CMS is  also responsible for monitoring the adequacy of state survey activities. The standards  differentiate between “existing” and “new” facilities. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. We believe that this is  particularly important in homes that lack sprinkler protection but claim to  have compensating construction features. 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. Linen chute did not have a fire-resistance rating of  at least 1 hour.
Why GAO Did This Study

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.

What GAO Found

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.