California Should Improve Oversight w/Federal Requirements for Life Safety/Emergency Preparedness

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare

From September to December 2018, OIG (Office of Inspector General) conducted unannounced site visits of 20 nursing homes in California (there are 1,202 such facilities in this state) from a nonstatistical sample that included a number of high-risk deficiencies that California reported to CMS.  OIG checked for life safety violations and each facility’s emergency preparedness.  (OIG did not include the deficiencies for 1 facility in its report because that facility was destroyed by a wildfire after the visit.)

All 19 facilities had deficiencies in areas related to life safety and emergency preparedness.  OIG found “137 instances of noncompliance with life safety requirements related to building exits, smoke barriers, and smoke partitions; fire detection and suppression systems; hazardous storage areas; smoking policies and fire drills; and electrical equipment testing and maintenance…also found 188 instances of noncompliance with emergency preparedness requirements related to written emergency plans; emergency power; plans for evacuation, sheltering in place, and tracking residents and staff during and after an emergency; emergency communications plans; and emergency plan training and testing. As a result, nursing home residents at the 19 nursing homes were at increased risk of injury or death during a fire or other emergency.

The identified deficiencies occurred because nursing homes lacked adequate management oversight and had high staff turnover. In addition, California did not adequately follow up on deficiencies previously cited, ensure that surveyors were consistently enforcing CMS requirements, or have a standard life safety training program for all nursing home staff (not currently required by CMS).”

OIG recommended that “California (1) follow up with the 19 nursing homes to ensure that corrective actions have been taken regarding the deficiencies we identified, (2) conduct more frequent site surveys at nursing homes to follow up on deficiencies, (3) ensure that all surveyors consistently enforce CMS requirements, and (4) work with CMS to develop life safety training for nursing home staff.

California concurred with our first and third recommendations and described actions that it had taken or planned to take to address the recommendations. However, California did not concur with our second and fourth recommendations. After reviewing California’s comments, we maintain that our findings and recommendations are valid.”

The just-released 27-page report is a must-read for all LTC facilities.  Appendix B summarizes the areas of noncompliance and the number of deficiencies that were identified at each CA nursing home.  E-tags as well as K-tags were issued for these deficiencies.   The Report in Brief provides an overview.



Where does your facility stand with Life Safety and Emergency Preparedness?  Do you meet Federal requirements?  Are you doing all you can to protect the lives of the individuals that live and work in your facility?

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