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DOH Rescinds Flexibility in Enforcement of ACF Fire Drill Regulations

On April 8, 2021, the Department of Health (DOH) sent an email, which we shared with members, rescinding the flexibility in enforcement of adult care facility (ACF) fire drill requirements outlined in this directive issued June 28, 2020. As such, ACFs should resume conducting fire drills and ensure that they are in compliance with all regulatory requirements noted below. It should be noted that flexibility remains in place for nursing homes regarding the enforcement of regulations regarding fire drills; see page 29 of the Centers for Medicare and Medicaid Services' (CMS) COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers document.

Below is the email sent by DOH:

New York State regulations at 18 NYCRR 487.12 and 488.12 identify the frequency at which staff and residents must participate in fire drills. As fire drills result in massing and moving of staff and residents, and based on the Centers for Medicaid and Medicaid Services waiver of such requirements in nursing homes, in June 2020 the New York State Department of Health ("Department") elected to exercise enforcement discretion when surveilling adult homes' and enriched housing programs' compliance with the fire drill requirements set forth in 18 NYCRR 487.12(f),(g) and 488.12(g).

As articulated in its June 28, 2020 advisory, to exercise such enforcement discretion, the Department required facilities to implement a documented orientation training program related to the facility's fire plan, which considered current facility conditions. However, since effectuating discretion, the Department has identified substantial breaches in facilities' fire plans and thus will recommence full enforcement of all provisions of 18 NYCRR 487.12(f),(g) and 488.12(g). Please understand that 18 NYCRR 487.12(h) and 488.12(h) will remain in full effect. 

If you have any questions, please contact your regional office program manager.

Contact: Diane Darbyshire, ddarbyshire@leadingageny.org, 518-867-8828