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Sprinklers Now a Must for Nursing Homes

By Cindy Skrzycki
Tuesday, August 26, 2008

After decades of partial solutions to fire threats in nursing homes, regulators are finally requiring sprinkler systems for the 2,466 facilities that still don't have them fully installed.

On Aug. 13, the Centers for Medicare and Medicaid Services issued a rule declaring that the $144 billion long-term care industry has five years to install the systems. Some 1.4 million residents live in 16,000 U.S. nursing homes.

The government, which has adopted fire standards developed by the nonprofit National Fire Protection Association since 1971, was spurred to action by the deaths of 31 nursing home residents in incidents in Nashville and Hartford, Conn., in 2003.

"It is 35 to 40 years overdue," said Janet Wells, director of public policy for the National Citizens' Coalition for Nursing Home Reform, a Washington group that works to protect residents' rights.

The Department of Health and Human Services recently began listing on a Medicare Web site, under "nursing home compare," whether a facility has sprinklers, when fire-safety inspections took place, and the number of deficiencies found and corrected.

Nursing homes support the rule and pushed for it, said Lyn Bentley, director of regulatory services for the American Health Care Association, a Washington trade group. Until now, sprinklers only had to be installed when providers built new facilities or made major renovations.

Two-thirds of nursing homes are for-profit operations. HCR ManorCare of Toledo, which had 38,372 beds, was the largest at the end of last year, according to Provider, the trade group's magazine. Carlyle Group, the D.C. private-equity firm, purchased Manor Care for $6.3 billion last year.

"The concern was primarily the cost," Thomas Hamilton, director of CMS's survey and certification group, said in explaining opposition to the blanket requirement. The rule estimates that the industry will have to spend $847 million over the five-year phase-in period to meet the new standard.

The industry said the cost of sprinklers will be a financial hardship on some owners, especially in rural areas.

The Centers for Medicare and Medicaid Services told homes without ceiling-installed sprinklers in 2006 that they could use smoke alarms instead. The alarms won't be required under the new rule, a change opposed by advocates for the elderly.

Long-term care facility owners have been lobbying Congress for a bill that would provide $450 million in loans and another $100 million in hardship grants to finance the new sprinklers. The federal government spends almost $50 billion a year on nursing homes.

The trade group also supports offering waivers to homes that, "through no fault of a particular facility," can't meet the five-year phase-in schedule.

The new regulation says the best insurance against fires is sprinklers: "There has never been a multiple-death fire in a long-term-care facility that had an automatic sprinkler system installed throughout the facility."

The blazes in Hartford and Nashville focused regulators on gaps in fire-protection rules. Intense media scrutiny and a Government Accountability Office report in July 2004 helped prompt the push for mandatory sprinklers.

The GAO report was critical of "weaknesses" in federal fire standards and oversight. It said neither home had smoke alarms or sprinklers where the fires originated. It was critical of waivers that regulators handed out to excuse homes from fire standards. And it said state and federal oversight relied on faulty and unaudited state surveys.

Still, the number of fatal nursing home fires has dropped dramatically since 1971 when 15 to 18 fires a year resulted in three or more deaths each, the government said in issuing the rule. The average number of deaths each year since then is 5.

The reduction is "reflective that they aren't fire traps or horribly unsafe places to be," Bentley, of the nursing home trade group, said of the facilities.

That's not to say nursing homes are hazard-free. The GAO report said that from 1994 to 1999, an average of 2,300 facilities reported a fire each year.

Hamilton said his agency and state inspectors, in responding to the GAO's findings and recommendations, have cracked down on fire-code violations.

In 2004, inspections uncovered 48,732 problems with fire-safety rules, 11.5 percent of which were considered to have widespread potential for harm. Last year, 62,359 deficiencies were found, with 23.5 percent considered severe.

Enforcement actions, including other issues besides fire safety, have increased from 306 in 2004 to 1,299 in 2006.

Nursing home advocates and fire-safety experts say they are pleased regulators won't permit waivers to the sprinkler requirement, and that stronger state laws won't be preempted.

Advocates said in comments and interviews that they are opposed to a provision in the rule that allows smoke alarms to be taken out once sprinklers are installed.

Hamilton said the rule took into account the expense of maintaining smoke alarms. "You have to balance the cost involved with the benefits," he said.

Cindy Skrzycki is a regulatory columnist with Bloomberg News. She can be reached at cskrzycki@bloomberg.net.

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