Multi-State Skilled Nursing System
Skilled Nursing System had received multiple citations by CMS in various jurisdictions for lack of life safety drawings, missing fire barriers, non-compliant doors, non-compliant dampers, and numerous other K-Tags. The client attempted to remediate the items internally, but failed to pass re-inspection in the timeframe provided by CMS, thus leading to significant fines, equally well over $30,000 (per facility), with rolling fines for every day citations were not remedied. LSS had to deploy anywhere between 25 – 30 team members to attempt to remedy the issues as quickly as possible for the client given the dire situations, of not only the daily fines, but the potential of losing CMS funding
How LSS Helped the Client:
- LSS created life safety drawings in compliance with CMS and NFPA 101, 2012 edition (currently enforced by CMS). By having the life safety drawings, it eliminated many of the fire rated barriers the facilities were being cited for and saved the skilled nursing system hundreds of thousands of dollars in remediation work on barriers that were no longer needed and fines.
- Helped the facility compile NFPA 101 required documentation and reports needed to provide the CMS surveyors to close out the K-Tags that multiple facilities had been cited.
- Performed inspections and repairs of numerous items that multiple facilities were out of compliance on, including but not limited to, dampers, doors, and fire rated assemblies.
- Worked with the corporate office on a daily basis to develop plans to close out the highest priority facilities to lessen the financial impact to the skilled nursing system, and to develop future programs to help the system avoid future citations.
Industries We Serve
Project Highlights
- Total Items: 60 Facilities with multiple citations (CMS – K-Tags) AND fines, for life safety violations.
- No Life Safety Drawings existed for any of the facilities identifying rated barriers, means of egress, emergency evacuation, location of extinguisher’s, fire doors, fire dampers, smoke detectors, hazardous areas, and numerous other items required on life safety drawings, per NFPA 101
- Facility had significant above ceiling issues, including missing complete fire rated barriers and numerous barriers. However, facility was also being cited and fined for barriers that were not fire rated, but the client could not push back on CMS, because they had no life safety drawings.
- Facility had no documentation on numerous NFPA 101 (and CMS) requirements that require testing.
Services Performed
- Life Safety Drawings
- Multi-State Skilled Nursing System
- Statement of Conditions