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

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 1102, 1819 (d)(2)(B),1820 (e)(3), 1832 (a)(2)(F)(i), 1861 (dd)(2)(G), 1861(e) (9), 1861 (ss)(J), 1871,1881 (3)(c), 1894(e)(4)(v), 1905(d) (I),and 1919 (d)(2)(B), 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 under Condition for coverage.

On April 15, 2008 CMS-3818-F, Final Rule, “Medicare and Medicaid Programs; Conditions for Coverage for End-Stage Renal Disease Facilities,” was published in Federal Register (73FR 20370). 42 CFR 494.60(e)(1) states, “Except as provided in paragraph (e) (2) of this section, by February 9, 2008. The dialysis facility must comply with applicable provisions of the 2000 edition of the Life Safety Code of the National Fire Protection Association (which is incorporated by reference at section 403.744 (a)(1)(i) of this chapter.)” CMS-2786U is used to survey and assess compliance with Life Safety Code (LSC) standards specified in 416.44(b) for ambulatory surgical centers (ASCs). Because the same LSC standards apply to End-Stage Renal Disease facilities the CMS-2786U is being revised accordingly.

Other Fire Safety Survey Report forms are used to assess compliance with standards specified in 42 CFR 403.744 for religious nonmedical health care institutions (RNHCI), 42 CFR 482.41(b) for hospitals, 42 CFR 483.70(a) for skilled nursing facilities and nursing facilities, 42 CFR 483.470(j) for intermediate care facilities for the mentally retarded (ICF/MR), 42 CFR 485.623 for Critical Access Hospitals (CAH), 42 CFR 418.100(d) for hospices, and 42 CFR 460.72 for programs of all-inclusive care for the elderly (Pace). There is no change in burden associated with the collections related to these forms.

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 - used to survey and assess compliance with Life Safety Code (LSC) standards specified in 416.44(b) for ambulatory surgical centers (ASCs);

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 1102, 1820(e)(3), 1832(a)(2)(F), 1861(dd) (2) (g), 1861(e)(9), 1861(ss)(J), 1871, 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. Compliance with the National Fire Protection Association’s Life Safety 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 for other types of providers and suppliers: 42 CFR 416.44(b), 42 CFR 418.100(d), 42 CFR 483.70(a), 42 CFR 483.470(j), 42 CFR 494.60(e), 42 CFR 482.41(b) and 42 CFR 485.623(d). 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 Life Safety Code forms that are specific to the type of provider or supplier.

2. Information Users

The information from this form is used by the Medicare program. 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 services.

3. Improved Information Technology

This form has 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 and other 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 Mission & Priority Document. For example, for FY 2009 the ASC and ESRD survey frequency for providers/suppliers surveyed under the CMS-2786U is at least 10% of existing providers each year, and initial ESRD surveys are as needed. Complaint surveys also occur on an as-needed basis, but rarely involve survey of LSC compliance, and thus are not considered in this collection. For other Fire Safety Survey Report Forms for other provider supplier types, the frequency in FY 2009 is:

Nursing Homes

15-Month Maximum Interval

CMS performs 12-month Average

Home Health Agencies

36-Month Maximum Interval

CMS performs surveys pursuant to Complaints

ICFs/MR

12-Month Maximum Interval

Hospitals Accredited

1% Validation Surveys (5% - CAHs)

Hospitals Non-Accreditation

6 Year Maximum Interval

CMS performs 5% targeted Sample

Psychiatric Residential Treatment Facilities

5.0 Year Average

CMS performs 20% Validation & Complaint

New Providers Initial Surveys

CMS performs as needed for initial certification

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 November 14, 2008.

CMS has consulted with and will continue to consult with State Survey Agencies 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 and Surveyor time. The revised ASC/ESRD form cost is:

ASC/ESRD form – 2,442 surveys X 1 hour surveyor time X $41.66 per hour = $101,733.00

Health Care – 25,499 surveys x 1 hour of surveyor time x $41.66 per hour = $1,062,288.00

FSES 2000 Code - 100 surveys x ½ hour of surveyor time x $41.66 per hour = $2,083.00

Evaluation Worksheet 2000 Code - 100 surveys x ½ hours of surveyor time x $41.66 per hour =$2,083.00

ICF/MR – 100 surveys x 1 hour of surveyor time x $41.66 per hour = $4,166.00

Part III Chapter 7-101A FSES for Board Care 100 surveys x ½ hour surveyor time x $41.66 per hour = $2,083.00

TOTAL $1,174,436.00

Printing

Printing of the forms results in annual printing costs of :

CMS-2786M - $ 970 CMS-2786U - $3,300

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

CMS-2786S - 4,300 CMS-2786W - 2,428

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

CMS-2786Y - 1,200

SUBTOTAL $19,854.00

FINAL TOTAL $1,194,290.00

15. Changes in Burden/Program

The CMS-2786U form was revised because the same LSC standards apply to End-Stage Renal Disease facilities. There are no changes in burden.

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.