November 1, 1997

Information Bulletin 97-2
NH-17

Implementation Of The Federal Enforcement Process For The Life Safety Code In Skilled Nursing Facilities And Nursing Facilities

The United States Department of Health and Human Services, Health Care Financing Administration has directed State Survey Agencies to include Life Safety Code deficiencies issued to Skilled Nursing Facilities and/or Nursing Facilities in the Enforcement Process implemented during the summer of 1995 for Long Term Care Facilities. Thus, as of November 1, 1997, Life Safety Code deficiencies, issued under "K Tags", will indicate the scope and severity and be considered as part of the enforcement process in determining any possible remedies along with deficiencies issued under the long term care regulations, "F Tags".

The inclusion of the Life Safety Code deficiencies within the enforcement process has several ramifications as follows:

Life Safety Code deficiencies (those issued under K tags) and Long Term Care deficiencies (those issued under F tags) will both be considered in determining any recommended remedies and will need to be in substantial compliance within the time frame established by the "Date Certain" in order to avoid implementation of any recommended remedies.

Plans of correction for Life Safety Code deficiencies, as well as those for the Long Term Care deficiencies, must include how corrective action will be accomplished for those residents found to have been affected by the deficient practice; how the facility will identify other residents having the potential to be affected by the same deficient practice; what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; how the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur, i.e., what program will be put into place to monitor the continued effectiveness of the systemic changes; and, date of correction.

The facility will need to provide an "Allegation of Compliance" for the Life Safety Code Deficiencies (K tags) and other "Allegation of Compliance" for the Long Term Care deficiencies (F tags).

In order to ensure appropriate processing of facility recertification, the Minnesota Department of Health will send both the Long Term Care and Life Safety Code survey results to the facility under one cover letter. This mailing will direct the facility to return the Life Safety Code deficiencies (K tags), if any, along with the Plans of Correction and an Allegation of Compliance to the Department of Public Safety, Fire Marshal's office and to mail the Long Term Care deficiencies (F tags), if any, to the Minnesota Department of Health, Licensing and Certification Program office. The cover letter will provide the addresses for the Fire Marshal's office and the Licensing and Certification district office. The mailing will also include envelopes with the appropriate addresses.

Questions and assistance with Life Safety Code deficiencies (K tags) should be directed to or Mr. Robert Imholte, Supervisor, Deputy State Fire Marshal at 320-685-8559. Questions and assistance with Long Term Care deficiencies (F tags) should be directed to the Minnesota Department of Health, Licensing and Certification Program unit supervisor listed on the cover letter to which the deficiencies are attached.

Updated Thursday, March 17, 2011 at 12:43PM