CMS has released updated interpretive guidelines specifically addressing rehab agency fire standards. Rehab Agencies are also known as ORFs (Outpatient Rehabilitation Facilities) and are referred to as OPTs, (physical therapy) or OSTs (Speech Language Pathology) in various CMS guidelines. Rehab Agencies are subject to Survey and Certification according to the Rehab Agency Conditions of Participation as enrollment as a Medicare provider. If you are a current rehab agency it is important to be aware of standards that are effective immediately. Rehab Agencies and/or their extension locations that are not in compliance are subject to corrective action in a certain timeframe. The CMS update also provided guidance on the use and placement of fire extinguishers, as well as the necessity to have a specific fire protection plan as part of the overall required disaster plan per 42CFR 485.727(a).
Rehab Agency Fire Standards – New Guidance
Fire standards have always been part of the Rehab Agency Interpretive Guidelines, including the requirement for a fire alarm with local alarm capabilities. Generally this has been interpreted to be a pull alarm that is electronically wired in the building. Most hospitals, major medical office buildings and many others types of facilities subject to high construction standards likely have pull alarm capability. CMS provided this summary guidance:
Rehabilitation Agencies must meet certain fire safety requirements to protect the health and safety of patients, personnel, and the public. According to regulations at §485.723, Rehabilitation Agencies are required to have a permanently attached automatic fire-extinguishing system in hazardous areas, fire extinguishers, fire regulations that are prominently posted, and a fire alarm system with local alarm capability.
Updated guidance on fire extinguishers “should be distributed throughout every rehabilitation agency so that the distance between extinguishers is no more than 75 feet.” There is also specific guidance on the required fire extinguisher safety checks to be documented every 30 days, records that must be kept and how they are to be posted. Additionally CMS indicated that the use of “hand held air horns” in place of an alarm system is not acceptable.
In order to participate in Medicare a Rehab Agency must complete a survey and certification process. This can be done through the State Agency contracted with CMS to conduct Medicare surveys, or via a deeming authority. The American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF), known as “Quad A” has been granted deeming authority by CMS for rehab agencies. Quad A accreditation standards for Rehab Agencies must meet, and may exceed the Medicare Conditions of Participation. Additionally if you are accredited, or plan to be accredited, your organization is still subject to a survey of your main site and all extension locations by the state agency at any time. Any site visit conducted by the state agency is likely to be unannounced.
Are you a rehab agency? Have you had a recent survey by the state agency? Have you updated you policies and procedures to be compliant with all the Conditions of Participation and Interpretive Guidelines? Do you need help getting ready for a potential survey? Contact us directly if you need updated rehab agency policies and procedures, or a copy of the updated CMS guidance.