[Above: L to R: Compliance Specialist Matthew Rodriguez, Deputy State Fire Marshal David Mills, Compliance Specialist Gordon Simeral, Assistant Chief Deputy Michael Trabue, and Compliance Specialist Mark Crawford.

by Deputy State Fire Marshal David Mills
This article provides an update of staffing and process changes in the OSFM Fire and Life Safety Services Branch.

Over the past twelve months, we have been revising the process in our Healthcare Unit on how we perform fire and life safety surveys of the federal government’s Centers for Medicare and Medicaid Services (CMS) licensed healthcare facilities. These changes, made in collaboration with our agency partners at the Department of Human Services (DHS) and the Oregon Health Authority (OHA), are in response to industry stakeholder demands for improved delivery of this service.

So what is the CMS Program?
The federal government’s CMS maintains oversight for compliance with the Medicare health and safety standards for laboratories, acute and continuing care providers, [including hospitals, nursing homes, home health agencies (HHAs), end-stage renal disease (ESRD) facilities, hospices, ambulatory surgery centers (ASC)], and other facilities serving Medicare and Medicaid beneficiaries. This is an optional program with which many of these facilities participate in order to receive federal reimbursement for services provided to patients covered by Medicare or Medicaid insurance programs.

What is a CMS facility Survey?
The survey (inspection) is to determine a facility’s compliance to participate in this federal reimbursement program and is performed on behalf of CMS by the individual State Survey Agencies. The functions the states perform for CMS under the agreements in Section 1864 of the Social Security Act are referred to collectively as the certification process. In Oregon, the State Survey Agencies are the Department of Human Services (DHS) and the Oregon Health Authority (OHA).

What is the role of the Office of the State Fire Marshal (OSFM)?
The OSFM conducts Life Safety Code (LSC – NFPA 101 & NFPA 99) surveys on behalf, and under the direction of, DHS and OHA as part of their performance of the CMS certification process of participating healthcare facilities in Oregon. The portions of a facility receiving an LSC survey is generally limited to patient care areas and those portions providing direct support of patient care. This survey work has most recently been performed by OSFM Deputy State Fire Marshals (DSFM) Sean Condon and Jonathon Jones.

What are the changes in the CMS Survey Program at OSFM?
The people, the scope, and the services we provide.

The people:
For the past eight months, the OSFM has been preparing to transition the CMS healthcare survey work that DSFMs Condon and Jones have been performing to our three new Health Care Unit CMS Compliance Specialists. Compliance Specialists Matt Rodriguez, Gordon Simeral, and Mark Crawford have completed their transition to full time LSC surveyors of CMS facilities. They have been well trained and prepared for their new roles in the unit. DSFM David Mills will assist as their lead for the next six to twelve months as they get comfortable with their new responsibilities.

The scope:
LSC surveys are now solely focused on Life Safety Code requirements (NFPA 101 & NFPA 99), verifying compliance with federal fire and life safety standards of existing facilities and for new facilities who wish to be certified to receive federal CMS funding. This is a significant change in the scope of the CMS program at OSFM as our Healthcare Unit surveyors no longer enforce Oregon Fire Code requirements when they are conducting their healthcare facility surveys.

The services:
New construction and tenant improvement plan review – The OSFM will begin participating in OHA’s expansion of their new construction and tenant improvement plan review process by the end of September. This new service will allow our LSC surveyors to determine compliance with federal requirements prior to facility construction, with the goal to minimize any conflicts with state construction codes and lack of CMS compliance at the time a Certificate of Occupancy is issued.

Unified code and standard interpretation services – All requests for OSFM interpretation of CMS code and standards are now being referred to the Codes and Technical Services Unit of the Fire and Life Safety Services Branch, the same unit that currently provides for interpretations of the Oregon Fire Code (OFC). This change is in response to stakeholder demands for consistent code interpretations of CMS-related compliance questions that will also identify and address any potential conflicts with State Building and Fire Codes. This new service will provide for one voice and one contact for code-related questions ensuring we deliver the best customer service available.

Regulated community/stakeholder outreach – We have met with, and will continue to meet with, healthcare facility management and maintenance directors to educate them on the changes we are making at OSFM, increasing collaboration on our process improvements and to get feedback on how we can continue to improve service delivery.

What does this mean to the fire service?
Determining compliance with the OFC in healthcare facilities is now the responsibility of local fire jurisdictions within their respective communities. Any assistance required from the OSFM will be mutually determined in concert with the DSFM serving the local jurisdiction’s region. It will also mean more collaboration in addressing fire code and CMS regulation conflicts that occasionally arise when multiple regulatory Authorities Having Jurisdictions (AHJs) all look at the same issue being regulated.

Benton, Linn, and Marion counties will now have a dedicated DSFM assigned to provide them service. Fire inspection and investigation service support for theses counties has been provided by Deputy State Fire Marshals Shannon Miller, Kristina Deschaine, and Ted Megert for the past thirteen months as our office has been making these changes.

Effective June 19th, DSFM Sean Condon has transitioned out of our Healthcare Unit and is serving District 3 (Marion County). DSFM Jonathon Jones will follow on July 3rd and will serve District 4 (Linn/Benton counties). This will mean a decrease in workload for DSFMs Miller, Megert, and Deschaine as they have been filling the gaps in those Districts. Sean’s and Jonathan’s priority will be to become familiar with the needs of the fire departments and districts in their service areas and increase the level of service to them.

Please welcome Sean and Jonathan as they assume their new roles in the branch and congratulate Matt, Gordon, and Mark with the completion of their very intense training and testing, and their new role in our Healthcare Unit.