Nursing Home Fire Safety: Recent Fires Highlight Weaknesses in	 
Federal Standards and Oversight (16-JUL-04, GAO-04-660).	 
                                                                 
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. 							 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-04-660 					        
    ACCNO:   A10957						        
  TITLE:     Nursing Home Fire Safety: Recent Fires Highlight	      
Weaknesses in Federal Standards and Oversight			 
     DATE:   07/16/2004 
  SUBJECT:   Elderly persons					 
	     Emergency preparedness				 
	     Federal/state relations				 
	     Health surveys					 
	     Nursing homes					 
	     Safety regulation					 
	     Safety standards					 
	     Standards evaluation				 
	     Strategic planning 				 
	     Fire safety					 
	     CMS Online Survey Certification and		 
	     Reporting System					 
                                                                 
	     Hartford (CT)					 
	     Nashville (TN)					 
	     NIST Fire Safety Evaluation System 		 

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GAO-04-660

United States Government Accountability Office

GAO

                       Report to Congressional Requesters

July 2004

NURSING HOME FIRE SAFETY

      Recent Fires Highlight Weaknesses in Federal Standards and Oversight

GAO-04-660

Highlights of GAO-04-660, a report to congressional requesters

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.

GAO is making several recommendations to the Administrator of CMS to (1)
improve oversight of nursing home fire safety, such as reviewing the
appropriateness of exemptions to federal standards granted to
unsprinklered facilities and (2) strengthen the fire safety standards and
ensure thorough investigations of any future multiple-death nursing home
fires in order to reevaluate the adequacy of fire safety standards. CMS
concurred with GAO's recommendations.

www.gao.gov/cgi-bin/getrpt?GAO-04-660.

To view the full product, including the scope and methodology, click on
the link above. For more information, contact Kathryn G. Allen at (202)
512-7118.

July 2004

NURSING HOME FIRE SAFETY

Recent Fires Highlight Weaknesses in Federal Standards and Oversight

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.

Contents

  Letter

Results in Brief
Background
Despite Effectiveness, Cost Has Been a Barrier to Requiring

Sprinklers for All Older Nursing Homes Federal Fire Safety Requirements
for Unsprinklered Nursing Homes Are Weak State and Federal Oversight of
Nursing Home Fire Safety Is

Inadequate Conclusions Recommendations for Executive Action Agency, State,
and NFPA Comments and Our Evaluation

                                       1

                                      3 6

13

17

26 39 40 41

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

Appendix III Comments from the Centers for Medicare & Medicaid Services

  Tables

Table 1: Scope and Severity of Deficiencies Identified during Nursing Home
Surveys 9 Table 2: Key Facts about the Hartford and Nashville Nursing Home
Fires 12 Table 3: Sprinkler Requirements for Existing Nursing Homes, by
Construction Type 14

Table 4: Potential Weaknesses in Federal Standards Contributing to
Multiple-deaths in Hartford and Nashville Nursing Home Fires 18

Table 5: Violations of Federal Standards in Hartford and Nashville Nursing
Home Fires Not Identified during Prior Surveys 28 Table 6: States with
Large Proportions of Current Fire Safety Surveys Conducted in 2 hours or
Less 34

Table 7: Comparison of the Number and Type of Federal Monitoring Surveys
Including Quality-of-Care and Fire Safety Standards, Fiscal Year 2003 36

  Figures

Figure 1: How Nursing Homes May Address Fire Safety Deficiencies 10

Figure 2: Percentage of Nursing Homes Reported to Have Fire Safety
Deficiencies on Their Most Recent Surveys in States with at Least 100
Homes 31

Abbreviations

AHCA American Health Care Association
CMS Centers for Medicare & Medicaid Services
FSES Fire Safety Evaluation System
HVAC heating, ventilating, and air-conditioning system
NFPA National Fire Protection Association
OSCAR On-Line Survey, Certification, and Reporting system

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United States Government Accountability Office Washington, DC 20548

July 16, 2004

The Honorable Charles E. Grassley
Chairman
Committee on Finance
United States Senate

The Honorable Bill Frist, MD
United State Senate

Two deadly nursing home fires in 2003 focused considerable attention on
the safety of the nation's 1.5 million nursing home residents, a highly
vulnerable population of elderly and disabled individuals. The
development and enforcement of fire safety standards for nursing homes
is critical because many residents have restricted mobility that may be
accompanied by cognitive impairments, conditions that can limit their
ability to escape if a fire should occur. To ensure the health and safety
of
nursing home residents, the federal government adopts and enforces
standards that all homes serving Medicare or Medicaid beneficiaries must
meet, and state survey agencies conduct periodic inspections, known as
surveys, to determine whether the standards are being met.1 The most
recent data show that an average of about 2,300 of the nation's
approximately 16,300 nursing homes reported a structural fire each year
from 1994 through 1999 and that annually, the average number of fire
related nursing home deaths nationwide was about five.2 Over this same
time frame, one multiple-death nursing home fire resulted in three
fatalities.3 In contrast, the fire-related death toll in 2003 was
considerably
higher-a total of 31 residents died in the nursing home fires in Hartford,
Connecticut (16 deaths), and Nashville, Tennessee (15 deaths). Neither
home was required to have an automatic sprinkler system even though

1Federal fire safety standards for nursing homes are based on requirements
developed and periodically updated by the National Fire Protection
Association, a nonprofit membership organization.

2While cooking and dryers were the leading causes of fires, resident
deaths were largely due to smoking, and resident rooms were the leading
areas of fire origin. These data, published by the National Fire
Protection Association, are based on fires reported to municipal fire
departments.

3Fire safety experts often focus on fires that result in multiple-deaths
(three or more) because they may suggest the need to reevaluate the
adequacy of the standards.

such systems have proven very effective in reducing the number of multiple
deaths from fires. Federal fire safety standards do not require sprinklers
in existing nursing homes of certain noncombustible construction, and it
is estimated that 20 to 30 percent of nursing homes nationwide lack full
automatic sprinkler protection.

The large number of resident deaths in the Hartford and Nashville fires
raised serious questions about nursing home fire safety. You asked us to
report on (1) the rationale for not requiring all nursing homes to have
sprinklers and the status of any initiatives to change that requirement;
(2) the adequacy of federal fire safety standards for, and their
application to, nursing homes that lack automatic sprinkler systems; and
(3) the effectiveness of state and federal oversight of nursing home fire
safety. To do so, we used information related to the Hartford and
Nashville fires as a context for addressing these broader issues. In
responding to the first two questions, we reviewed federal fire safety
standards with a focus on why some homes are not required to install
sprinklers and on features in such homes that compensate for the lack of
sprinklers. We discussed the process for developing the standards and
their evolution over time with officials from the Centers for Medicare &
Medicaid Services (CMS), the federal agency responsible for managing
Medicare and Medicaid and overseeing compliance with federal nursing home
standards, including those related to fire safety; the National Fire
Protection Association (NFPA), a nonprofit membership organization that
develops and advocates scientifically based consensus standards regarding
fire, building, and electrical safety;4 associations representing nursing
homes, state fire marshals, and the sprinkler industry; and officials in
selected states that exceed federal requirements because nursing homes
were required to install automatic sprinkler systems. CMS and the
associations we contacted are either NFPA members or are represented on
one of its technical committees that develops criteria for the standards.
NFPA shared with us data it collects on significant structural fires,
including those in nursing homes. We also reviewed multiple investigative
reports on the Hartford and Nashville fires conducted by state and local
fire marshals and state survey agencies to determine if they identified
any weaknesses

4Both NFPA and CMS refer to fire safety standards as the "Life Safety
Code." The purpose of the code is to provide minimum requirements for the
design, operation, and maintenance of buildings and structures for
minimizing danger to life from fire, including smoke, fumes, or panic. The
federal code is based on NFPA's life safety code, known as NFPA 101.
Throughout this report, we use the term federal fire safety standards when
referring to the Life Safety Code.

in the standards for unsprinklered homes. Because nursing homes are
allowed to operate in some circumstances without correcting all
deficiencies identified during state surveys, we worked with CMS to
identify states having both a high proportion of unsprinklered nursing
homes and certain uncorrected deficiencies that could contribute to the
spread of smoke-a factor that often results in multiple fire fatalities.
We then examined the rationale for exemptions from federal standards for a
sample of uncorrected deficiencies in unsprinklered homes in four states.

To assess state and federal oversight of nursing home fire safety, we
reviewed the investigations of the Hartford and Nashville fires conducted
by the respective state survey agencies; examined the fire safety records
of the two homes, including the most recent surveys prior to the fires;
and discussed oversight issues with officials in both states and their
respective CMS regional offices. In addition, we analyzed data in CMS's
On-Line Survey, Certification, and Reporting (OSCAR) system on the results
of periodic state nursing home surveys for compliance with federal fire
safety requirements. We discussed state fire safety compliance with
officials at CMS headquarters and in each of CMS's 10 regional offices and
collected data on CMS oversight activities, such as the results of federal
monitoring surveys, which are conducted to assess the adequacy of state
survey activities. We conducted electronic testing of the OSCAR data for
completeness and to identify obvious errors. CMS officials generally
recognize OSCAR data to be reliable, and throughout the course of our
work, we shared our analysis of OSCAR data with CMS officials at both
headquarters and the regions to ensure that the data accurately reflected
state fire safety activities. Based on these reliability checks, we judged
OSCAR to be appropriate for our work. We conducted our review from
November 2003 through July 2004 in accordance with generally accepted
government auditing standards.

                                Results in Brief

Although the substantial loss of life in the Hartford and Nashville fires
could have been reduced or eliminated by the presence of properly
functioning automatic sprinkler systems, the potential retrofit cost has
been a barrier to CMS requiring them for all homes nationwide. Older
homes, such as the Hartford and Nashville facilities (built in 1970 and
1967, respectively), are generally allowed to operate without sprinklers
if they are constructed with noncombustible materials that have a certain
minimum ability to resist fire. According to CMS, the decline in
multipledeath fires after the adoption of NFPA fire safety standards in
1971 and their subsequent enforcement suggested that the estimated cost to
retrofit all older nursing homes nationwide outweighed the benefit. This
position

is being reevaluated, however, because of the 2003 nursing homes fires,
and the nursing home industry has indicated its support for requiring
older homes to install sprinklers. Industry officials believe that there
must be a discussion about how to pay for the cost of installing
sprinklers and a transition period for homes to come into compliance. It
is likely to be several years before all older homes would be required to
install sprinklers because of the process and time required for affected
stakeholders- including NFPA, CMS, and the nursing home industry-to
develop a consensus on and implement such a standard.

The recent nursing home fires in Hartford and Nashville revealed
weaknesses in federal fire safety standards and their application in
unsprinklered facilities. For example, even in the absence of sprinklers,
the standards do not require smoke detectors in most nursing homes, yet
investigations of the Hartford and Nashville fires suggested that the lack
of smoke detectors in resident rooms where the fires started may have
delayed staff response and activation of the buildings' fire alarms.
Moreover, walls between resident rooms are not required to resist the
passage of smoke, yet residents in rooms adjacent to where the fires
originated died from smoke inhalation. In addition, inadequate staff
response contributed to the loss of life in the Hartford fire, suggesting
that the standards' reliance on staff response as a key component of fire
protection may not always be realistic, particularly in an unsprinklered
facility. CMS did not conduct its own independent review of the two fires,
thus forgoing an opportunity to obtain critical information on which to
evaluate the adequacy of the standards. While the surveys of the Hartford
and Nashville facilities conducted shortly before the fires found that the
facilities met all applicable federal standards, many other unsprinklered
nursing homes are not required to meet all standards if they obtain a
waiver from CMS or demonstrate a level of fire protection equivalent to
the standards. However, we found that the exemption of some unsprinklered
facilities from certain standards may jeopardize resident safety. For
example, unsprinklered facilities in some states have received CMS waivers
of certain ventilation system requirements for preventing the spread of
smoke, yet fire safety experts consider such waivers to present an
unacceptable hazard. Furthermore, while facilities that demonstrate
equivalency are not required to meet all federal standards, in some cases
facilities are exempt from important standards, such as that the fire
alarm be either monitored or linked directly to the local fire department.
We also identified assessments of equivalency in unsprinklered facilities
that were not evaluated correctly or not updated as facility conditions
changed, placing residents at unnecessary risk.

State and federal oversight of nursing home compliance with fire safety
standards is inadequate. Postfire investigations by Connecticut and
Tennessee revealed deficiencies that existed, but were not cited, during
prior surveys. The Hartford facility was surveyed less than 1 month before
the fire, and no violations of federal standards were identified. However,
the survey agency's postfire investigation found that the home was not
conducting required fire drills during the night shift, and that on the
night of the fire the staff failed to follow the facility's fire plan. The
agency did not interview night shift staff during its prefire survey and
was provided inaccurate documentation of fire drills by the nursing home.
During routine fire safety surveys, Tennessee surveyors repeatedly failed
to detect a deficiency that would allow smoke to travel between floors-a
problem that may have contributed to the spread of smoke to upper floors
where one-third of residents who died succumbed to smoke inhalation.
Tennessee's postfire investigation did not cite the home for any
deficiencies and did not pursue potential deficiencies that may have been
present at the time of the fire. For example, surveyors did not determine
if the nursing home staff appropriately implemented the home's fire plan
during the fire, even though the home had been cited repeatedly for this
deficiency on prior surveys. The results of CMS's federal fire safety
monitoring surveys conducted during fiscal year 2003 found that state
surveyors either missed or failed to cite an average of more than two
deficiencies per home surveyed, such as inadequate construction to contain
fire and smoke or missing or improperly maintained sprinkler systems. CMS
provides insufficient oversight of state survey activities to address
these and other fire safety concerns. CMS did not fully comply with the
statutory requirement to conduct federal monitoring surveys in at least 5
percent of surveyed nursing homes in each state-a total of over 800
federal surveys annually; only 40 federal surveys conducted in fiscal year
2003 covered fire safety, a required element of both state and federal
surveys. No federal assessments of fire safety were conducted in 27
states. Four of CMS's 10 regions did not require states to request waiver
renewals or states in those regions did not submit waiver renewals, and 8
of 10 regional offices did not routinely review the accuracy of fire
safety equivalency assessments, as CMS requires. Furthermore, CMS lacks
data to identify the extent to which facilities have sprinklers, data that
would be useful in reviewing the appropriateness of waivers or equivalency
assessments.

We are making several recommendations to the Administrator of CMS to (1)
improve oversight of federal fire safety standards, such as ensuring that
the fire safety component is included in federal monitoring surveys and
reviewing the appropriateness of exemptions to federal standards

granted to unsprinklered facilities and (2) strengthen fire safety
standards by working with NFPA to reexamine standards for unsprinklered
homes and by ensuring thorough investigations of multiple-death nursing
home fires in order to reevaluate the adequacy of fire safety standards.
In commenting on a draft of this report, CMS concurred with our
recommendations and provided examples of steps it is already taking to
implement those recommendations. We also provided a draft of this report
to the Connecticut and Tennessee state survey agencies and NFPA for
comments. CMS, Connecticut, and NFPA provided technical and clarifying
comments, which we incorporated as appropriate. Tennessee did not provide
comments.

                                   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.5 The agency has the
authority to modify or make exceptions to the

5CMS proposed updating federal fire safety standards in 1990, but no
changes were adopted because of the estimated cost of implementing some of
the new requirements.

NFPA standards but has rarely done so.6 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.

6Under federal law, CMS is generally required to specify in regulation
which provisions of the NFPA fire safety code are applicable to nursing
homes. See 42 U.S.C. S: 1395i-3(d)(2)(B) (2000). Until 2003, CMS adopted
the NFPA standards without any changes. In adopting NFPA's 2000 code,
however, CMS modified the application of the code's roller latch
requirement in unsprinklered buildings and strengthened requirements for
emergency lighting.

    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.7 A standard
survey is conducted by state survey agency personnel and entails an
assessment of both federal quality of care and fire safety requirements.8
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).9 States are required
to enter information about surveys and complaint investigations, including
the scope and severity of deficiencies identified, in CMS's OSCAR
database.

7See 42 U.S.C. S: 1395i-3(g)(2) and 42 U.S.C. S: 1396r(g)(2). Among other
things, these statutory provisions require standard surveys to include
assessments of the physical environment, which is defined by CMS to
include fire safety standards. See 42 C.F.R. S: 483.70(a) (2003).

8See 42 C.F.R. S: 488.110. CMS guidance also contains a specific reference
to the fire safety component of a standard survey.

9Most fire safety deficiencies identified during routine inspections are
cited at less than actual harm because actual harm is reserved for
fire-related injuries. Nationwide, only 43 deficiencies on current fire
safety surveys as of December 1, 2003, were cited at the actual harm or
higher level. A somewhat higher proportion of deficiencies were cited at
the D-F level (57 percent) than at the A-C level (43 percent).

Table 1: Scope and Severity of Deficiencies Identified during Nursing Home
Surveys

                                     Scopea

                                       Severity Isolated  Pattern  Widespread 
                            Immediate jeopardyb     J        K         L      
                                    Actual harm     G        H         I      
           Potential for more than minimal harm     D        E         F      
                    Potential for minimal harmc     A        B         C      

Source: CMS.

aCMS defines the scope levels as follows: isolated-affecting a single or a
very limited number of residents; pattern-affecting more than a very
limited number of residents; and widespread-affecting or having the
potential to affect a large portion of or all residents.

bActual or potential for death/serious injury.

cNursing home is considered to be in "substantial compliance."

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.10 FSES uses a grading system to compare the overall level of
fire safety in a specific facility to a hypothetical facility that exactly
matches

10The institute was formerly known as the National Bureau of Standards.

each requirement of the fire safety standards.11 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.

Figure 1: How Nursing Homes May Address Fire Safety Deficiencies

Source: GAO analysis of CMS guidance.

Federal Oversight of State CMS is responsible for assessing the adequacy
of state survey activities to

Survey Agencies 	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.12 The federal monitoring
surveys are required to include an assessment of the fire safety component
of states'

11Point values are assigned to various fire safety features, such as
sprinklers, smoke detectors, construction types, and corridor doors. A
facility passes FSES if its point score meets or exceeds that of the
hypothetical facility.

12See 42 U.S.C. S: 1395i-3(g)(3) and 42 U.S.C. S: 1396r(g)(3).

standard surveys.13 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-yearold cognitively impaired resident
set the fire.14 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.

13The monitoring surveys must be sufficient in number to allow inferences
about the adequacy of the states' surveys. CMS is required to conduct
monitoring surveys using the same protocols as states are required to use
in their surveys. In addition, CMS may determine that a nursing home does
not meet applicable requirements, including fire safety requirements.

14Various authorities, including the state fire marshal's office, the
local fire departments, and the state survey agencies, conducted
investigations of these two nursing home fires.

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.15

Table 2: Key Facts about the Hartford and Nashville Nursing Home Fires

Key facts Hartford Nashville

Date and time of fire 	February 26, 2003; alarm September 25, 2003; alarm
received by fire department received by fire department at 2:38 a.m. at
10:18 p.m.

Date of last fire safety January 29, 2003 May 27, 2003 inspection

Number of residents 148 118
Fire department response 6 minutes after notification 9 minutes after
notification

Origin of fire Resident's room Resident's room

Nursing home staff on duty 12 12

Construction type 	Noncombustible with 1-hour Noncombustible with
fire-rated exterior walls and 2-hour fire-rated exterior structural frame.
walls and structural frame. Unsprinklered. Unsprinklered.

                Year(s) of construction    1970 and 1974                 1967 
                    Number of floors in                1                    4 
                               facility                  
                       Number of deaths 16, primarily in 15; 10 residents     
                                        vicinity of      died on              
                                        room where fire  2nd floor where fire 
                                        broke out.       
                                                             originated. Five 
                                                                    residents 
                                                         died on 3rd and 4th  
                                                         floors.              

                      Cause of fire    Arson by cognitively     Undetermined. 
                                      impaired resident with a 
                                    history of self-inflicted  
                                         cigarette burns.      

Sources: Hartford and Nashville Fire Departments and Connecticut and
Tennessee State Fire Marshals.

15On March 11, 2004, CMS issued new guidance outlining procedures to be
followed by state survey agencies, CMS regional offices, and the CMS
central office in the event of a fire resulting in serious injury or death
in a Medicare- or Medicaid-certified health facility. The guidance directs
the state survey agency to inform the CMS regional office and to conduct
an on-site fire safety survey of the facility as part of its
investigation. Regional office and central office staff are available to
consult and may, at their discretion, accompany state survey agency staff
during their on-site survey. The CMS central office is directed to consult
with the regional office following the state survey agency investigation
to determine if further investigation is warranted concerning the adequacy
and application of current standards.

  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.

Table 3: Sprinkler Requirements for Existing Nursing Homes, by Construction Type
                              Sprinklers required

                                      Fire resistance rating of 
                                            exterior walls, the     Number of 
                                          structural frame, and        floors 
               Construction type            flooring (in hours)     (maximum) 

Noncombustible 0-1

Mixed combustible/noncombustible 2

Combustible (heavy timber) 2a

Combustible 0-1

                            Sprinklers not required

Noncombustible 2-4b No limit

Noncombustible 1

Sources: CMS and NFPA.

Note: These requirements are based on the current federal fire safety
standards that were updated in 2003.

aThe 2-hour fire resistance rating applies to exterior walls only. Heavy
timber is permitted for the construction of the structural frame and
flooring.

bFor buildings with 3 to 4 hour fire-rated walls, the fire resistance
rating for flooring is 2 to 3 hours.

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.16
From

16States can enforce such requirements because facilities must obtain a
state license in order to operate. During the course of our work, we
contacted state survey agencies and fire marshals in several states that
were reported to have required existing nursing homes to install
sprinklers. We were able to confirm that the following states had required
homes to be retrofitted with sprinklers: Ohio, Utah, Virginia, Vermont,
and West Virginia. In addition, a 1990 New Jersey statute required many,
but not all, existing homes to install sprinklers.

1990 through 2002, there were no major nursing home fires with such a high
number of fatalities.17

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.18 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.19 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.20 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.21

17In Arkansas and Mississippi, nursing home fires in 1990 and 1995,
respectively, resulted in the deaths of three residents in each facility.

18To determine the sprinkler status of facilities, Connecticut state
survey officials relied on data collected during prior surveys and, if
there was a question, sent a surveyor out to the home. Of Connecticut's
254 nursing homes, 206 are fully sprinklered, 31 are partially
sprinklered, and 17 have no sprinklers. In contrast, state survey
officials in Tennessee visited each nursing home. Of Tennessee's 343
nursing homes, 229 are fully sprinklered, 90 are partially sprinklered,
and 24 have no sprinklers.

19In the NFPA code development process, the proposal will be reviewed
again in November 2004 and presented to the NFPA membership in June 2005.

20To update federal fire safety standards, CMS must publish and solicit
comments on the proposed new standards in the Federal Register. After
reviewing public comments, CMS publishes a final version of its standards
with an effective date. The process of adopting NFPA's 2000 standards in
2003 took CMS about 16 months.

21Although it may vary from state to state, a portion of the cost of
installing sprinklers, equal to a home's percentage of Medicaid
beneficiaries, may be eligible for reimbursement as a capital improvement
under the Medicaid program.

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.22 Furthermore, CMS as well as
states lack complete and reliable data on the extent to which homes are
partially sprinklered.23 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.

22For example, a partially sprinklered home could have sprinklers in
hazardous areas only (laundry rooms and storage areas), lack sprinklers
only in areas such as attics or closets in residents' rooms, or have
sprinklers in only one wing of a multiwing facility.

23Neither of the informal CMS or AHCA surveys conducted after the 2003
fires asked for data on partially sprinklered homes. CMS asked for the
number of sprinklered and unsprinklered homes in each state, while the
AHCA survey of its state affiliates requested data on the proportion of
homes fully sprinklered. CMS obtained information for 30 states, and 33
state affiliates responded to the AHCA survey. Since AHCA represents
primarily for-profit nursing homes, its state affiliates' survey excludes
many not-for-profit nursing homes.

  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.24 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.

24NFPA was on-site following the Harford fire but did not conduct a full
investigation or publish its own investigation report. Although the
Connecticut and Tennessee state survey agencies each conducted complaint
investigations after the fires in their respective states, the objective
of such complaint surveys is to determine whether the homes had failed to
comply with any federal fire safety standards, not to assess the adequacy
of the standards.

Table 4: Potential Weaknesses in Federal Standards Contributing to
Multiple Deaths in Hartford and Nashville Nursing Home Fires

                          Federal standard         Hartford nursing home      
Smoke detectors                                 Smoke detectors not        
                        Depending on date of       required.                  
                     construction, smoke detectors      No smoke detectors in 
                                                                     resident 
                   may be required in corridors or rooms.                     

a

resident rooms.

Fire and smoke barriers 	Complete fire and smoke Residents in room
adjacent to barriers required between room of origin died from smoke
corridor and resident rooms; not inhalation. Smoke and fire required
between resident spread through space above rooms. false ceiling.

Heating, ventilating, and air-Depending on date of Not applicable.b

conditioning (HVAC) system 	construction, dampers may be required in
ductwork to prevent the spread of fire and smoke.

Potential weaknesses

Nashville nursing home

Smoke detectors not required. No smoke detectors in resident rooms.

Residents in room adjacent to room of origin died from smoke inhalation.
Investigative reports do not indicate if fire spread through space above
false ceilings.

Under the 1967 standards, the home was not required to have dampers in
ductwork. Ductwork did not have dampers, allowing smoke to spread to upper
floors of building.

Staff response	The staff is expected to Staff may have failed to close all
Not clear from available implement the written plan for resident room
doors, and all investigations. the protection of all residents, designated
staff did not respond such as taking steps to contain to assist in
containment and the fire and evacuate residents. evacuation of residents
as

                            called for in fire plan.

Sources: GAO analysis of information provided by state and local fire
investigations in Hartford and Nashville, and by CMS and NFPA.

aAlthough both homes had corridor smoke detectors, they were not required.
The requirement for smoke detectors in either corridors or resident rooms
was added to federal standards in 1981 and only for new facilities
constructed after that date. Older, existing facilities, such as the
Hartford and Nashville nursing homes, were exempt from this requirement.

bThe facility did not have a central heating and cooling system with
ductwork but rather relied on wallmounted heat pumps in each resident's
room.

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.25 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.26

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

25In contrast, the presence of smoke detectors in resident rooms made a
significant difference in a December 2003 nursing home fire in Nevada. A
resident smoking in bed while on oxygen started a fire at 2:20 a.m. Staff
were alerted by the in-room smoke detector, and the fire was extinguished
before it caused a significant amount of damage. While the resident who
started the fire subsequently died as a result of the fire, no other
deaths were reported. Although the facility was equipped with automatic
sprinklers, the buildup of heat from the fire had not reached a level
sufficient to activate the sprinklers.

26Although it was not enacted, the bill originally required all
unsprinklered nursing homes to install smoke detectors in resident rooms
if a sprinkler system had not been installed within 1 year of the
legislation's effective date.

spread of smoke, although subsequent editions of the standards do require
such dampers.27

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.28 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

27Because the facility was originally certified when the 1967 federal fire
safety standards were in effect, it was grandfathered and continued to be
surveyed under the 1967 standards.

28Even though the fire safety standards call for closing all doors in the
event of a fire, an NFPA official acknowledged it can be difficult for
staff to abandon a resident who cannot be evacuated from the room of fire
origin in order to focus on the safety of other residents.

compliance with current fire safety standards.29 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.30 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.31 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.

29Multiple-death nursing home fires investigated by CMS, NFPA, or both
included fires in Ocean Springs, Mississippi (1995); Dardanelle, Arkansas
(1990); Norfolk, Virginia (1989); Memphis, Tennessee (1988); and Little
Rock, Arkansas (1984).

30An NFPA official told us that the organization did work on-site with
Hartford authorities but did not conduct a full investigation or issue a
report. However, NFPA did publish an article on the fire in the May/June
2003 Fire Journal.

31We focused on examining waivers and FSES results in four states reported
by CMS to have high proportions of unsprinklered nursing homes: Arkansas,
Iowa, Pennsylvania, and Wisconsin. We examined waiver and FSES
documentation for selected facilities that were not fully sprinklered and
had deficiencies that could contribute to the spread of smoke, the factor
that led to most of the deaths in the Hartford and Nashville nursing home
fires.

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.32 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

32CMS officials disagreed with this characterization, emphasizing that a
waiver is granted to a specific home and therefore is not applicable to
other nursing homes. However, we identified CMS program guidance that set
out criteria for granting specific types of waivers, demonstrating that
waivers have been used to set across-the-board nursing home fire safety
standards.

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.33 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.34 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:

o  	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

33Construction type refers to whether combustible or noncombustible
materials were used to build a facility and to the number of floors. An
unsprinklered facility that is required to be fully sprinklered might be
cited for a deficiency of construction standards, sprinkler standards, or
both.

34"Protected" refers to construction materials designed or rated to
withstand fire for a minimum of 1 hour.

facility currently has a temporary waiver to complete installation of a

sprinkler system.  o  Another one-story wood frame facility had
construction-type and sprinkler

waivers despite a lack of smoke detection in both corridors and resident
rooms.35 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
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

Some FSES-Certified Nursing Homes Lack Adequate Compensating Features for
Sprinklers

35The type of construction was unclear from the available documentation.
While the statement of deficiencies from the facility survey indicated the
one-story facility was of protected wood-frame construction, the FSES
documentation identified it as unprotected wood-frame construction.
According to CMS guidance, no waiver of sprinkler requirements may be
granted for unprotected wood construction.

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.

o  	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.

o  	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.36 The facility originally failed FSES in 1995,
but indicated firerated 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.

o  	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.

36This facility was of unprotected noncombustible construction, requiring
sprinkler protection according to federal standards.

  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.37 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.38 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.

37During the prefire survey, Connecticut surveyors reviewed the records of
25 residents, including smokers and non-smokers and residents with and
without cognitive impairments. Following the fire, approximately 48
residents were a part of the state's investigation- focusing specifically
on residents who smoked and had cognitive impairments.

38While not a federal requirement, Connecticut and Tennessee fire safety
surveyors routinely pull the fire alarm during fire safety surveys to
determine if staff follow the home's fire plan.

Table 5: Violations of Federal Standards in Hartford and Nashville Nursing Home
              Fires Not Identified during Prior Surveys Violations

Federal standard Hartford nursing home

Nashville nursing home

Smoking policy	Smoking by residents classified as not Facility failed to
control and monitor Not applicable. responsible shall be prohibited except
smoking for 21 residents-including when under direct supervision. 3 whose
records were reviewed

during the prior survey, but no violations were identified at that time.

Staff response	Fire drills are conducted quarterly on all Staff may have
failed to close all shifts, and all staff are familiar with resident room
doors, and all facility fire plan and appropriate designated staff did not
respond with procedures. fire extinguishers as called for in the

                                   fire plan.

HVAC system 	Air handling system is required to shut Not applicable.a down
automatically when fire alarm is triggered to prevent the spread of smoke.

Vertical openings 	Vertical openings or penetrations Not applicable.b
between floors are required to be protected (fire rated and resistant to
the passage of smoke).

Not clear from available investigations.

Air handling system may have failed to shut down as required, contributing
to spread of smoke.

Unprotected vertical opening in group shower room ceiling where penetrated
by plumbing allowed smoke to migrate to upper floors of the building.

Sources: GAO analysis of information provided by Connecticut and Tennessee
state survey agencies.

aThe facility did not have a central heating and cooling system with
ductwork but rather relied on wallmounted heat pumps in each resident's
room.

bThe facility is only one-story.

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
walkthrough 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.39 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.40

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

39Tennessee survey agency officials said that their investigation was
limited because the fire was treated as a crime scene An official with the
Nashville Fire Department told us that the facility was treated as a crime
scene with restricted access for less than 24 hours. Once the restriction
was lifted, he indicated, nothing prevented the state survey agency from
following up on concerns identified during its walk-through.

40Federal fire safety survey protocols do not require state surveyors to
test the ventilation shut-off safety feature during fire safety surveys by
pulling the fire alarm to see if ventilation systems shut down as
required. Because Tennessee typically only checks such a fire safety
feature on initial surveys, it may not have been reviewed by the state
survey agency since the home began operating in 1967.

smoke.41 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.42 Figure 2 shows the considerable
variation that exists in states with at least 100 nursing homes.43

41The nursing home's fire plan also called for staff to shut off blowers,
fans, and air conditioners during a fire to prevent the spread of fire and
smoke. In addition, staff were expected to prevent residents from
reentering the building during a fire. With the exception of the resident
who died in the room where the fire began, all the victims died as a
result of smoke inhalation, and one resident was severely injured upon
reentering the building after having been safely evacuated. Because of the
limited investigation, it is unclear to what extent the nursing home staff
followed these two fire plan procedures designed to minimize the loss of
life.

42Because actual harm is reserved for fire-related injuries, most fire
safety deficiencies are cited at less than actual harm. Of the
approximately 39,000 fire safety deficiencies cited nationally during the
most recent nursing home surveys, 19 states cited a total of 43
deficiencies at the level of actual harm or higher.

43We excluded 12 states and the District of Columbia from our analysis
because they had fewer than 100 homes, and even a small number of homes
with fire safety deficiencies produces a relatively large percentage of
homes with such deficiencies. The 12 states excluded were Alaska,
Delaware, Hawaii, Idaho, Nevada, New Hampshire, New Mexico, North Dakota,
Rhode Island, Utah, Vermont, and Wyoming.

Figure 2: Percentage of Nursing Homes Reported to Have Fire Safety
Deficiencies on Their Most Recent Surveys in States with at Least 100
Homes

           Percentage of nursing homes with reported fire safety deficiencies

Fewer than 25

From 25 to 50 13

From 51 to 75 13

More than 75

0 3 6 91215

Number of states with at least 100 nursing homes

Source: GAO analysis of OSCAR data as of December 1, 2003.

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."44

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.45 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.46 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.

44As a result of a CMS regional office investigation, a state official was
ultimately charged with falsifying fire safety survey forms. While the
official admitted to misrepresenting information on fire safety survey
forms, a federal jury acquitted her in February 2004. According to a CMS
regional office official, criminal intent could not be proven.

45In some cases, state surveyors identified deficiencies that federal
surveyors did not cite. Several regions stated that this situation
typically occurs when homes correct deficiencies identified by the state
before federal surveyors arrive to conduct their survey.

46Our examination of quality-of-care comparative surveys has consistently
found that federal surveyors find serious deficiencies missed or not cited
by state surveyors in a sizeable percentage of surveys conducted. See U.S.
General Accounting Office, Nursing Home Quality: Prevalence of Serious
Problems, While Declining, Reinforces Importance of Enhanced Oversight,
GAO-03-561 (Washington, D.C.: July 15, 2003).

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:

o  	State surveyors incorrectly classified nursing home construction
types, thus failing to identify buildings that were required to be
sprinklered under federal standards.

o  	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.

o  	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.

o  	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.

o  	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.47

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.48 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

47Homes completely lacking fire alarm systems are to be cited for
immediate jeopardy.

48A Connecticut survey agency official stated that missed deficiencies can
also be attributed to the lack of surveyor training and the infrequency of
fire safety training courses offered by CMS. In addition, while we did not
look at this issue in depth, officials in several regional offices stated
that inadequate surveyor training and lack of experience may explain some
of the interstate variability in reported fire safety deficiencies.

because features do change over time due to routine maintenance and
renovation. For example, homes may replace their false ceilings with
nonfire-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).49 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.

Table 6: States with Large Proportions of Current Fire Safety Surveys
Conducted in 2 hours or Less

Percentage of homes surveyed in
2 hours or less States

From 25 to 50 percent 	Colorado, Indiana, Maine, Minnesota, Oklahoma,
South Carolina, and Virginia

From 51 to 75 percent 	Georgia, Iowa, Kentucky, Nebraska, Vermont, and
Washington

More than 75 percent Maryland, Oregon, and Rhode Island

Source: GAO analysis of OSCAR data as of January 22, 2004.

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.50 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

49However, in 22 states, fewer than 5 percent of homes have such quick
surveys. 50See http://www.medicare.gov/NHCompare.

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.51 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

Evaluation of State Surveyors' Performance Is Limited

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.

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.52 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
qualityof-care standards in fiscal year 2003, only 40 such surveys
assessed fire safety-all of them comparative.53 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

51See http://app2.health.state.pa.us/commonpoc/nhlocatorie.asp.

52A federal monitoring survey may be either comparative or observational.
A comparative survey is conducted within 2 months of the state survey and
provides an independent evaluation of whether state surveyors identified
all deficiencies of federal standards and an observational survey allows
federal surveyors who accompany a state survey team to observe the team's
performance.

53Some regions conducted informal fire safety training surveys with state
surveyors. In addition, while one region does not conduct fire safety
comparative surveys, its fire safety specialist does cite fire safety
deficiencies noted while on-site during quality-of-care comparative
surveys.

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.

Table 7: Comparison of the Number and Type of Federal Monitoring Surveys
Including Quality-of-Care and Fire Safety Standards, Fiscal Year 2003

Federal monitoring surveys Quality-of-care Fire safety

                             Total surveys 871 40a

Proportion of homes surveyed

 More than 5 percent About .2 percent Number of states in which All states plus
                                the District of

federal monitoring surveys were conducted

                                    Columbia

23 states plus the District of Columbia

b

                     Proportion comparative 20 percent All

                    Proportion observational 80 percent None

Data Limitations and Inconsistent Use of Available Information Hamper CMS
Oversight

Source: CMS.

aOur analysis excluded 15 surveys in four of the six regions that were
conducted either before the state survey or more than 60 days after the
state survey. We excluded these surveys because by statute a federal
survey must begin within 2 months of the state's survey to ensure a valid
comparison.

bWe noted in 1999 that comparative surveys, though insufficient in number,
were the most effective technique for assessing state agencies' abilities
to identify deficiencies in nursing homes because they constitute an
independent evaluation of the state survey. See U.S. General Accounting
Office, Nursing Home Care: Enhanced HCFA Oversight of State Programs Would
Better Ensure Quality, GAO/HEHS-00-6 (Washington, D.C.: Nov. 4, 1999).

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.54 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-

54There is no data field in OSCAR to capture the sprinkler status of
nursing homes. Another CMS database has the capacity to store nursing home
sprinkler coverage information; however, CMS does not require states to
report such data.

CMS Does Not Review All Waiver Renewal Requests and FSES Results

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 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.55
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.56 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

55One CMS regional office did not require a particular state to submit
waiver requests or FSES results because the state was operating under a
later edition of the fire safety code. From February 1997 through
September 2003, CMS allowed the state to implement the 1994 NFPA life
safety code in lieu of the older federal standards, which were based on
NFPA's 1985 code. During these 6 years, there was no federal oversight of
the state's enforcement of fire safety standards for nursing homes.

56Three of the specialists in these five regions devote all of their time
to fire safety oversight activities while the other two are part-time fire
safety specialists. As of April 2004, a sixth region was working to fill a
vacancy due to the retirement of its fire safety specialist. A civil
engineer is trained in the design and construction of public works,
including buildings, roads, and bridges.

Conclusions

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.

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 	To improve federal oversight of state fire safety
activities, provide the public with important information about the fire
safety status of nursing

Executive Action 	homes, and better ensure the adequacy of fire safety
standards, we recommend that the Administrator of CMS take the following
seven actions.

o  	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.

o  	Ensure that data on sprinkler coverage in nursing homes are
consistently obtained and reflected in the CMS database.

o  	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.

o  	On an expedited basis, review all waivers and FSES assessments for
homes that are not fully sprinklered to determine their appropriateness.

o  	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.

o  	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.

o  Ensure that thorough investigations are conducted following multiple-

  Agency, State, and NFPA Comments and Our Evaluation

death nursing home fires so that fire safety standards can be reevaluated
and modified where appropriate.

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.57

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.

Kathryn G. Allen
Director, Health Care-Medicaid

and Private Health Insurance Issues

57Our prior work found that nursing home records can contain misleading
information or omit important data, making it difficult for surveyors to
identify deficiencies during their on-site reviews. See U.S. General
Accounting Office, California Nursing Homes: Care Problems Persist Despite
Federal and State Oversight, GAO/HEHS-98-202 (Washington, D.C.: July 27,
1998).

    Appendix I: Percentage of Surveyed Nursing Homes Cited with Fire Safety
              Deficiencies on Their Most Recent Surveys, by State
  Percentage         Number    with fire                                                                                                                                                                                                                         District                                                                                                                                                                                                                                                                                                                           
          of State of homes       safety North  84  Montana 101  Utah 90  Wyoming 39  Nevada 44  Michigan 431  South  113  Kansas 374  Texas 1,143  Pennsylvania 740  Iowa 454  Tennessee 337   New   81  Louisiana 314  Delaware 42  Arizona 135  Illinois 831     of    21 71.4 Ohio 990 70.8 Georgia 360 70.8 Oregon 141 68.8 Alaska 14 64.3 Alabama 228 61.0 Florida 694 60.5 Nation 16,334 58.9 Wisconsin 408 56.4  North   423 56.3 Arkansas 242 56.2 Virginia 278 53.2 California 1,342 51.0 Mississippi 204 49.5 Colorado 216 48.2  New   356 48.0 Massachusetts 481 47.6              
    surveyed       surveyed deficiencies Dakota                                                                Dakota                                                                          Mexico                                                            Columbia                                                                                                                                               Carolina                                                                                                           Jersey                                   West       
       homes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Virginia 136 45.6

Page 43 GAO-04-660 Nursing Home Fire Safety

Appendix I: Percentage of Surveyed Nursing Homes Cited with Fire Safety
Deficiencies on Their Most Recent Surveys, by State

                                                 Percentage of surveyed homes 
        State         Number of homes surveyed  with fire safety deficiencies 
       New York                            671                           45.6 
      Washington                           260 
       Missouri                            534 
       Indiana                             527 
       Maryland                            243 
       Oklahoma                            370 
     Rhode Island                           95 
     Connecticut                           252 
      Minnesota                            425 
    New Hampshire                           81 
       Vermont                              43 
        Hawaii                              45 
        Maine                              119 
       Nebraska                            228 
        Idaho                               80 
    South Carolina                         178 
       Kentucky                            296 

  Source: GAO analysis of most recent state surveys in OSCAR as of December 1,
                                     2003.

Appendix II: Federal Comparative Survey Results for Fiscal Year 2003-Examples of
Fire Safety Deficiencies Missed or Not Cited

CMS regional office (state) Federal fire safety standard

Atlanta Corridor walls must be fire-rated, extend from

(Georgia) 	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 firerated, and must
only resist the passage of smoke.

Depending on construction type and number of stories, sprinklers required
throughout home.

Fire safety deficiencies missed or not cited by state surveyors

o  	Not all corridor walls extended to the roof deck to provide the
minimum fire resistance rating.

o  	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.

o  	Approximately 95 percent of the building was not protected by an
automatic sprinkler system, even though the building construction type
required complete sprinkler protection.

Boston Depending on construction type and number of  o  Wood roof overhang
used as a screened porch
(Connecticut, stories, sprinklers required throughout home. was not
protected by sprinkler system.

Massachusetts, and  o  Home failed to provide complete sprinkler
New Hampshire) protection for a three-story wood frame building.

o  Beauty salon closet was missing sprinkler.

Sprinkler system is operational and properly  o  Sprinkler in storage area
was obstructed. maintained.

Doors are provided with latching devices, which will keep the doors
tightly closed in their frames.

Vertical openings or penetrations between floors are required to be
protected (fire-rated and resistant to the passage of smoke).

Fire drills are conducted quarterly on all shifts, and all staff are
familiar with facility fire plan and appropriate procedures.

o  	Home failed to maintain corridor doors so that they closed tightly to
resist the passage of smoke.

o  	Two resident room doors had obstructions that did not allow them to
close completely.

o  	Linen chute did not have a fire-resistance rating of at least 1 hour.

o  	Home failed to conduct fire drill on third shift (from 11 p.m. to 7
a.m.

Chicago
(Illinois, Michigan,
Minnesota, Ohio, and
Wisconsin)

Depending on construction type and number of stories, sprinklers required
throughout home.

Sprinkler system is operational and properly maintained.

Hazardous areas have an approved fire extinguishing system or a 1-hour
fire-rated construction. Doors shall be self-closing.

o  	Two exterior combustible canopies were not sprinklered.

o  	Soiled-linen room in the basement contained unprotected steel framing
for the floor above, which required the building to have complete
sprinkler protection.

o  Home failed to properly maintain sprinkler system.

o  	Home did not replace six sprinklers on known recall list.

o  	Hazardous area not separated with 1-hour firerated construction.

o  	Employee lockers were not properly separated by a 1-hour fire-rated
construction from the means of egress.

o  	Mechanical room ceiling had a large opening and unprotected hole.

Appendix II: Federal Comparative Survey Results for Fiscal Year
2003-Examples of Fire Safety Deficiencies Missed or Not Cited

CMS regional office Fire safety deficiencies missed or not cited by
(state) Federal fire safety standard state surveyors

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 firerated, and must only resist the passage of smoke.

Doors are provided with latching devices, which will keep the doors
tightly closed in their frames.

Vertical openings or penetrations between floors are required to be
protected (fire-rated and resistant to the passage of smoke).

o  	Smoke barrier above the ceiling at the corridor doors was open the
entire width of corridor.

o  	Corridor doors separating the second floor dining room from the
corridor had been removed.

o  	Linen chute discharge door was not self-closing and remained open.

Dallas
(Louisiana and New Mexico)

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 firerated, and must only resist the passage of smoke.

Fire drills are conducted quarterly on all shifts, and all staff are
familiar with facility fire plan and appropriate procedures.

o  	Home failed to ensure that the corridor walls formed a smoke-tight
barrier between the corridor and other areas of the facility.

o  	Home failed to ensure that smoke barriers were maintained, which would
ensure appropriate resistance to the passage of smoke by making
penetrations smoke-tight.

o  	Two separate holes in the smoke barrier were identified above the
doors outside the staff conference room.

o  	Home had a hole in the smoke barrier above the ceiling between the
cardiac clinic equipment and the nursing home conference room.

o  	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  o  Home failed to ensure
that there were no maintained. obstructions to the water flow of installed

sprinklers.

o  	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.

o  	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

o  	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.

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.

Appendix II: Federal Comparative Survey Results for Fiscal Year
2003-Examples of Fire Safety Deficiencies Missed or Not Cited

CMS regional office Fire safety deficiencies missed or not cited by
(state) Federal fire safety standard state surveyors

Denver Sprinkler system is operational and properly
(Colorado, North Dakota, maintained.
South Dakota, Utah, and
Wyoming)

Hazardous areas have an approved fire extinguishing system or a 1-hour
fire-rated construction. Doors shall be self-closing.

o  	Several sprinklers on known recall list were not replaced.

o  	Four large coffee pots on the top shelf of the store room could
obstruct the spray pattern of the adjacent sprinkler.

o  	Two hoses from the floor-cleaning machine were hanging on the
sprinkler piping in the basement housekeeping room.

o  	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.

o  	Boiler room doors to the corridor were missing self-closing devices.

o  	Boiler room door was lacking a strike plate to complete the required
latch.

o  	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 firerated, and must only resist the passage of smoke.

Doors are provided with latching devices, which will keep the doors
tightly closed in their frames.

o   o   o

o

o   o   o

o

o   o

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.

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.

Appendix II: Federal Comparative Survey Results for Fiscal Year
2003-Examples of Fire Safety Deficiencies Missed or Not Cited

CMS regional office Fire safety deficiencies missed or not cited by
(state) Federal fire safety standard state surveyors

Vertical openings or penetrations between  o  Stair leading from the
basement to the first floor floors are required to be protected
(fire-rated did not have a fire-rated construction between it and
resistant to the passage of smoke). and the elevator equipment room.

o  	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
8inch-by-12-inch access holes. These access holes were not closed with a
fire-rated material.

o  	The door at the top of the basement stair did not have a self-closing
device.

o  Basement stair door was missing its latch.

o  	All three stairway doors were not at least 1-hour fire-rated.

Approved smoke detectors are installed,  o  TV lounge did not have a smoke
detection approved, maintained, inspected, and tested in system.

accordance with the manufacturer's  o  Smoke detectors were located only
on one side of specifications. all six smoke barrier doors.

                  Hazardous areas have an  o  Soiled utility room had a door  
Philadelphia        approved fire                  without a self-         
(Delaware and extinguishing system or a          closing mechanism.        
                         1-hour fire-rated    
Pennsylvania) construction. Doors shall o     Two soiled utility rooms had 
                     be self-closing.                     doors that were not 
                                                       self-closing.          

Complete fire and smoke barriers required on  o  Wall separating personal
care area and the
each floor and between corridor and resident nursing home had unsealed
penetrations around

rooms. Doors are provided with latching pipes above the exit door.
devices, which will keep the doors tightly closed  o  A resident room door
could not be closed and

in their frames. latched at all times.

  Source: GAO analysis of federal comparative and corresponding state surveys.

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

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

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

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

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

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

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