John Allen Doe, Administrator

October XX, 2004

Page X

Sample “B” – Office of the State Fire Marshal Survey Cover Letter


STATE OF WASHINGTON

WASHINGTON STATE PATROL

General Administration Building, PO Box 42600 ٠ Olympia, Washington 98504-2600 ۰ (360) 753-6540

October XX, 2004

John Allen Doe, Administrator

Green Acres Nursing Home

1234 Main Street

New City, Washington 99992

Dear Mr. Doe:

On October 1, 2004, the Washington State Patrol, Office of the State Fire Marshal (OSFM) completed a life safety code (LSC) survey at your facility. The purpose of the inspection was to determine compliance with state fire safety standards for nursing homes and the Medicare/Medicaid Life Safety Code certification requirements. The results of the OSFM inspection are described on the enclosed CMS 2567L.

The Department of Social and Health Services, Residential Care Services (DSHS) has also been conducting a full standard (Health) survey to determine compliance with state licensing and federal certification requirements. The results of the completed Health survey will be delivered to you separately.

Plan of Correction (POC)[42 CFR 488.402]

You must submit a written, signed POC for the LSC survey deficiencies on the original CMS Form 2567L dated October 1, 2004, no later than 10 calendar days after you receive it to:

Washington State Patrol - Office of the State Fire Marshal

Attn: James Johnson, Deputy

PO Box 2223

Old City, WA 11112

phone: (222) 555-3456 / fax: (222) 555-9876

Your POC should address these issues:

  • How the nursing home will correct the deficiency as it relates to the resident;
  • How the nursing home will act to protect residents in similar situations;
  • Measures the nursing home will take or the systems it will alter to ensure that the problem does not recur;
  • How the nursing home plans to monitor its performance to make sure that solutions are sustained;
  • Dates when corrective action will be completed (no more than 45 days from the last day of the inspection); and
  • The title of the person responsible to ensure correction.

Failure to submit an acceptable POC by the 10th calendar day may result in the imposition of remedies. You are required to display the LSC survey CMS Form 2567L for public review.

If you modify your POC, you must immediately notify the OSFM in writing. You should address each modified "K" tag number and provide details about any modifications.

Recommended Remedies

DSHS will notify you if federal remedies are recommended as the result of deficiencies identified on the LSC survey (and/or any Health survey).

Informal Dispute Resolution (IDR)[42 CFR 488.331]

You may question cited deficiencies through an informal review and dispute resolution process. Unless you become entitled to a federal administrative hearing following imposition of a federal remedy, this will be your only opportunity to challenge the LSC deficiencies described on the enclosed CMS Form 2567L. If you request an IDR, you must still submit a POC within the time limits described above.

To request an informal dispute resolution meeting (IDR), please send your written request to:

Washington State Patrol

Office of the State Fire Marshal

PO Box 42600

Olympia WA 98504-2600

phone: (360) 753-0400 / fax: (360) 570-3136

The written request should:

  • Identify the specific deficiencies that are disputed;
  • Explain why you are disputing the deficiencies;
  • Indicate the type of dispute resolution process you prefer (face-to-face, telephone conference or documentation review);
  • Specify if an alternate Field Manager is preferred; and,
  • Be sent during the same 10 calendar days you have for submitting a POC for the cited deficiencies.

During the informal process you have the right to present written evidence refuting the deficiencies. An incomplete review and dispute resolution process will not delay the effective date of any enforcement action.

If you have any questions concerning the instructions contained in this letter, please contact me at (222) 555-3456.

Sincerely,

CHIEF LOWELL M. PORTER

Deputy State Fire Marshal

Enclosure

DSHS/RCS Field Manager

Linda Ronco, Nursing Home Enforcement Officer

All references to regulatory requirements contained in this letter are found in:

Title 42, Code of Federal Regulations (CFR); NFPA 2000 Life Safety Code

Chapters 19.27 and 48.48 of the Revised Code of Washington (RCW); and

Chapter 212-12