TOM SCHEIDEL Chief Operating Officer Compliance Management Service CMS Survey and Enforcement Process Life Safety Code Education and Compliance [email protected]

TOM SCHEIDELChief Operating Officer

Compliance Management Service

• CMS Survey and Enforcement Process• Life Safety Code Education and Compliance

• [email protected]• 817-456-6238• 8805 Ridge Run Drive, North Richland Hills,

Texas 76182

The LIFE SAFETY CODESurvey Process

Making Sure It Is Right

• Development and Redevelopment of the Regulations/Code

• Oversight of the Survey Process• Oversight of the State Agency and Surveyors• Oversight of the Enforcement & Interpretations• Balancing the System

Tom Scheidel, COO, Compliance Management Services, [email protected], 817-456-6238

WHO ARE THE PLAYERS?

• CONGRESS AND CMS– Don’t write the Code!!!– At the direction of Congress, CMS:• Incorporates the Regulations “by Reference”• Updates the Regulations to newer Codes• Adds additional Regulations where “Necessary”

– Congress responds to:• Advocates• Negative Events



• Centers for Medicare and Medicaid Services– Receives Authority from the Secretary– Writes Regulations (ex. State Ops Manual)– Enters into (1864) Agreements with States– Retains State Budget Allocation Authority– Details Oversight to 10 Regional Offices– Statistically oversees Outcomes at States’ Level– Evaluates Regulations effects / currency– Maintains Relations with Industry, Code Agencies



• CMS Consortia– Groups of the 10 Regional Offices– Efficiency in Sharing – Collections of Expertise– Virtual and Vague– Limited Impact on Providers



• CMS Regions– 10 Offices geographically follow the Federal Map• Assigned States within those Regions

– Division of Survey and Certification • Associate Regional Administrator (Waivers)• State Representatives• Certification / Decertification of Providers• Enforcement Branch (LTC and NLTC)• Survey Branch (Health, Life Safety Code, CLIA)


NATIONAL FIRE PROTECTION ASSOCIATION (NFPA)

• Write Codes and Standards– Couple Hundred Titles– 3 Year Cycle

• Membership Organization– Industry– Manufacturers– Consultants– Regulators– Advocates


AUTHORITIES

• Authority Having Jurisdiction– Depends on the Regulations being considered

• Local Fire Authority– Depends on the local organization

• Waiver Authority– Depends on the Regulation– Very limited delegation of authority beyond CMS


LIFE SAFETY CODE REQUIREMENTS• Written by NFPA (Usually)– Exceptions are AAMI, ANSI, CGA, ASME, UL, etc.)– Follow a Manual of Style– Written in Conference and Committee– Anyone can recommend a change

• Reviewed & Changed Every 3 Years– Limited change authority by NFPA

• NFPA 101 (2000 Edition)– Incorporated by Reference by CMS– Functions as coordinator– Mandatory References (Chapter 2)


LIFE SAFETY CODE REQUIREMENTS

• NFPA 101 (Life Safety Code)– Rewritten every 3 years– Not all incorporated by reference / non-regulatory

• Mandatory References• Additional Federal Regulations– Ex. Sprinkler Regulations, Corridor Lighting,

• State Regulations / State Licensure• In “Complimentary” Codes, Strictest Applies


NFPA 101 (Life Safety Code) 2000 Edition Quick Summary

• Background• Administration – Purpose, Applicability, Equivalency

• Mandatory References• Definitions• General Chapters – Applies to All• Occupancy Chapters – 18/19 Health Care• Appendix to the Requirements


THE SURVEY

• Occurs between the X-month and 15th month• Statewide average of 12 months (SA Managed)• More often for some facilities (SFF)• Complaints are in addition• Health plus Life Safety Code = Survey• Team for Standard Survey– One Nurse– Basic Surveyor Trained (Health and Life Safety)


STATE OPERATIONS MANUALQuick Summary

• Appendix P – Protocol for Long Term Care Survey – with some investigative protocols– http://cms.gov/manuals/Downloads/som107ap_p_ltcf.pdf

• Appendix PP – Guidance to Surveyors – “TAGS” – with some investigative protocols– http://cms.gov/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf

• Appendix I – Life Safety Code Survey– http://cms.hhs.gov/manuals/Downloads/som107ap_i_lsc.pdf

• Appendix Q – Guidelines for Immediate Jeopardy– http://cms.hhs.gov/manuals/Downloads/

som107ap_q_immedjeopardy.pdf• Chapter 7 – Enforcement Guidelines for LTC

– http://www.cms.hhs.gov/manuals/downloads/som107c07.pdf


LIFE SAFETY CODE PRINCIPLES OF COMPLIANCE

• Facilities Must Prove Compliance– (F-454) 42 CFR 483.70(a) – Shall comply with the

Life Safety Code • As Part of the Standard Survey, States MUST

determine compliance with the Health and LSC Requirements– K-Tag (LSC) Survey is performed by surveyor

having completed the LSC Basic training – F-Tag (Health) Survey is performed (lead) by

surveyor having completed LTC Basic training


STATE OPERATIONS MANUALExample of LSC/Health Crossover

• F323 - §483.25(h) – …as free as possible from accidents / supervision to prevent accidents– Smoking Regulations– Electric Cords / Tripping– Doors Blocked Open– Heating Unit Surfaces

• F456 - §483.70(c)(2) Maintain all essential mechanical, electrical, and patient care equipment in safe operating condition.


Example of LSC/Health Crossover• F454 - §483.70 Physical Environment – §483.70(a) Life Safety From Fire – NFPA 101 (Life Safety Code) 2000 Edition– The facility must be designed, constructed, equipped, and

maintained to protect the health and safety of residents, personnel and the public.

• F459 - §483.70(d)(1)(iii) Have direct access to an exit corridor; – There is no authority under current regulations to approve

a variation to this requirement. – Additional guidance is available in NFPA 101), 12-2.5.1,

which is Tag K41 of the Life Safety Code Survey


Example of LSC/Health Crossover

• F455 - §483.70(b) Emergency Power – §483.70(b) (1) An emergency electrical power system

must supply power adequate at least for lighting all entrances and exits; equipment to maintain the fire detection, alarm, and extinguishing systems; and life support systems in the event the normal electrical supply is interrupted.

– §483.70(b)(2) When life support systems are used, the facility must provide emergency electrical power with an emergency generator ( as defined in NFPA 99, Health Care Facilities) that is located on the premises


DEMONSTRATE “LSC” COMPLIANCE

• Demonstrate compliance with the PRESCRIPTIVE Life Safety Code

• Demonstrate EQUIVALENCY to PRESCRIPTIVE requirements of the Life Safety Code

• WAIVER of the PRESCRIPTIVE requirements• Plan of Correction with WAIVER of the

PRESCRIPTIVE requirements


BOTTOM LINE WITH LSC COMPLIANCE

• MULTIPLE AGENCIES– CMS / Feds– State– Local Fire

• MULTIPLE MANUALS– NFPA– SOM– LICENSURE

• MANY REQUIREMENTS – Too Many To Count


ACTIONABLE ITEMS

• Staff can be taught– Maintenance Staff • How to establish controls of the environment• How to monitor compliance for “hot button” issues• How to work with contractors (Signatures)• What to report to Admin/Assistant

– Clinical Staff• What systems are in place• How to comply / When to compromise systems• What to report to Admin/Assistant


CMS OVERSIGHT OF STATE AGENCY

• Prospectively through– State Plan Amendments– Budget process (Staff and Resources)

• On Line through– Periodic meetings and Conference Calls– Complaints against the State Agency

• Retrospectively through– Reporting– State Agency Evaluation Program


State Agency Evaluation Program

• Q-1 through Q-9 • Can directly affect Federal Financial

Participation (FFP) • Evolving Standard – sometimes late!• Some Steady-State Issues– Surveyor Performance• Skills in Survey• Documentation

– Enforcement Actions (DPNA / CMP / Revisit)


GAO Reporting

• State Agencies Under-report Scope and Severity & Understate Serious Care Issues

• State Agencies Under-utilize Temporary Managers

• State Agencies not overseeing SFF’s• CMS is not overseeing LSC Training Program• CMS CO is not Overseeing State Agency Data• CMS Correctly Implemented “2013 Sprinklers”


Inspector General Reports

• CMP not being collected• DPNA not being implemented• Fraud not being reported• State Fraud Task Force – (50% Accepted / 30% from SA)


Actionable Items

• State Agency Evaluation impact will become more noticeable and changes evident (+ / - )

• GAO Revisits CMS Issues approximately every 5-6 years– Think LSC– Think MDS – Think Data Accuracy

• OIG Publishes their work list annually


Balancing the System

• State Survey Agencies serve many masters– State Legislature• Program Direction• Funding • Staffing• Leadership and Oversight

– Industry– CMS– Public


Balancing The System

• CMS serves many masters– Administration– Congress– Inspector General– GAO– Advocacy– Industry– Professional Associations


Survey Process Actionable Items

• Complaint Surveys can get out of hand– A place in the “Annual” survey– A role for advocates– Investigative Guides can help

• New Health Survey (QIS) – can be assisted but not managed– Data Intense (TIME!!!)

• LSC Survey – No process change– More invasive as surveyors get smarter


Enforcement ProcessActionable Items

• Enforcement process begins at the first finding• Asking questions will help with POC and Dates

of Correction• Informal Dispute Resolution– Based on schedule in “Letter”– When something “Should Not Have Been Cited”– Interpretation Request is a form of IDR

• Equivalency to the Code is Compliance• Waivers are a LEAST FAVORITE option


LSC Actionable Items• Administrator / Assistant Administrator – Principles of the Life Safety Code (Classes)– Systems to Monitor Life Safety Systems– Contracting to promote LSC Compliance– Principles of Non-Compliance (Forensics)– Monitoring Methods for Preventative Maintenance

• AR/BOM– Records Requirements for LSC Compliance (Copies)

• If you have a records expert, introduce LSC


SUMMARY – WHAT CAN BE DONE• Most Surveyors follow a format– Records should match that format– Tour should be done with pen & paper & keys!

• Records should be scanned for back-up– In the same format– Available in case others “disappear”– Second person with access

• Responsive but not maniacal!• Ask lots of questions at exit – real questions


SUMMARY - WHAT CAN BE TAUGHT(That will impact Compliance / Enforcement)

• Principles of the LSC• Top 10 Deficiencies• Immediate Jeopardy Items / Responding• Last 2 Years Deficiencies• How to respond to Paperwork / Signatures• Care and Feeding of the LSC Surveyor• When/Who to raise an interpretation

questionTom Scheidel, COO, Compliance Management Services, [email protected], 817-456-6238

The LIFE SAFETY CODESurvey Process

• What is going to happen to the LSC is known 2-3 years in advance.

• The Survey Process changes due to Demand for Change from others

• Oversight of the State Agency and Surveyors is done by the State itself, CMS, HHS, and GAO (CMS)

• Oversight of the Enforcement & Interpretations is performed by Regional Office and Central Office

• Balancing the System – Documentation and Communications are the best policy for minimizing or eliminating enforcement actions


Documents

TOM SCHEIDEL Chief Operating Officer Compliance Management Service CMS Survey and Enforcement Process Life Safety Code Education and Compliance [email protected]