CMS-2786 Supporting Statement

Supporting Statement

for the

Fire Safety Survey Report Forms

CMS-2786 M, R, S, T, U, V, W, X, and Y

A. BACKGROUND

The Medicare/Medicaid Health Insurance Program is authorized by Titles XVIII and XIX of the Social Security Act (the Act). This program provides reimbursement for the medical care of the aged, disabled persons and individuals whose income is insufficient to meet the cost of necessary medical services. Sections 1861(e) (9), 1820 (e)(3), 1861 (ss)(J), 1861 (dd)(2)(G), 1819 (d)(2)(B) and 1919 (d)(2)(B), 1832 (a)(2)(F)(i), 1881 (3)(c), 1894(e)(4)(v), 1905(d) (I), and 1102 of the Act require that facilities meet standards specified by the Secretary, Department of Health and Human Services, in order to be certified for Medicare/Medicaid reimbursement.

On January 10, 2003, a final rule was published in the Federal Register, which amended the fire safety standards to incorporate the 2000 edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).

These forms are used to assess compliance with standards specified in 403.744 for religious nonmedical health care institutions (RNHCI), 42 CFR 482.41(b) for hospitals, 483.70(a) for skilled nursing facilities and nursing facilities, 483.470(j) for intermediate care facilities for the mentally retarded (ICF/MR), 485.623 Critical Access Hospitals (CAH), 418.100(d) for hospices, and 416.44(b) for ambulatory surgical centers (ASCs), 460.72 programs of all-inclusive care for the elderly (Pace). The forms included with this request are:

CMS-2786M - Fire Safety Survey Report - ICFs/MR - Worksheet for Rating Residents

used or assessing the level of capability for evacuation of the group of residents in a facility

which determines the level of fire protection requirements to be met;

CMS-2786R - Form is used for facilities in compliance with the 2000 edition LSC;

CMS-2786S – Form is used for facilities in compliance with the 2000 edition LSC;

CMS-2786T - FSES Worksheet is a tool used as a method of determining compliance with

the 2000 edition LSC;

CMS-2786U - Form is used to survey ASCs to determine compliance with the 2000

edition LSC;

CMS-2786V - FSES - ICFs/MR - Small Facilities-- used for surveying 16 beds or less; (the majority of ICFs/MR are in this category);

CMS-2786W - FSES - ICFs/MR - Larger Facilities--used for surveying compliance for facilities of 17 beds or more;

CMS-2786X - FSES - ICFs/MR - worksheet for Rating Residents--used for surveying compliance for small residential occupancies located within an apartment house; and

CMS-2786Y- FSES - Part III Chapter 7-101A – Board & Care (Optional form for ICF/MR).

B. JUSTIFICATION

1. Needs and Legal Basis

Sections 1861(e)(9), 1861(dd) (2) (g), 1832(a)(2)(F), 1820(e)(3), 1861(dd)(2)(G), 1861(ss)(J), 1881(3)(c), 1994(e)(4)(v) and 1905(d)(1) of the Act require that providers of Medicare and Medicaid services meet such requirements as the Secretary finds necessary in the interest of the health and safety of the individuals who are furnished services. This has been defined as compliance with the NFPA’s LSC. Compliance with this code is required directly by sections 1819(d)(2)(b) and 1919(d)(2)(b) of the Act for nursing homes, and by the following regulations: 418.100(d), 416.44(b), 483.70(a), 483.470(j), and 482.41(b). In order to determine compliance, the Secretary has authorized States, through contracts, to conduct surveys of health care facilities. Certification is based on a facility’s compliance or noncompliance with health and safety requirements as recorded by the State survey agency. The compliance information required by the Centers for Medicare & Medicaid Services (CMS) is available only through data abstracted from these forms.

2. Information Users

The information from these forms is used by both Medicare and Medicaid. Compliance with the standards surveyed through the use of these forms is required in order to obtain certification for reimbursement as a provider of Medicare/Medicaid services.

3. Improved Information Technology

These forms have been automated and may be used electronically by those State Survey Agencies which have the necessary capability.

4. Duplication

The fire safety survey is a basic deliverable under CMS’ contracts with State Survey Agencies and is the only one of its kind conducted by CMS. There are no other existing forms which collect this information.

5. Small Business

These information collection requirements do not significantly affect small businesses.

6. Less Frequent Collection

All surveys are budgeted through the Fiscal Year (FY) State Survey & Certification Budget Letter. For example FY 2007 such as:

Nursing Homes

5-Month Maximum Interval CMS performs 12-month Average

Home Health Agencies

36-Month Maximum Interval CMS perform surveys pursuant to Complaints

ICFs/MR

12-Month Maximum Interval

Hospitals Accreditation

1% CAH Validation Surveys;

Hospital Non-Accreditation

6 Year Maximum Interval CMS performs 5% targeted Sample

ESRD

3.5 Year Average CMS performs 10% targeted Sample

Hospices

8.0 Year Average CMS performs 5% targeted Surveys

Outpatient Physical Therapy Providers

8.0 Year Average CMS performs 5% targeted Surveys

Comprehensive Outpatient Rehabilitation Facilities

8.0 Year Average CMS performs 5% targeted Surveys

Rural Health Clinics

8.0 Year Average CMS performs 5% targeted Surveys

Ambulatory Surgery Centers

8.0 Year Average CMS performs 5% targeted Surveys

Psychiatric Residential Treatment Facilities

5.0 Year Average CMS performs 20% Validation & Complaint

Portable X-ray Suppliers

8.0 Year Average CMS performs based on State judgment

Transplant Centers

Pilot test Supplemental funds provided States

New Providers Initial Surveys CMS performs as needed for initial certification

Complaint Investigations CMS performs as needed basic

Long Term Care Facilities

15-Month Maximum Interval CMS performs 12-month average interval

Religious Non-Medical Health Care Institutions

3-Year Maximum Interval

7. Special Circumstances

There are no special circumstances associated with this collection.

8. Federal Register and Outside Consultation

A 60-day Federal Register notice was published on September 19, 2006.

CMS has consulted with and will continue to consult with State Life Safety Code surveyors and surveyor supervisors to ensure that the forms collect the proper information.

9. Payments or Gifts

There are no payments or gifts associated with this collection.

10. Confidentiality

We do not pledge confidentiality.

11. Sensitive Questions

There are no questions of a sensitive nature associated with these forms.

12. Estimate of Burden

These survey report forms are completed by the State agency surveyor based on the results of his/her investigation of provider compliance with each individual requirement of participation. The surveyor compiles all information pertaining to the providers’/suppliers’ compliance with health and safety requirements and summarizes this on the survey form. The surveyor ascertains and documents, as objectively as possible, whether the provider meets each requirement. In relation to each standard on the form, the surveyor checks “met” or “not met”. The mere checking of these blocks does not, in all cases, provide sufficient information to support a conclusion.
A brief statement is needed to support a finding of compliance or noncompliance with the regulatory requirements.

The burden on the facility consists of showing or making available, documentation to the surveyors as necessary. We estimate that this will take no longer than 5 minutes per facility. There are approximately 27,900 facilities surveyed annually. Thus, there is an estimated burden of 2,325 hours. We assume that the person making the information available earns approximately $15 per hour, for a total cost of $34,875 annually. Generally, the surveyor uses one form per facility per year.

13. Capital Costs

There is no capital cost associated with this collection.

14. Cost to Federal Government

All costs associated with this information collection are incurred by the Federal Government.

Surveyor time to complete forms: (includes salary, benefits, travel time, training, etc.)

Health Care – 25,499 surveys x 1 hour of surveyor time x $54.00 per hour = $1,376,946.00

FSES 2000 Code - 100 surveys x ½ hour of surveyor time x $54.00 per hour = $2,700

Evaluation Worksheet 2000 Code - 100 surveys x ½ hours of surveyor time x $54.00 per hour =$2,700.00

ASC Form - 1,000 surveys x ½ hour surveyor time x $54.00 per hour = $27,000

ICF/MR – 100 surveys x 1 hour of surveyor time x $54.00 per hour = $5,400.00

Part III Chapter 7-101A FSES for Board Care 100 surveys x ½ hour surveyor time x $54.00 per hour = $2,700.00

TOTAL $1,417,446.00

Printing

Printing of the forms results in annual printing costs of :

CMS-2786M - $ 970 CMS-2786U - 1,650

CMS-2786R - 2,428 CMS-2786V - $2,428

CMS-2786S - 4300 CMS-2786W - 2,428

CMS-2786T - 970 CMS-2786X - 1,830

CMS-2786Y - 1,200

TOTAL $15,374

15. Changes in Burden/Program

There are no program or burden changes.

16. Publication and Tabulation Dates

There are no publication and tabulation dates with this collection.

17. Expiration Date

CMS would like an exemption from displaying the expiration date as these forms are used on a continuing basis. To include the expiration date would result in having to discard potentially large numbers of forms.

18. Certification Statement

There are no exceptions to the certification statement.

B. Collections of Information Employing Statistical Methods

There are no statistical methods employed in this information collection.

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