commonly accomplished via the use of a central monitoring service. However, there are a handful of other arrangements that lead to the same outcome. Ensure your procedures specifically spell out how alarms are transmitted to the fire department. <br><br></li><li><strong>Emergency Phone Call to Fire Department:</strong> Although the fire alarm system is required to automatically contact the fire department, a direct phone call to the fire department (usually via 911), is an extremely important step. Not only does it serve as a back-up communication, but it allows the facility to provide details regarding the situation directly to emergency personnel. Specific information can be extremely valuable to dispatchers and firefighters and may have a direct impact on the emergency response. Make sure your procedures include a back-up phone call and clarify who is to make the back-up call on all shifts. <br><br></li><li><strong>Response to Alarms:</strong> It is important that procedures clarify who should respond to the fire area when. For example, during normal business hours, there are often additional staff in the building available to respond to alarms. However, in the evening and overnight, it may be necessary for additional clinical staff to report to the fire area to ensure there are enough hands to implement the procedures. Procedures should detail roles for all staff upon activation of the alarm. <br><br></li><li><strong>Isolation of the Fire:</strong> Health care occupancies are specifically designed to contain smoke, thereby limiting its ability to travel throughout the building. Closing doors, and keeping them closed, is a critical step in limiting smoke travel. Staff procedures should clarify their role in closing the door to the fire room along with the remaining doors in the building. <br><br></li><li><strong>Evacuation of Immediate Area:</strong> Quick removal of the occupants of the fire room is essential. Procedures should place emphasis on evacuation of the fire room followed by closure of the fire room door to keep smoke from spreading. <br><br></li><li><strong>Evacuation of the Smoke Compartment:</strong> Extended evacuation beyond the fire room is an important decision to be made and depends on a few factors. Procedures should clarify when it is appropriate to evacuate the remainder of the smoke compartment, order of evacuation, and the evacuation destination. Evacuation floorplans are often a helpful visual reference that clarify smoke barrier boundaries, evacuation direction, and fire department entry. <br><br></li><li><strong>Preparation of Floors and Building for Evacuation:</strong> While the initial point of focus is the immediate fire area, staff should simultaneously be taking action throughout the remainder of the building as well. This includes preparing for possible extended evacuation of the fire floor, floors above or below, or possibly the entire building. Procedures should outline who will determine the need for further evacuation, how it will be communicated, and what the extended evacuation process will entail. This may include vertical evacuation techniques for multi-story buildings. <br><br></li><li><strong>Extinguishment of Fire:</strong> It may be appropriate for staff to extinguish a fire. Procedures should clarify the situations, methods, and supporting equipment available for fire suppression. </li></ol></div><div><br></div><div><span style="font-size:11pt;">Fire drills serve as an opportunity to evaluate staff knowledge and test staff implementation of the fire safety plan. Fire drills are required to be conducted quarterly on each shift with the drill times and conditions varied. Drills conducted between 6:00am and 9:00pm should include the activation of the building fire alarm system. Otherwise, overnight fire drills are permitted to use a coded announcement instead of audible alarms. It is not the intent of fire drills to excite or disturb residents. Detailed fire drill requirements are found in Section 19.7.1 of the Life Safety Code® (2012 edition) and referenced in CMS tag K-712. </span></div><div><br></div><div><span style="font-size:11pt;">Knowledge of applicable codes and standards is your best tool for ensuring life safety compliance. You can purchase a copy of the Life Safety Code® (NFPA 101) online at <a href="http://www.nfpa.org/" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">www.nfpa.org</a>. The AHCA/NCAL <a href="/Survey-Regulatory-Legal/Pages/Fire-Life-Safety.aspx" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083">website</a> is also a good source for on-going fire safety education, tools, and resources. </span><span style="font-size:11pt;"></span></div><p></p> | Fire safety is a critical component of any healthcare organization’s overall safety program. | |
| CMS Releases Revised Guidance for Federal Monitoring Surveys | https://www.ahcancal.org/News-and-Communications/Blog/Pages/CMS-Releases-Revised-Guidance-for-Federal-Monitoring-Surveys-.aspx | CMS Releases Revised Guidance for Federal Monitoring Surveys | | | | | 1/21/2025 5:00:00 AM | | <span data-contrast="auto" lang="EN-US" style="font-size:11pt;">On January 17, 2025, the Centers for Medicare and Medicaid Services (CMS) released a revised </span><a href="https://www.cms.gov/files/document/admin-info-25-06-nh.pdf" target="_blank" rel="noreferrer noopener" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" style="font-size:11pt;"><span data-contrast="none" lang="EN-US"><span data-ccp-charstyle="Hyperlink">Admin Memo: 25-06-NH</span><span data-ccp-charstyle="Hyperlink"> </span></span></a><span data-contrast="auto" lang="EN-US" style="font-size:11pt;">related to guidance for Federal Monitoring Surveys (FMS). According to the memo, FMS are performed each fiscal year to validate the State Survey Agency’s performance. In the Fiscal Year (FY) 2025 FMS memo, CMS notes FMS will only consist of Resource and Support Surveys (FSS) and Health Comparatives. CMS will not conduct any Focused Concern Surveys (FCS) in FY 2025. In addition, CMS reports RSS will be conducted throughout the year. Previously, they were conducted in the first six months of the year. </span><span data-ccp-props="{}" style="font-size:11pt;"> </span><div><span data-ccp-props="{}"><br></span></div><div><span data-contrast="auto" lang="EN-US">CMS also notes that a Health Comparative survey may now follow a standard or complaint survey. Previously they only followed standard surveys. These surveys should be conducted within 60 calendar days of the State Agency’s survey exit.</span><span data-ccp-props="{}"> </span></div><div><span data-ccp-props="{}"><br></span></div><div><span data-contrast="auto" lang="EN-US">CMS did add a type of Emergency Preparedness (EP) and Life Safety Code (LSC) FMS. Previously there were four types, and now there are five. The types of EP/LSC FMS include the following:</span><span data-ccp-props="{}"> </span></div><div><ol role="list" start="1"><li data-leveltext="%1." data-listid="1" data-list-defn-props="{"335552541":0,"335559685":720,"335559991":360,"469769242":[65533,0],"469777803":"left","469777804":"%1.","469777815":"hybridMultilevel"}" aria-setsize="-1" data-aria-posinset="1" data-aria-level="1" role="listitem"><span data-contrast="auto" lang="EN-US">An EP/LSC Resource and Support Survey</span><span data-ccp-props="{}"> </span></li></ol></div><div><ol role="list" start="2"><li data-leveltext="%1." data-listid="1" data-list-defn-props="{"335552541":0,"335559685":720,"335559991":360,"469769242":[65533,0],"469777803":"left","469777804":"%1.","469777815":"hybridMultilevel"}" aria-setsize="-1" data-aria-posinset="2" data-aria-level="1" role="listitem"><span data-contrast="auto" lang="EN-US">An EP/LSC Comparative</span><span data-ccp-props="{}"> </span></li></ol></div><div><ol role="list" start="3"><li data-leveltext="%1." data-listid="1" data-list-defn-props="{"335552541":0,"335559685":720,"335559991":360,"469769242":[65533,0],"469777803":"left","469777804":"%1.","469777815":"hybridMultilevel"}" aria-setsize="-1" data-aria-posinset="3" data-aria-level="1" role="listitem"><span data-contrast="auto" lang="EN-US">An EP/LSC Revisit Resource and Support Survey</span><span data-ccp-props="{}"> </span></li></ol></div><div><ol role="list" start="4"><li data-leveltext="%1." data-listid="1" data-list-defn-props="{"335552541":0,"335559685":720,"335559991":360,"469769242":[65533,0],"469777803":"left","469777804":"%1.","469777815":"hybridMultilevel"}" aria-setsize="-1" data-aria-posinset="4" data-aria-level="1" role="listitem"><span data-contrast="auto" lang="EN-US">An EP/LSC Revisit Comparative</span><span data-ccp-props="{}"> </span></li></ol></div><div><ol role="list" start="5"><li data-leveltext="%1." data-listid="1" data-list-defn-props="{"335552541":0,"335559685":720,"335559991":360,"469769242":[65533,0],"469777803":"left","469777804":"%1.","469777815":"hybridMultilevel"}" aria-setsize="-1" data-aria-posinset="5" data-aria-level="1" role="listitem"><span data-contrast="auto" lang="EN-US">NEW: An EP/LSC Desk Audit</span><span data-ccp-props="{}"> </span></li></ol></div><div><span data-contrast="auto" lang="EN-US">CMS Reports that the new type of survey, the EP/LSC Desk Audit, is a desk review conducted by a Federal Surveyor after the State Agency has conducted the facility’s recertification survey. The purpose is to monitor the State Agency’s performance.</span><span data-ccp-props="{}"> </span></div><div><span data-ccp-props="{}"><br></span></div><div><span data-contrast="auto" lang="EN-US">Please send any questions to </span><a href="mailto:regulatory@ahca.org" target="_blank" rel="noreferrer noopener" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083"><span data-contrast="none" lang="EN-US"><span data-ccp-charstyle="Hyperlink">regulatory@ahca.org</span></span></a><span data-contrast="auto" lang="EN-US">.</span><span data-ccp-props="{}"> </span></div> | CMS released a revised Admin Memo: 25-06-NH related to guidance for Federal Monitoring Surveys | |
| Public Health Emergency Waivers for Providers Impacted by California Wildfires | https://www.ahcancal.org/News-and-Communications/Blog/Pages/Public-Health-Emergency-Waivers-for-Providers-Impacted-by-California-Wildfires-.aspx | Public Health Emergency Waivers for Providers Impacted by California Wildfires | | | | | 1/15/2025 5:00:00 AM | | <span data-contrast="none" lang="EN-US" style="font-size:11pt;">The U.S. Department of Health and Human Services Secretary has used Public Health Service Act authorities to </span><a href="https://aspr.hhs.gov/legal/PHE/Pages/CA-Wildfires-Jan2025.aspx" target="_blank" rel="noreferrer noopener" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" style="font-size:11pt;"><span data-contrast="none" lang="EN-US"><span data-ccp-charstyle="Hyperlink">declare</span></span></a><span data-contrast="none" lang="EN-US" style="font-size:11pt;"> a public health emergency (PHE) as a result of the consequences of wildfires and straight-line winds on the State of California on January 10. This declaration gives the Centers for Medicare and Medicaid Services (CMS) the ability to issue regulatory flexibilities and waivers under Sections 1135 and 1812(f) of the Social Security Act to support providers and beneficiaries in the State of California. These flexibilities and waivers are effective retrospectively since January 7, 2025 and are listed in the CMS </span><a href="https://www.cms.gov/about-cms/what-we-do/emergency-response/current-emergencies" target="_blank" rel="noreferrer noopener" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" style="font-size:11pt;"><span data-contrast="none" lang="EN-US"><span data-ccp-charstyle="Hyperlink">Current Emergencies</span></span></a><span data-contrast="none" lang="EN-US" style="font-size:11pt;"> webpage. </span><span data-ccp-props="{"201341983":0,"335557856":16777215,"335559738":240,"335559739":240,"335559740":240}" style="font-size:11pt;"> </span><div><span data-ccp-props="{"201341983":0,"335557856":16777215,"335559738":240,"335559739":240,"335559740":240}"><br></span></div><div><span data-contrast="none" lang="EN-US">Key </span><a href="https://edit.cms.gov/files/document/2025-southern-ca-wildfires-waiver-list-01-12-25.pdf" target="_blank" rel="noreferrer noopener" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083"><span data-contrast="none" lang="EN-US"><span data-ccp-charstyle="Hyperlink">blanket </span><span data-ccp-charstyle="Hyperlink">waivers</span></span></a><span data-contrast="none" lang="EN-US"> impacting AHCA/NCAL members and their residents in the impacted areas that do not require an individual waiver request by the provider include:</span><span data-ccp-props="{"201341983":0,"335557856":16777215,"335559738":240,"335559739":240,"335559740":240}"> </span></div><div><span data-ccp-props="{"201341983":0,"335557856":16777215,"335559738":240,"335559739":240,"335559740":240}"><br></span></div><div><ul role="list"><li data-leveltext="" data-font="Symbol" data-listid="2" data-list-defn-props="{"335552541":1,"335559685":720,"335559991":360,"469769226":"Symbol","469769242":[8226],"469777803":"left","469777804":"","469777815":"hybridMultilevel"}" aria-setsize="-1" data-aria-posinset="1" data-aria-level="1" role="listitem"><span data-contrast="none" lang="EN-US">Reporting Minimum Data Set (MDS)</span><span data-ccp-props="{"201341983":0,"335557856":16777215,"335559738":240,"335559739":240,"335559740":240}"> </span></li></ul></div><div><ul role="list"><li data-leveltext="" data-font="Symbol" data-listid="2" data-list-defn-props="{"335552541":1,"335559685":720,"335559991":360,"469769226":"Symbol","469769242":[8226],"469777803":"left","469777804":"","469777815":"hybridMultilevel"}" aria-setsize="-1" data-aria-posinset="2" data-aria-level="1" role="listitem"><span data-contrast="none" lang="EN-US">Waive Pre-Admission Screening and Annual Resident Review (PASARR)</span><span data-ccp-props="{"201341983":0,"335557856":16777215,"335559738":240,"335559739":240,"335559740":240}"> </span></li></ul></div><div><ul role="list"><li data-leveltext="" data-font="Symbol" data-listid="2" data-list-defn-props="{"335552541":1,"335559685":720,"335559991":360,"469769226":"Symbol","469769242":[8226],"469777803":"left","469777804":"","469777815":"hybridMultilevel"}" aria-setsize="-1" data-aria-posinset="3" data-aria-level="1" role="listitem"><span data-contrast="auto" lang="EN-US">3-Day Prior Hospitalization</span><span data-ccp-props="{"201341983":0,"335557856":16777215,"335559738":240,"335559739":240,"335559740":240}"> </span></li></ul></div><div><ul role="list"><li data-leveltext="" data-font="Symbol" data-listid="2" data-list-defn-props="{"335552541":1,"335559685":720,"335559991":360,"469769226":"Symbol","469769242":[8226],"469777803":"left","469777804":"","469777815":"hybridMultilevel"}" aria-setsize="-1" data-aria-posinset="4" data-aria-level="1" role="listitem"><span data-contrast="none" lang="EN-US">Physician Visits in Skilled Nursing Facilities/Nursing Facilities</span><span data-ccp-props="{"201341983":0,"335557856":16777215,"335559738":240,"335559739":240,"335559740":240}"> </span></li></ul></div><div><ul role="list"><li data-leveltext="" data-font="Symbol" data-listid="2" data-list-defn-props="{"335552541":1,"335559685":720,"335559991":360,"469769226":"Symbol","469769242":[8226],"469777803":"left","469777804":"","469777815":"hybridMultilevel"}" aria-setsize="-1" data-aria-posinset="5" data-aria-level="1" role="listitem"><span data-contrast="none" lang="EN-US">Physical Environment</span><span data-ccp-props="{"201341983":0,"335557856":16777215,"335559738":240,"335559739":240,"335559740":240}"> </span></li></ul></div><div><ul role="list"><li data-leveltext="" data-font="Symbol" data-listid="2" data-list-defn-props="{"335552541":1,"335559685":720,"335559991":360,"469769226":"Symbol","469769242":[8226],"469777803":"left","469777804":"","469777815":"hybridMultilevel"}" aria-setsize="-1" data-aria-posinset="6" data-aria-level="1" role="listitem"><span data-contrast="none" lang="EN-US">Staffing Flexibilities for ID/DD residences</span><span data-ccp-props="{"201341983":0,"335557856":16777215,"335559738":240,"335559739":240,"335559740":240}"> </span></li></ul></div><div><span data-contrast="none" lang="EN-US">If a provider needs flexibilities not listed on the blanket waivers document, the CMS </span><a href="https://www.cms.gov/about-cms/what-we-do/emergency-response/current-emergencies" target="_blank" rel="noreferrer noopener" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083"><span data-contrast="none" lang="EN-US"><span data-ccp-charstyle="Hyperlink">Current Emergencies</span></span></a><span data-contrast="none" lang="EN-US"> webpage provides links to guide providers on how to apply.</span></div><div><span data-contrast="none" lang="EN-US"> </span><span data-ccp-props="{"201341983":0,"335557856":16777215,"335559738":240,"335559739":240,"335559740":240}"> </span></div><div><span data-contrast="none" lang="EN-US">The waivers are effective for 90 days unless the HHS Secretary declares an extension of the local PHE. </span><span data-ccp-props="{"201341983":0,"335557856":16777215,"335559738":240,"335559739":240,"335559740":240}"> </span></div> | The U.S. Department of HHS Secretary has used Public Health Service Act authorities to declare a public health emergency as a result of the consequences of wildfires and straight-line winds on the State of California on Jan 10. | |
| Disaster Response and Recovery – Collaborating Through Mutual Aid Plans | https://www.ahcancal.org/News-and-Communications/Blog/Pages/Disaster-Response-and-Recovery-–-Collaborating-Through-Mutual-Aid-Plans-.aspx | Disaster Response and Recovery – Collaborating Through Mutual Aid Plans | | | | | 12/30/2024 5:00:00 AM | | <p></p><div>Long Term Care Mutual Aid Plans (MAP) are collaborative networks of providers that maintain voluntary agreements to support each other before, during, and after a disaster. These formalized partnerships can provide a facility needing assistance with various resources such as supplies, equipment, personnel, pharmaceuticals, transportation, or even evacuation destinations when a disaster overwhelms their community or exceeds the capability of their own internal emergency preparedness program. </div><div><br></div><div><span style="font-size:11pt;">While MAPs are primarily made up of long </span><span style="font-size:11pt;">term care providers, they often include other collaborative partners, including various health care organizations, governmental organizations, and community groups.</span><span style="font-size:11pt;"> After natural catastrophes, such as hurricanes, MAPs can provide critical support, helping affected facilities to recover, reopen, and provide e</span><span style="font-size:11pt;">ssential care to their residents. </span></div><div><br></div><div><span style="font-size:11pt;">The key to an effective MAP is establishing the partnership before disaster strikes. MAP groups can start small. In many cases, corporate entities are structured as a MAP, where facilities under the same ownership are positioned to support each other. However, more robust plans will include facilities from different entities. </span><span style="font-size:11pt;">Participants are typically linked by geography (e.g., a town, county or region), sometimes expanding to statewide or cross-state groups. </span><span style="font-size:11pt;">MAP plans, and the associated agreements to support each other work best when documented and formally agreed to by the participants. </span></div><div><br></div><div><span style="font-size:11pt;">A natural path to develop a MAP is through an established Health Care Coalition. <a href="https://asprtracie.hhs.gov/hcc-resources" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">Health Care Coalitions</a> are increasingly tasked to include all levels of the health care continuum of care. A long term care subset of these coalition members can work to address disaster support, often serving as the incipient phase of MAP development. </span></div><div><br></div><div><span style="font-size:11pt;">MAP agreements should clearly define roles, responsibilities, and expectations, including protocols for resource sharing, reimbursement, and liability. Comprehensive Memorandums of Understanding (MOUs) should be developed and signed by all participating facilities. It is important that MAPs partner with local emergency management agencies and public health officials to ensure alignment with their disaster response plans and protocols. Effective MAPs will conduct regular training and exercises. Exercises are key to educating, testing, and ensuring the MAP’s effectiveness. Exercises should include, but not be limited to, scenarios that focus on both shelter in place and evacuation. </span></div><div><br></div><div><span style="font-size:11pt;">Collaborating with other providers through a MAP is an effective resource to complement your organization’s emergency preparedness program. Partnerships such as MAPs can mitigate the impact of a disaster, ensure continuity of operations, and support rapid recovery. Some AHCA/NCAL members participate in well-organized MAPs in various regions of the country. For more information on MAPs, email <a href="mailto:emergencyprep@ahca.org" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">emergencyprep@ahca.org</a> or reach out to your state affiliate.</span></div><p></p> | Long Term Care Mutual Aid Plans are collaborative networks of providers that maintain voluntary agreements to support each other before, during, and after a disaster. | |